Abstract: At about 2:00 a.m. on July 20, 2004, Employee #1, a Senior Administrative Nurse Supervisor at Community Hospital of Long Beach, fell down several steps in a stairwell while making nursing rounds in a hospital. Employee #1 was found by a respiratory technician, conscious and in pain at the stair landing between the first and second floors. Employee #1 was hospitalized in the same facility for a fracture of the right femur. Employee #1 was not clear on why she fell, stating to witnesses that she tripped, later stating in writing that her shoe had stuck to something. A director conducted an inspection of the stairs and later provided a written statement that the stairs showed no trip hazards or debris and were well-lighted immediately following the accident. An inspection by state OSHA personnel on August 4, 2004 confirmed these findings, and confirmed that the stair geometry, landings and guardrails were in compliance (steps 42-in.-wide with 7-in. risers and 12-in. steps, 12 steps between landings, and single handrails on either side mounted 34-in. above the steps).