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Claim by Chiquitta CarrollMasterpiece on the Mississippi TRACEY STECKLEIN PARALEGAL To: Mayor Roy D. Buol and Members of the City Council This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa Communities Assurance Pool. MEMORANDUM DATE: April 6, 2010 RE: Claim Against the City of Dubuque by Chiquitta Carroll Claimant Date of Claim Date of Loss Nature of Claim Chiquitta Carroll 04/01/10 03/30/10 Personal Injury This is a claim in which claimant alleges that her son, Canaan Webster, tripped on a hole in Comiskey Park, causing him to fall and break his leg. cc: Michael C. Van Milligen, City Manager Bob Fritsch, Park Division Manager Chiquitta Carroll OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944 TELEPHONE (563) 583 -4113 / FAx (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org )/ ' ✓/j CLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim. The claim must be filed with the City Clerk at City Hall, 50 West 13 St., Dubuque, IA 52001. It will then be referred to the appropriate department for investigation and to the City Attorney's Office. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. The final decision on all claims is made by the City Council. No employee of the City of Dubuque has the authority to make any representation to you as to whether your claim will or will not be paid. 1. Name of Claimant: 2. Address: \Q ? v 3. Telephone Number 5( - LA ° 15 - 4. Date of Incident: 3 - /0 5. Time of Incident: '). 00 prn 1 I et nc ( A - Q65 - e SZo©\ ■ 6. Location of Incident (Be specific): (Igo n (tsnh A pet',k b�.S-e_ /i d:' armoficl 1,4 id 7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.) /1)l Lin /�nr�r�.� illcS p/ i //? GL heti /ef 12 Sk /It' 16 ✓ r '�4 ar - /Vat rtlnni'n� fViu / 5 - b j-c iv 2hd (�Ct .f-! 40-4,7 J_ hie i At 11,7 a x,41J h It /1✓7 e A:4 .1 cir a C, rtl h, n 4Yec -L L 1s y 8. What were weather conditions like? jitei4. r ee /1_5 /.rh°re jOa; t S-/2ny /-M c- 6r-ft• 9. � Give name and address of any witnesses: a h / or ;d 0/1,./77' C a s 0411 Tu C, 4n / a <4_0 � )1 4,77e, 741,d C /- ri -f of .h in t o >'-f ', e /Ci { /r/ r;,�� / �e,(�Q.�=1.+'n5 n 10. Did police investigate? (If so, give names of officers.) L r - t /) ' ?7 7ctJ € f-e ,7 /,mbf.i / /3 o /.S— 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). ( s, e cif c, (r i-P.I i4f' too i i1 r. v ,'-r d , he hoes) has 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) D r- vhmcxr i Lc)u.s i;e 7 v p ia pry 13. What other damages do you claim, if any? kr f)ti Sa k ilv // bt tei e",. ac , 9t our) cis. cis. u T{rt rot ` y r1- • 14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.) ti lt Dated this / day of A Ok i f1,' - are (Signat ) Cam .• a Y / / (Print I me) 15. What amount do you claim from the City of Dubuque? 3000. , r, 16. Why do you C u claim the City of > D � Dubuque is responsible? / I° 1. 40 4he 1' J Da- t7t.l90 -e �� Y-e.S ! • /, ('G�i d€ Ay .1 ! T 1 � e /' P (114( M (J ®i7 e C / / 14/ i 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) Alo 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? A-(4) , 20 JO . n crz cp D n a -o CA) - v w rn 0 m 0 J Masterpiece on the Mississippi Dubuque a AFImekawl 11111 `° —/3675 Kurt Rosenthal 2007 Patrol Officer - 83A Police Department Dubuque Law Enforcement Center 770 Iowa Street PO Box 875 Dubuque, Iowa 52004 -0875 (563) 589 -4410 Office (563) 589-4497 Fax (563) 589 -4415 Dispatch 911 Emergency (563) 583 -1711 TTY elive uDae�, �� ' a ��. �> �.�•N�,:.::��:. �: • ,., ,ii . _ ., . n ... .:.. ..-.s � _.. ��'� lL lx� �� Ho 6 '' on a of €:`;."''j ate- �. � h 'f' '�.m _ - �:: ;� I3o et , Y��.. �.?'e:` ^�`,,, .fG >�'� ... .. .: ... <i...e'�t: ^ i": .' ., .':.LFL�.�'%...s,. .3/ l /1 s63 6 3 Y 41Y1 LOcaiu_. N i a y� (�'''�.n n' }. .:4'.;: .'^ t `a•�rv�{ �'rr V. l��' +.T',..� .. �i z .. W :• ...,.. ;� ��e', 4• ^'r• i ,,) K.7 e1.Vm �iVi��l a .Fac � /;. e'.r:'.:,� ':c a.