I can see how easily it happens, a typical ward in my hospital has 4 back bays 2 with 6 beds and 2 with 4, then usually a 4 beded bay in the middle then a minimum of 6-10 cubes, its quite a large area to cover, 30 patients!
Most night shifts are 2 nurses and 2 auxiliaries and days not much better. If you have a room with 4 confused or sick patients you’re going to spend a lot of time in there and not much in the others some patients especially the ‘wellest’ or most capable will often not see anyone for a couple of hours, possibly more!
There just isn’t enough of us to get round and check on everyone regularly 😢 it’s heartbreaking no one should come to harm in the place they should be the most safe!