ACMH RN/CRNA: Unsafe Staffing Form
NOTE: Supervisor must be informed as soon as inadequate staffing situation is known.
Staffing grid for unit per union contract:
Number of trained RNs on shift at the time of dispute:
Were there any cancellations during the shift?
Patient census at start of shift:
Patient census at time of dispute:
Did management include pending admissions in the unit grid?
Were discharges counted in the census number?
Reason for short staffing (describe assignment and acuity):
Which of the following steps did Management take to rectify the unsafe staffing?
Utilize pool floats
Utilize casual staff
Offer financial & other incentives
Utilize agency or traveling RNs
Charge nurse takes an assignment
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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