� °. ...../`'._., Cct (V0-184-1-- �. �t� /03 E f— . , 6(bd uLe, / �0_,T'he client is alert, able to verbalize and /or (demonstrate correct use and care for this equipment. .. f /�� p C eck` ��e>�. ' o�l�' SaTe''a `tiii � -s ::�`Cb:�ck�size:i>k tiQZ�' DCS'Cr1 tjUri; i�1., - �„.. Ll�� +; �` $D p Under Arm Crutches / ❑ Tall AA20055 /174113 ❑Adu1t AA20058 /187531 Youth AA20057 /174114 OR $10.00 /month OS $53.00 OR $10.00 /month OS $53.00 /4,1010.00 O S $53.00 Crutches are sale items only unless your insurance specifies otherwise. Medical Associates Plans only rent this item. It is your responsibility to return this item to Mercy Home Care when you no longer need it. QSafety : Make sure your walk way is clear of any obstacles including throw rugs and electrical cords. ri Hazard of attempting HME Repair: Do not attempt to repair this equipment yourself, contact Mercy Home Care and they will This equipment may be covered by warranty, which will be voided if you try to repair yourself. assist you with repair or replacement. If you have concerns about safety or the quality of care provided you may report these concerns directly to: The Joint Commission at 1- 800 - 994 -6610 or by emailing• complaint@ajointcommission.org C.0,1- Einergeiicy,� Contact:7n+forniatioii Name: ear Phone: , 3 - 2CRelationship: 3 EixiergencyPhgne Numbers Mercy Home Care Equipment Services — 24 hour phone# 1- 800 - 637 -2944 or563 -589 -8118 Mercy HOME CARE A saris °`Mary Medial Carer- Dubuque PRIMARY % SECONDARY % CLIENT 100% until insurance is verified I understand that my insurance carrier (s) is expected to pay the following percentage of cost for the new equipment and /or supplies listed above. I understand that my estimated costs may change upon confirmation of insurance coverage. I understand that I may be financially responsible for co- pays and deductibles not covered by my insurance carrier. I further understand that if the insurance company(ies) deny payment of prior services or does not pay the charges in full, I am financially responsible for all charges. A reasonable estimate of my cost share is listed above. I acknowledge that this order is subject to all the condition and terms set forth on this order and the attached information sheet, which terms are hereby incorporated by reference, and made part of this agreement between Mercy Home Care and myself. I further acknowledge that I have received, read and understand all terms appearing above and on the attached information sheet. I acknowledge that I have received a copy of the clients rights and responsibilities, privacy practices, supplier standards, educational /safety information, fall safety prevention sheet, warranty information, purchase agreement information and written information on the advanced directive. I further acknowledge that I have received this equipment and the instructions for the safe operation, cleaning and maintenance of this equipment and that the equipment is in good working order and without defects. I understand that my signature on this agreement authorizes Mercy Home Care to provide products, equipment, or services to me. Assignment of Benefits - I authorize insurance payments directly to Mercy Home Care for products, equipment or services provided to me by Mercy Home Care. I authorize my insurance company to provide Mercy Home Care all insurance benefit and claim status information for products, equipment or services provided to me. I authorize Mercy Home Care to release to my insurance company (ies) or Medicare and its agents any and all information pertaining to me for benefit determination. ti \ 1 lient Signature Signature of family member /designee Full address of person signing on behalf of the patient Reason Patient unable to sign: in ( } /l% lO( - White: Mercy Home Care Yellow: Client I:\Homecare\EVERYONE,Word4IM'PT Invoices\ crutches underarm 021 108.doc rcy'Home Care 200 Mercy_Drive, Suite 302, fbuque, IA 52001 -7392 (563) -589 -8118 Date Date Relationship If l Company Representative 3 Date MEDICAL RECORD O Face sheet (ID /diagnosis /procedures) O Discharge Summary/History O History/Physical Examination 0 Mental Health History O Psychosocial /Social History 0 Mental Health Progress 0 Psychologist Evaluation /Report 0 Mental Health Evaluation 0 X -Ray Reports 0 Lab Reports 0 Consultation Other Physicians DATE This authorization is provided for the following purpose: 00411 '"` Sept.2007 Name of Patient 0 O._ 61 Q_Q 61 Medical Record # ( ? (} Date of Birth � Date(s) of treatment: 3 — 3 - l 0 I hereby authoriz9 r9 I _/ U NA---/ of Mercy Medical Center,pbDubuque, IA 0 Dyersville, IA ,' disclose to: 'Y ',9a 0 obtain from: Address: A't . () r* 9--- the following information contained in the medical records of the above named patient. This information may be verbal, written, or copies of such records. 0 Operative Report 0 Complete Record O Pathology Report O Nurses Notes O Dr. Order /Progress O EEG /EKG /Stress Test O Heart Cath Report O Medications O Emergency Room Report O Treatment Participation /Plan 0 Treatment Plan & Updates y 0 This information has been disclosed to you from records protected by Federal and Iowa State Confidentiality rules, 42 CFR, Part 2, Iowa Chapter 228, and /or Section 141.23 (3) of the Iowa Code. These rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Federal Rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient. I specifically authorize the release of 0 Mental Health Initial 0 Substance Abuse Initial 0 HIV (Aids) information Initial I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this authorization will expire in six months. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or request a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosures of my health information, I can contact the Medical Record Department. Mercy Medical Center Authorization to Release and /or Receipt of Confidential Information (`?t..l pt,d PATIENT SIGNATURE / PATIENT REPRESENTATIVE RELATIONSHIP O Discharge Summary (counselor) 0 Continuing Care Plan 0 PT, OT, SP, PC Notes 0 Verbal Progress Report 0 Substance Abuse Assessment 0 Integrated Summary O Family Assessment O Recommendations O Progress tafing ,12YOther (' (1.D1 O Other Mercy Medical Center Emergency Department - Du buque, IA 52001 Phone: 563 -- 589 -9666 rent Date: 03/30/2010 2 Name: CANAAN WEBSTER Emergency Department Physician: Lorence MD, Anna M Mercy Medical Center - Dubuque would like to thank you for allowing us to assist you with your health care needs. Please review these instructions when you return home in order to better understand your diagnosis and the necessary further treatment and precautions related to your condition. Medication prescriptions provided during the Mercy Emergency Department visit cannot be refilled over the telephone. If your symptoms persist, it is usually necessary to be seen by your personal physician, or in a clinic, for continued medical management. If you are having a reaction to your medication, please call your physician or return to the Mercy Emergency Department immediately. The Mercy Emergency Department physician has looked at your lab tests, EKG, and /or other diagnostic tests and has given you an opinion. If the final reading is different and further treatment is needed, we will try to contact you. If tests results were not available while you were here and later indicate that you need further treatment, we will try to contact you. You will be referred to another physician or clinic for further evaluation or tests. Please be sure to provide complete contact information. When x -rays are done the Mercy Emergency Department provider will give a preliminary report to you. A radiologist will review your x -rays the next working day, and you will be notified of any information that would change your care. Sometimes fractures or abnormalities may not show up on x -ray for several days. If symptoms persist or worsen, call your doctor or return to the Mercy Emergency Department. Warning: Do not drive or use machinery under the following conditions: Seizures not