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Asked by ProfessorPolarBear264

Michael, a personal care assistant who has recently joined the aged care facility, left an elderly client undressed in his room for 20 minutes after showering him. Michael was distracted and lost track of time he was away from the client.  His absence contravened both his duty of care and his job description, which specified that he must never leave a client alone after showering and before they were dressed. The client attempted to dress himself and had a nasty fall. Fortunately, there was no permanent injury, but the client sustained lacerations on the left limb. First Aid was provided, and a dressing was applied. A doctor saw the client. 

 

The client’s family decided to take legal action for negligence but was advised by their solicitor that, while there were grounds for establishing negligence, it was felt that the action would be unsuccessful because the client had not been permanently injured.

Activity – The  supervisor has asked you to complete the Incident Report Form based upon the above scenario.
INCIDENT REPORT FORM
Incident Reference No:

Personal Details (of the injured): First Name_________________________     Surname: ______________________

Address:  ___________________________________________________________________________________________

DOB Resident: _________________________________    Male/Female: _____________________________________

 

The incident resulted in: Injury          Accident       Damage to environment/ property    

 

Near miss                               first aid                Medical treatment              Death  

Incident Details:

 

Date/ time: __________________________________________________

 

Place of the incident: ________________________________________

 

 

Name of the person reporting: ________________________________

 

 

Full details of the incident: 

 

 

 

 

Description of the injuries:

 

Was first aid or further treatment required?                   Yes                       No     
Was the injured person required hospitalisation              Yes                       No     
NOK notified of the incident              Yes                       No       
Were there any witness              Yes                       No     

Witness Details:

 

 

Full Name: _______________________________________________

 

Address: _________________________________________________

 

__________________________________________________________

 

Position:   _________________________________________________

 

Contact Details: __________________________________________

 

Follow up Plan Yes                        No     
 Action  Responsible team   Time framework      Outcome
       
       

Reporting person:

 

Name:   ____________________________________________________

 

Position: ___________________________________________________

 

Date/time: ________________________________________________

 

 

Signature: _________________________________________________

SCIENCE
HEALTH SCIENCE
NURSING
AGE CARE CHCCOM005

 

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