During Evening Rounds the Nurse Finds a Client Lying on the Floor

During evening rounds the nurse finds a client lying on the floor next to the bed.What should the nurse do when documenting this situation?

A) Complete an incident report.
B) Document in the medical record that an incident report was completed.
C) Document that the supervisor was notified of the incident in the medical record.
D) Document the incident in the medical record but not mention an incident report was completed.