Incident Report

• Audit Title

• Document No.001

• Client / SiteJames Johnston

• Conducted Odyssey Nursing Home

  Date

• Prepared by Andreia Collins

• Location1/13 Fortune ST Commera
  Address

• PersonnelKristine Handerson

SECTION I

• Date and time of incident21/04/2120

  Date

• Date and time incident was reported. 3 pm

  Date

• To whom was the incident reported?To the supervision

• Location of incident. (Specify site location)At Odyssey Nursing home

• Supervisor's NameKristine Handerson

• Supervisor's Phone Number0412795033

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

PERSON(S) INVOLOVED

• Name (Person 1):James Johnston

• Phone:5751005

• Sex:Masc

  Male

  Female

• Age;93 y.o

• Job Title: bossiness man

• Time on job: (Yrs & Mos)

• Job Status:Client

  Full-time

  Part-time

  Temporary

  Seasonal

• Classification:

  Select First-Aid only Medical Near miss Lost time OH&S Reportable None

  • First-Aid only
  • Medical
  • Near miss
  • Lost time
  • OH&S Reportable
  • None

• Employee Disposition Status:Retired

  Returned to Work

  Modified Duties

  Sent Home

  To Doctor

  To Hospital

• Medication prescribed? If yes list medications.

  Yes

  No

  N/A

NATURE OF INJURY

• Describe injury. Booked arm

• Detail any first-aid or medical treatment administered. (Provide names)St John's Ambulance

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

• Photo of damage.

  Media

• Estimated cost of damage:

• Vehicle ID:

• Make/Model:

• Age:

• Equipment ID:

• Model:

• Age:

• Detailed description of incident. (Include environmental conditions at time of incident Fall of the bed

• Environmental photo:

  Media

• Environmental photo:

  Media

• Immediate (Direct Causes):James was not sure where he was caused by Dementis

• Direct cause photo:

  Media

• Direct cause photo:

  Media

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Select date

  Date

• SignatureK. Handerson

  Sign