PASNAP Documentation of Inadequate Staffing Situation

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PASNAP Documentation of Inadequate Staffing Situation - Temple Jeanes Hospital

NOTE: Supervisor MUST be informed as soon as inadequate staffing situation is known. By filling out and signing this form, you understand that the form and the information it contains may be shared with management in order to address the situation.

Date: *

YYYY

Unit: *

Name of Supervisor Notified: *

Incident Report Number, If Filed:

Reason for Short Staffing:

Unit Specialty:

Unit Capacity:

Patient Census on Shift Start:

Patient Census At Time of Dispute:

Describe Assignment and Acuity:

Outcomes of Inadequate Staffing

Medications/treatments delayed or not given

Patients not receiving necessary emotional support

Delays in responding to patient calls

Patients not receiving education

Lack of relief for break/lunch

Not able to complete work in a timely manner

Other:

Number of Staff at Time of Objection (RNs)

Number of Staff at Time of Objection (LPNs)

Number of Staff at Time of Objection (Ancillary)

Number of Staff at Time of Objection (Techs/Professionals)

Number of Staff Requested to Provide Proper Coverage

Signatures

We, the undersigned nurses and/or professionals, support the above documentation. As a result of this inadequate staffing, our patient(s) did not get the best care possible.

Signatory 1

Signatory 1 - Email Address

Signatory 2

Signatory 2 - Email Address

Signatory 3

Signatory 3 - Email Address

Signatory 4

Signatory 4 - Email Address

Signatory 5

Signatory 5 - Email Address

Signatory 6

Signatory 7

Signatory 8

Signatory 8 - Email Address

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