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 KSMC or KWMC. This form is not HIPAA approved. Please do not submit PHI.
Date of Incident
My assignment was unsafe because:
Not staffed to RN Matrix
Not staffed to support staff matrix/shorted ancillary staff CNA, Tech, RT, Rehab, etc
Not staffed to patient acuity
Charge forced to take an assignment beyond two hours
Equipment and resource issues
Manager performed work usually done by a staff member
Not oriented to unit
Did you ask for additional staff?
Yes, support staff (CNA, Transport/Mobility, RT, Rehab, etc)
No, I did not ask.
Did you receive requested staff?
Did your concerns lead to a violation of your right to uninterrupted rest or meal breaks?
Did you work overtime?
Yes, I volunteered.
Yes, I was mandated.
No, I did not.
Did this incident explicitly violate your approved hospital staffing plan?
Unsure / My department isn't covered by the hospital staffing plan
Type narrative here
Kaiser Westside Medical Center
Kaiser Sunnyside Medical Center
KWMC Critical Care
KWMC Respiratory Therapy
KWMC Surgical Services
KSMC Critical Care
KSMC Surgical Services
KSMC Care Management
Should be Empty: