A nurse witnesses a client climbing over the side rails and falling out of bed to the floor. Restraints had been ordered for the client but were not in place. When the nurse completes the incident report, what information should the nurse include?

1-the fact that the nursing staff was not at fault because the client initiated the accident
2-the facts of the incident witnessed by the nurse as it occurred
3-the name of the nurse who was responsible for monitoring the restraints
4-the reason why the ordered restraints were not on the client