ASSIGNMENT DESPITE OBJECTION
Report an incident or ongoing concern about workload or staffing that impacts quality of patient care or quality of work life at KP Continuing Care Services. This form is not HIPAA approved. Please do not submit PHI.
INCIDENT INFORMATION
Incident Date
*
-
Month
-
Day
Year
Date
Did this assignment jeopardize your health and safety or that of your coworkers?
*
Yes
No
How was care compromised, whether actually or potentially?
*
Care delay or missed care needs
Care Denial/Patient not seen
Unsafe for patient or staff member
Medical Error/Near Miss
Supervisory visit (PTA-LPN-HHA)
30-day reassessment not done
Delay in Closing Charts
Scheduled visits pushed forward or cut short
The assignment or work/patient was unsafe due to:
*
Insufficient backfill
Case load too big (above agreed upon limits)
Inappropriate staffing for census and case loads
Excessive drive time and mileage
Assignment above productivity expectations
Delays due to care coordination phone calls and other follow-up needs
Describe the situation
*
It is helpful to include context like the number of patients waiting and special acuity. Remember - No PHI.
Employee Name
*
Employee Email
*
example@example.com
Employee Title
*
Program
e.g. BVT or EIN. If not applicable, say n/a
Service Area
Supervisior/Manager Name
*
Supervisior/Manager Email
*
This is now a required field. If you do not know your manager's email address, enter itsmyunion@ofnhp.org
Were you required to work mandatory overtime or over your coded hours?
*
Yes
No
Did you miss or have to work or drive through any paid rest breaks
*
Yes
No
If yes to last question, how many rest breaks did you miss or have to work through?
*
Enter "one", "two", "three" or "four"
Did you have a full-length, uninterrupted meal period?
*
Yes
No
Background
Assessment
Recommendations
Suggest remedy that would improve the situation.
Submit
Should be Empty: