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  • Assg Incidentreportformjpirkle 20180122 Ah102

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    This incident report form summarizes an incident involving Deloris Lawry, a student, that occurred on January 30, 2018 at 9:43AM in her dorm room 313. Ms. Lawry, who has diagnoses of dementia and diabetes, became aggressive with her nurse Nancy when she tried to assist her out of bed. Nancy nurse was struck in the leg but was not seriously injured. As a result of being unable to care for herself, Ms. Lawry was transported to Beachwood Manor. The report was completed and submitted by Nancy Nurse on the date of the incident.

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    This incident report form summarizes an incident involving Deloris Lawry, a student, that occurred on January 30, 2018 at 9:43AM in her dorm room 313. Ms. Lawry, who has diagnoses of dementia and diabetes, became aggressive with her nurse Nancy when she tried to assist her out of bed. Nancy nurse was struck in the leg but was not seriously injured. As a result of being unable to care for herself, Ms. Lawry was transported to Beachwood Manor. The report was completed and submitted by Nancy Nurse on the date of the incident.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    28 views2 pages

    Assg Incidentreportformjpirkle 20180122 Ah102

    Uploaded by

    api-393582204
    This incident report form summarizes an incident involving Deloris Lawry, a student, that occurred on January 30, 2018 at 9:43AM in her dorm room 313. Ms. Lawry, who has diagnoses of dementia and diabetes, became aggressive with her nurse Nancy when she tried to assist her out of bed. Nancy nurse was struck in the leg but was not seriously injured. As a result of being unable to care for herself, Ms. Lawry was transported to Beachwood Manor. The report was completed and submitted by Nancy Nurse on the date of the incident.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    IncidentReportForm

    Usethisformtoreportaccidents,injuries,medicalsituations,orstudentbehaviorincidents.(Incidentsinvolvingacrimeortrafficincid
    entshouldbereporteddirectlytotheCampusPublicSafetyoffice.)Ifpossible,thereportshouldbecompletedwithin24hoursoftheev
    ent.SubmitcompletedformstothePresident’sOffice.

    INFORMATIONABOUTPERSONINVOLVEDINTHEINCIDENT
    FullName Deloris Lawry
    HomeAddress 8205 Palm Terrace
    D Student x Employee D Visitor D Vendor
    PhoneNumbers Home904-764-8445 Cell 904-553-6780 Work 9045536784

    INFORMATIONABOUTTHEINCIDENT
    DateofIncident 01/30/2018 Time 9:43AM PoliceNotified  Yes X No

    LocationofIncident
    The incident took place in Ms. Lawry’s room 313

    DescriptionofIncident(whathappened,howithappened,factorsleadingtotheevent,etc.)Beasspecificaspossible
    (attachedadditionalsheetsifnecessary)
    Ms. Lawry was transported to Beachwood Manor due to the fact she is unable to care for herself. She has a diagnosis of
    Dementia, and Diabetes. She became aggressive with Nancy nurse when she tried to assist her while she attempted to get
    out of bed.

    Werethereany witnessestotheincident?  Yes  No


    Ifyes,attachseparatesheetwithnames,addresses,andphonenumbers.
    Wastheindividualinjured?Ifso,describetheinjury(laceration,sprain,etc.),thepartofbodyinjured,andanyother
    informationknownabouttheresultinginjury(ies).
    Ms. Lawry was not injured in the incident. Nancy nurse was struck in the leg with no serious injury.

    Wasmedicaltreatmentprovided? X No  Refused
    
    YesIfyes,wherewastreatmentprovided:  on site UrgentCare  EmergencyRoom  Other

    REPORTERINFORMATION
    IndividualSubmittingReport(printname) Nancy Nurse

    Signature

    DateReportCompleted01/30/2018

    FOROFFICEUSEONLY

    ReportReceivedby Date _
    FOROFFICEUSEONLY

    Documentanyfollow-upactiontakenafterreceiptoftheincidentreport.

    Date ActionTaken ByWhom

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