SAFE STAFFING FORM
IMPORTANT: You are encouraged to complete this form prior to clocking out and leaving the facility (you will be paid for your time). Complete and submit within 7 days of incident:
1) Keep a copy for yourself
2) Email a copy of the completed form to your manager/supervisor.
3) Fax a copy to HNA at (808) 524-2760 or Email a copy to HNAFrontOffice@hinurse.org
Prior to filling out a Safety Concern Form, follow the chain of command (as applicable): Charge Nurse, House Supervisor, Supervisor, Manager
As a patient advocate, this form confirms my notification to you that, in my professional judgment, today's assignment is unsafe and places my patients at risk. As a result, I will under protest carry out the assignment to the best of my ability.
I,
RN, protest my assignment on
(shift)
Bargaining Unit
*
Please Select
Kap RN
Kap RT
Kap CA
Kap UC
Kap Techs
on grounds that (check all that apply)
I was not trained or experienced in the area assigned.
I am not experienced in providing care for the type of patient(s) in my assignment.
The unit was staffed with unqualified personnel.
I was floated in the area that I am not trained in.
I was not trained on equipment used to care for patient, specify:
Equipment and/or supplies were inadequate for patient care.
I was not given adequate staff for patient acuity.
I believe the number of staff provided is/was not adequate.
Skill mix issues; specify: (e.g. large proportion of less experienced or float staff)
Lack of staff on shift of objection:
Lack of Staff on shift of ocjection:
Please Select
RNs
RTs
CAs
UCs
Techs
New patients were transferred or admitted to unit without adequate or qualified staff.
Mandatory Overtime: There was no volunteers and I was told I was required to stay overtime.
Voluntary Overtime: I volunteered to stay overtime.
Work flow/assignments are different from past practice.
Case load assignment is excessive and interferes with delivery of adequate patient care.
I missed lunch and breaks due to case load assignment: specify:
Acuity system does not reflect patient need/acuity accurately.
I was not able to take a pump break (maternity need).
Staffing Matrix not followed.
Unit:
Matrix at time of unsafe staffing:
Other:
Notified whom (name):
Position (circle one): Charge Nurse / House Supervisor / Manager / Clinical Supervisor
Date
-
Month
-
Day
Year
Date
Time reported
Hour Minutes
AM
PM
AM/PM Option
The safe staffing form is (to be filled out by Nurse):
Resolved
and this form will serve as a written response. Action taken:
House Supervisor/Supervisor/Manager
RN (s) filling out Form
Unresolved.
HNA will receive an additional follow up in writing from the appropriate unit manager within seven (7) working days.
Suggestions to improve/prevent this situation from occurring in the future (May write on back of form):
Employees who raise staffing issues and/or initiate a staffing concern shall be free from any reprisal or retaliation. If there is more than one person filling out form for the same situation and not resolved, please provide a contact person to assist with answering questions if needed from both the Union and Management.
Contact:
Phone #:
Format: (000) 000-0000.
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