ACMH RN/CRNA: Unsafe Staffing Form
NOTE: Supervisor must be informed as soon as inadequate staffing situation is known.
Date *
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Unit *
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Supervisor Notified: *
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Staffing grid for unit per union contract:
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Number of trained RNs on shift at the time of dispute:
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Were there any cancellations during the shift?
Patient census at start of shift:
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Patient census at time of dispute:
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Did management include pending admissions in the unit grid?
Were discharges counted in the census number?
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Reason for short staffing (describe assignment and acuity):
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Which of the following steps did Management take to rectify the unsafe staffing?
We, the undersigned nurses, support the above documentation. As a result of the above inadequate staffing, our patients did not get the best care possible.
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