Incident Report Form

Use this form to report accidents, injuries, medical situations, or student behavior incidents. (Incidents involving a crime or
traffic incident should be reported directly to the Campus Public Safety office.) If possible, the report should be completed
within 24 hours of the event. Submit completed forms to the President’s Office.

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT

Full Name: Doris Lowery
Home Address: 6565 Insane in the Membrane Lane, Hollywood CA
D Student D Employee x Visitor D Vendor
Phone Numbers Home: 410-453-0092 Cell: N/A Work: N/A

INFORMATION ABOUT THE INCIDENT

Date of Incident: 3/26/18 Time: 9:00am Police Notified  Yes X: No

Location of Incident:
Room 313 in Beachwood Manor

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
The nurse knocked on Ms. Lowry's' door and introduced herself, but before Ms. Lowry could respond the nurse was trying
to help her without her consent, and Ms. Lowry became frightened and aggressive. Which has been noted in her file that
when she receives a new caregiver she can become anxious and aggressive.
Ms. Lowry became scared because she did not know the new caregiver and wanted to protect herself, so she used her cane
to strike the nurse as a form of protection.

Were there any witnesses to the incident?  Yes X: No

If yes, attach separate sheet with names, addresses, and phone numbers.
Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other
information known about the resulting injury(ies).
Ms. Lowry was not injured in this incident but the nurse received brusining on her left leg from being hit with the cane.

Was medical treatment provided?  Yes X: No 

Refused
If yes, where was treatment provided:  on site Urgent Care  Emergency Room  Other

REPORTER INFORMATION
Individual Submitting Report (print name) Laura Malynn Riley

Signature

Date Report Completed 3/26/18

FOR OFFICE USE ONLY

Report Received by Date _

 FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

Date Action Taken By Whom

3/30/18 Follow up with Ms. Lowry on how she was feeling after incident Dona (supervisor)

4/1/18 Implemented care plan for Lowry Dona (supervisor)

4/10/18 New medications were implemented in Lowry's care plan Chief Physician