MIRF REPORT
Request:
Fall
Campus:
Vista
Location/Building:
[68]
Date of Incident:
December 21, 2025
Time of Incident:
9:20 AM
Number of Patients for this Incident:
[75]
List Patient(s) Name, Age, Parent/Guardian (if under 18),… :
Samuel Zappia, 4YO, Mom: Rebekah Kirsch (760) 458-6324
Grace Kirsch- (760) 877-5700 -Karen O’Donnell (7600) 500-3099
Describe Medical Event:
Grace and Samuel were walking holding hands in waking on gravel area on black top. Grace who has Down’s syndrome tripped and accidentally pulled Samuel with her. Grace sustained superficial scrapes to bilateral knees which were cleaned with NS and bandaged with Telfa non adherent gauze and coban. Her left ring finger critical also had mild cut which was bandaged as well.
Samuel sustained deep laceration to left upper lip and more superficial laceration to right upper lip both beneath the nares. Small scrape to tip of nose as well. Provided gauze to apply pressure to bleeding wounds. Advised Samuel’s mother Rebekah to take Samuel to urgent care for evaluation and probable stitches.
Actions Taken by Team Members:
[79]
Number of NCSM Team Members Involved:
[81]
List Name(s) of NCSM Team Members Involved:
Chris – Safety,
Sarah Sammons -medical
Travis Sybert- pastor
Was medical attention accepted?”:
Yes
Medical attention was refused by (name and relationship to… :
Was 911 emergency service called?:
No
Was patient transported via 911 emergency services?:
No
What hospital was victim transported to?:
NCS team lead:
[249]
If any revisions or updates are needed to be made to this incident, complete the form below.
Please select a valid form