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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 Melkia Hayes
Home Address 135 Gooseleg RD Springfield Ga, 31329
D Student D Employee: YES D Visitor D Vendor
Phone Numbers Home Cell (912)-428-0007 Work

INFORMATION ABOUT THE INCIDENT


Date of Incident Time Police Notified  Yes  No
3/30/2018 4:43 p.m NO
Location of Incident
Beachwood Hospital (in patient room)

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)

Went to patient Mrs. Lawry room to check on her. Knock on the door and didn’t get no answer so I walk in pronouncing
myself. When I enter the room, I seen Mrs. Lawry up out her bed I rushed in to try and help her. She got very angry and hit
me with her cane in my leg. Before I came to the patient room nurse Debbie said she haven’t had the chance to look into her
chart but she was confused and upset earlier so I want to see if I take her breakfast will that calm her down.

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


If yes, attach separate sheet with names, addresses, and phone numbers. NO
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).

No the patient was not injured.

Was medical treatment provided?  Yes  No  Refused


If yes, where was treatment provided:  on site Urgent Care  Emergency Room  Other
No

REPORTER INFORMATION
Individual Submitting Report (print name)

Signature

Date Report Completed

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


3/25/2018 Call family and let them know about patient confused and aggressive Melkia hayes
behavior so they can come and the patient can see a familiar face.
3/27/18 Make sure all the nurses knows the patient is hard of hearing and has Melkia hayes
Demetria.
3/28/18 Mark in the chart how her behavior when nurse come in to take care of Melkia hayes
her.
3/29/18 Make sure if possible don’t go in the room alone in case you need help Melkia hayes
with assisting patient to lay down or get comfortable.