A 72 year old with Alzheimer’s Disease was admitted to a respite unit for several weeks so that his wife could go on holiday. At home he would sleep in his own bed although occasionally in the night he would get up and wander around. He did not require a stick and had no problems with his sense of balance. He was able to feed and clothe himself with minimal assistance. The Respite Unit was part of a more general ward in a Community Hospital. He was in a four bed unit as part of a 24 bed ward which at night was staffed by two nurses and three nursing assistants. There were no bed rails on his bed and the floors were carpeted. Ten days after admission he got out of bed at 3am as he wanted