controlled by medicine; wearing an eye patch; fainting spells for any reason; use of drugs, alcohol, and /or medications that may cause drowsiness. Smoking: If you do smoke, we encourage you to stop. Smoking affects all Name: WEBSTER, CANAAN JOSEPH 2 of 9 03/30/2010 21:58:29 aspects of your health and the health of those around you. Suicide Hotline: Your mental and emotional well -being are important. If you are in a mental health crisis or are having thoughts of suicide, please call the nationwide suicide hotline, anytime day or night at 1- 800 - 273 -TALK. Please remember to always BUCKLE -UP! Seatbelts and child car seats do save lives! - Thank you for choosing Mercy Medical Center - Dubuque Emergency Department.- Name: WEBSTER, CANAAN JOSEPH MRN: (DB)- 000180358 3 of 9 03/30/2010 21:58:29 Medication(s) you took at home prior to your visit and should continue taking as prescribed. Medicaciones que Ud tome, en casa antes de su visita y deberia tomar como prescrita. Medication Medicaciones Details Detalles Comment Comentarios amphetamine - dextroa mphetamine(Adderall XR) 30 mg , By Mouth , once a day , Dispense Quantity 30 Medication(s) you received while in the ED. Las medicaciones que Ud. recibio mientras que estaba en la sala de emergencia. Medication Medicaciones Details Detalles Comment Comentarios hydromorphone 1 mg Adm Date /time: 03/30/2010 20:28 Route: IM Emergency Services Medication List Lista de Medicaciones de los Servicios de Emergencia This list may not be a true source of information, as your doctor may have changed doses, added, held or discontinued some of your medications. If you should have any questions, please contact your physician. Es posible que esta lista no incluya toda la informacidn correcta, a causa de que su medico haya cambiado dosis, haya anadido o parado algunas de sus medicaciones. Por cualquier duda, favor de pacer preguntas a su medico. Name: WEBSTER, CANAAN JOSEPH 1 of 9 03/30/2010 21:58:29 MRN: (DB)- 000180358 Follow -Up Instructions CANAAN WEBSTER has been given these follow -up instructions: Follow Up With: Where: When: Julie Hanson Medical Associates; 1000 Within Follow -up as Langworthy needed Dubuque, IA 52001 (563) 584 -3440 phone, fixed, business (1) Comments: -C� Sao,. ollow Up With: Medical Associates Clinic Musculoskeletal Comments: Nurse will call you tomorrow with an appointment to follow up in 3 -4 days. Prescriptions Where: 1500 Associates Dr Dubuque, IA 52002 563.584.4460 phone, fixed, business (1) CANAAN WEBSTER has been given the following prescriptions: No prescriptions were provided. Patient Education Materials CANAAN WEBSTER has been given the following patient education materials: Family Medicine Your child has a break in the bone (fracture) in the tibia. This is the large bone of the lower leg located between the ankle and the knee. These fractures are diagnosed with x -rays. Name: WEBSTER, CANAAN JOSEPH MRN: (DB)- 000180358 Tibial Fracture (Child) When: Within Follow -up as needed 6 of 9 03/30/2010 21:58:29 Fibula Tibial Fracture Metatarsals Tibia In children, when this bone is broken and there is no break in the skin over the fracture, and the bone remains in good position, it can be treated conservatively. This means that the bone can be treated with a long leg cast or splint and would not require an operation unless a later problem developed. Often times the only sign of this fracture is that the child may simply stop walking and stop playing normally, or have tenderness and swelling over the area of fracture. DIAGNOSIS This fracture can be diagnosed with simple X -rays. Sometimes in toddlers and infants an X -ray may not show the fracture. When this happens, x -rays will be repeated in a few days to weeks while immobilizing your child's leg. TREATMENT In younger children treatment is a long leg cast. Older children may be treated with a short leg cast, if they can use crutches to get around. The cast will be on about four to six weeks. This time may vary depending on the fracture