Home > RATIOS AND PATIENT CARE ISSUES FORM

RATIOS AND PATIENT CARE ISSUES FORM

Section I

 Primary Nurse Charge Nurse Relief Charge

As a patient advocate, in accordance with the California Nursing Practice Act, this is to confirm that I notified you, in my professional
judgment, today’s assignment is unsafe and places my patients at risk. As a result, the facility is responsible for any adverse effects
on patient care. I will, carry out the assignment to the best of my ability.

Section IIa See Title 22 Regulations
 i am objecting to the aforementioned assignment on the grounds that: i was given an assignment where i did not receive or complete orientation to the unit/clinical area( Title 22 sec 70213,70214,70217) validation of current demonstrated competency(Title 22 sec 70213,7021670217)
 I was given an assignment which posted a threat to the health and safety to my patients( examples in Section V )
 Staffing/Skill mix is/was insufficient to : Meet the individual patient care needs/requirements of my patients due to failure to provide additional staff based on acuity ( Title 22 section 70217 ) Perform effective assessments of patients assigned to me( Title 22 section 70215,70217 ) Meet the teaching /discharge needs identified by the patient's condition(Title 22 section 70215) Provide breaks by a direct care RN to prevent fatigue, accident, and/or errors ( Title 22 sec 70217 )
 This unit is staffed with unqualified : Licensed Competent Unlicensed Certified Staff Nursing personnel whose competency was not validated ( Title 22 section 70213, 70016.1 & 70217 )
 Direct patient care duties did not allow time for charge nurse duties-clinical supervision/coordination of care
 Hospital non-compliance with required ratios: 1:1 1:2 1:3 1:4 1:5 1:6 other ( Title 22 section 70217 )
 New patients were transfered/ admitted to unit without adequate staff to stay in compliance with the ratios (Title 22 sec 70717)
 Patient(s) on the unit require a higher level of care then can be provided( Title 22 sec 70217 )
 I was forced to work beyond my scheduled hours of FTE status (Example: Mandatory on Call/Standby)
 Other: Explain in Section V
Section IIb Working Conditions:

 Yes No
 Yes No
 Yes No
Section III Type of Unit:

 ICU/CCU NICU MED/Surg L&D MIU ER OR MHU ARU PACU IR Peds
 Low Medium High Extreme
Section IV Patient Care Staffing Count:

 Yes No
 Yes No
Section V Brief Problem Statement: If more space needed attach additional page.

Section VI Leadership Response

A leadership team member will respond to you via email.

To send this form please specify the person below by clicking their email, otherwise click the submit button and it will be sent to our general administrative inbox.

Choose Han on Duty or Reported to:

 

You need to log in to vote

The blog owner requires users to be logged in to be able to vote for this post.

Alternatively, if you do not have an account yet you can create one here.