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.
Did this assignment jeopardize your health and safety or that of your coworkers?
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:
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.
e.g. BVT or EIN. If not applicable, say n/a
This is now a required field. If you do not know your manager's email address, enter firstname.lastname@example.org
Were you required to work mandatory overtime or over your coded hours?
Did you miss or have to work or drive through any paid rest breaks
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?
Suggest remedy that would improve the situation.
Should be Empty: