LABOR MANAGEMENT COMMITTEE
To collaborate on issues affecting professional nurses
Documentation of Concern for Safe Staffing for Patient Care
The purpose of this form is to document a staffing concern, the action taken by each nurse to remedy the staffing problem, and the response of the supervisor. It is a tool to communicate, and to avoid similar situations in the future.
Bargaining Unit
Please Select
QMC RN (Manamana, West)
QMC Transporter (CTS) and Mail Room
QMC (Case Managers) (CM, UM/CR, PTC, CDI)
QMC Wound Clinic
QMC Radiation Therapy Techs
QMC Kahi Mohala
QMC Wahiawa
Date of Incident
-
Month
-
Day
Year
Date
Shift
(Please complete at time of concern)
I have notified, at the time of the incident (name)
(management position)
that in my professional opinion, I am unable to assure the delivery of safe or adequate nursing care because following conditions. (check all that apply)
Orientation/Experience
Not trained on using equipment used to care for patient:
Other
Not oriented to the unit
Other
Not experienced in providing care for the type of patients on unit.
Patient Acuity
Unplanned Events
Other
Case load assignment is excessive/acuity and interferences with delivery of adequate patient care
Number of patients assigned
Acuity (check one)
high
medium
low
I believe the number of staff provide is/was not adequate.
Other
Acuity system does not reflect patient need/acuity accurately.
Other
Lack of ancillary staff
Lack of ancillary staff (check all that apply)
housekeeping
pharmacy
clerical
nurse aide
maintenenance
Poor skill mix of staff
Other
Transferred, discharged, admitted new patient(s) to unit without adequate staff
# of Admits
# of Discharges
# of Transfers
Missed breaks
Missed meal
Late meal
Time:
Hour Minutes
AM
PM
AM/PM Option
Other: (Situation, Background, Assessment, Recommendation)
Situation:
Background
Assessment:
Recommendation:
I indicate my acceptance of the assignment despite objection. I will, despite objection attempt out to carry out the assignment to the best of my professional ability. However, I hereby give notice to my employer to the above facts.
Name (please print):
Signature Field
Date & Time:
-
Month
-
Day
Year
Date
Submit completed form to Unit Manager
Send a COPY to HNA or Unit Chairperson and keep a copy for your files.
Approved: LMC 10/17/06
QMCSS 6/20/16 lal
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