PFNHP Inpatient CFSS / ADO Form

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.
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)