PFNHP Inpatient CFSS / ADO Form

To (Supervisor) *

Unit/Department *

Date & Time *

I have notified you that the staffing provided is not adequate to meet the needs of the patients on/in this unit/department at this time. Proper staffing has not been provided. Therefore, I am informing you that I am concerned in regards to any errors or incidents that take place as a result of the staffing level on this unit.

Total # of patients:

Number of RNs:

Number of LPNs:

Number of LNAs:

As a patient advocate, in accordance with the Nurse Practices Act, this is to confirm that I/we notified you that in my/our professional judgment, my/our assignment is unsafe and places my/our patients at risk. I have been mandated to provide care and do not want to abandon my patient. As a result, the facility is responsible for any adverse effects on patient care. NOTIFICATION YOU HAVE GIVEN (You must notify charge nurse and manager/ANC at the time of need or concern)

1. Please indicate the reason(s) for use of this form:

Insufficient Staff Scheduled
Unexpected Call Out
Unexpectedly High Acuity

2. Specific staff deficiency (check all that apply)

Inappropriate number of nursing staff (RN, LPN, LNA)
Inappropriate number of ancillary staff (CPSA, MHT…)
No unit secretary

3. Additional Risk Factors (check all that apply)

Assignment is excessive and poses a threat to the safety and well-being of patients
Patients were transferred, discharged or admitted to unit without adequate staff
Staff members not oriented to unit
Staff members not trained or experienced with equipment and/or procedures

Details of Staffing:

Management's Response:

Please Provide Additional Information Here:

Signature (type your full name) *

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