type and location. HOME CARE INSTRUCTIONS • Immediately after casting the leg may be raised. An ice pack placed over the area of the fracture several times a day for the first day or two may give some relief. • Your child may get around as they are able. Often children, after a few days of having a cast on, act as if nothing has ever happened. Children are remarkably adaptable. • If your child has a plaster or fiberglass cast: • Keep them from scratching the skin under the cast using sharp or pointed objects. • Check the skin around the cast every day. You may put lotion on any red or sore areas. • Keep their cast dry and clean. If they have a plaster splint: • Wear the splint as directed. • You may loosen the elastic around the splint if their toes become numb, tingle, or turn cold. • Do not allow pressure on any part of their cast or splint until it is fully hardened. • Their cast or splint can be protected during bathing with a plastic bag. Do not lower the cast or Name: WEBSTER, CANAAN JOSEPH 7 of 9 03/30/2010 21:58:29 MRN: (DB)- 000180358 splint into water. • Notify your caregiver immediately if you should notice odors coming from beneath the cast, or a discharge develops beneath the cast and is seeping through to soil the cast. • Give medications as directed by their caregiver. Only take over -the- counter or prescription medicines for pain, discomfort, or fever as directed by your caregiver. • Keep all follow up appointments as directed in order to avoid any long -term problems with your child's leg and ankle including chronic pain, inability to move the ankle normally, and permanent disability. EEK IMMEDIATE MEDICAL CARE IF: Pain is becoming worse rather than better, or if pain is uncontrolled with medications. There is increased swelling, pain, or redness in the foot. Your child begins to lose feeling in the foot or toes. Your child develops a cold or blue foot or toes on the injured side. Your child develops severe pain in the injured leg. Especially if there is pain when they move their toes. ument Released: 09/12/2002 Document Re- Released: 06/05/2009 xitCare® Patient Information ©2009 ExitCare, LLC. You have been prescribed crutches to take weight off one of your lower extremities (legs /feet). / /t2 2r3, • Use of Crutches When using crutches, make sure you are not bearing your weight beneath your arms. This could cause damage to the nerves in the axilla (your armpit area) that extend to your hands and arms. When fitted properly the crutches should be two to three finger breadths below your axilla (armpit). Your weight should be supported by your holding of the crutches, and not by resting upon the crutches with your armpits. When walking, first step with the crutches and the injured leg, then swing the healthy leg through and slightly ahead. When going up stairs, first step up with the healthy leg and then follow with the crutches and injured Name: WEBSTER, CANAAN JOSEPH 8 of 9 03/30/2010 21:58:29 MRN: (DB)- 000180358 leg up to the same step, and so forth. When going down stairs, first step with the injured leg and crutches, following down with the healthy leg to the same step. To get up from a chair, hold injured leg forward, grab armrest with one hand and the top of the crutches with the other hand. Using these supports, pull yourself up to a standing position. Reverse this procedure for sitting. See your personal caregiver for follow up as suggested. If you are discharged in an ace wrap and develop numbness, tingling, swelling, or increased pain, loosen the ace and re -wrap looser. If these problems persist, see your caregiver as needed. If you have been instructed to use partial weight bearing, bear (apply) the amount of weight as suggested by your caregiver. Do not bear weight in an amount that causes pain on the area of injury. Document Released: 12/15/2001 Document Re- Released: 06/11/2007 ExitCare® Patient Information ©2009 ExitCare, LLC. Name: WEBSTER, CANAAN JOSEPH 9 of 9 03/30/2010 21:58:29 MRN: (DB)- 000180358