HPAE LOCAL 5131 UNSAFE STAFFING SITUATION

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Notice to Supervisor: Please be advised that despite an unsafe staffing situation I attempted to carry out my responsibilities and provided patient care to the best of my ability.

NAME OF SUPERVISOR YOU INFORMED/RESPONSE: First Name:   Last Name:


Division:   Department:  

 Date:  Shift:

Email Address:

Name of Staff filing (may be more than one person):  

What is the ratio of patients to nurses?:   What should it be? 

Situation (Please check)

  Equipment Shortage/Failure      Transport Delay                          Non-Nursing duties

Inadequate Staffing/Acuity        Loss of Staff due to 1:1               Inadequate supplies              

Delay in supervisor response       Delay/missed meds of patients    Staff Missed 15 min break or 30 min meal break  

other:              

Potential/Actual impact on care (Please check)

Delay in assessment                 Delay in ambulation/turning patient         Delay in cleaning incontinent patient               

Delay in feeding patient/medicating patient            Patient Fell                Delay in Scheduled Procedure  

Other:                

         

  


 

Health Professionals and Allied Employees (856) 663-0300, ext. 313, Fax (856) 663-0440