May 3, 2024 Freshy Support Test Post ADO (1) ADO Select your Employer* Akron General Medical Center Alliance Community Hospital Ashtabula County Medical Center City of Cleveland Division of Health Coshocton Regional Medical Center Cuyahoga County Health Department Defiance Regional Medical Center East Liverpool City Hospital Geneva Medical Center Hillside Rehabilitation Center Hoxworth Blood Center Lima Memorial Hospital Mary Rutan Hospital Mercy Allen Medical Center Ohio State University Hospitals OSU Bone Marrow Transplant Coordinators OSU Transplant Nurses Salem Regional Medical Center St. Vincent Charity Medical Center Summit County Health Department Toledo-Lucas County Health Department Trinity East Medical Center Union Hospital University of Cincinnati Medical Center Visiting Nurses Association ADO/Grievance FormFor OSUNO Members: This form serves as an ONA/OSUNO Combined Grievance and Assignment Despite Objection submission. It may be used to document an assignment which is potentially unsafe for the patients or staff and serves as a grievance filed over staffing. Your InformationName* First Middle Initial Last Phone #*Personal Email* Enter Email Confirm Email Manager's Email:* Enter Email Confirm Email A copy of this form will be sent directly to your manager at the email address provided.Additional Manager's Email: Enter Email Confirm Email A copy of this form will be sent directly to your manager at the email address provided.Incident InformationIn my professional opinion, the situation described here is not adequate to meet the needs of the patients assigned to me at this time. Please be aware that while I will do all that I can to ensure safe and proper care for my patients, I fear that my efforts and those of the staff may not be sufficient. Therefore, I am informing you that I am concerned about the possibility of any errors or incidents that may take place as a result of this unsafe condition created by inadequate staffing, systems / equipment failures. The Nurse Practice Act states that nurses shall promote a safe environment for each patient and implement orders in a timely manner. As a patient advocate, in accordance with the Nurse Practice Act, this is to confirm that I notified you that, in my professional judgment, I may be unable to fulfill one or more provision of the Nurse Practice Act because this assignment is unsafe and places the patients or staff at risk. I indicate my acceptance of the assignment under protest. It is not my intention to refuse to accept the assignment and thus raise questions of meeting my obligations to the patient or of my refusal to obey an order, which were given; however, I hereby give notice to my employer of the facts below and indicate that for the reasons listed, full responsibility for the consequences of this assignment must rest with the employer. Copies of this form may be provided to any and all appropriate State and Federal agencies.I hereby object to the assignment as made to me by:* Please list the supervisor/person in charge. (i.e. (Manager, Assistant Manager, or Nursing Supervisor)Was the supervisor notified of the objection prior to filing this ADO?* Yes No When did the incident occur?* Month Day Year What time did the incident occur?* : Hours Minutes Shift: Unit: Number of Patients at Start:Admissions/Transfers:Discharges:Number of Patients at End:Unit Capacity:Number of Nurses:Number of PCAs:Number of Patients:Was there a Clerk/Secretary? Yes No Did the Charge Nurse have patients? Yes No Was the Charge Nurse notified of staffing needs? Yes No Did the units in division call for resources? Yes No My Objections to this assignment are:*Staffing / AssignmentEquipmentPPE / SafetySystem FailureWorkplace ViolenceMissed BreaksEarned Time DeniedStaffing Objections (select all that apply) The unit staffing plan is inadequate The unit is not staffed according to the staffing plan The unit's staffing violates contract language Shift adjustments are inadequate. Short staffed for census Short staffed for acuity/complexity Not trained/experienced in area assigned Not oriented to this unit/case load Floating to multiple units during shift Necessary equipment not available Not trained/experienced to use equipment Transferred/admitted new patient(s) to unit without adequate staff Charge nurse unable to perform charge nurse duties Inadequate nurse to patient ratios Not provided with adequate ancillary staff Forced/mandatory overtime System failure Missed Breaks/Lunch Other (please explain later in the form) Equipment (check all that apply): Unavailable Substandard Need specialized equipment Not trained or experienced in area assigned or to equipment Other (describe later in the form) PPE & Safety Concerns (check all that apply): Unsafe nurse to patient ratio contributes to unsafe patient care and spread of disease Denied available PPE Lack of N95 respirators Not fit-tested Not given same size/model for which originally fitted Lack of impenetrable gowns Lack of masks Lack of face shield/eye protection Lack of gloves Lack of booties Lack of PAPRs Lack of ventilators Lack of disinfectant supplies Inadequate number of negative pressure rooms Infectious patient(s) not properly isolated Visitor policy not enforced RN given assignment who is immunocompromised, pregnant, breastfeeding or 65 and older Told not to use self-provided PPE Failure to test patients meeting signs and symptoms Other (explain later in form) System Failure (check all that apply): Computers Medication dispensing machine Medication bar coder Call system Other (describe later in form) Workplace ViolenceDate MM slash DD slash YYYY Time : Hours Minutes Patient of Visitor? Patient Visitor Was medical treatment required? Yes No Was management notified? Yes No Was a police report filed? Yes No Was there follow-up from management? Yes No Missed breaks (check all that apply) Meal break One rest break Two rest breaks Three or more rest breaks Earned Time Denied: Vacation PTO Sick Extended Illness Education Leave Additional InformationPlease provide additional information while maintaining HIPAA standards.ADO/Grievance FormFor OSUNO Members: This form serves as an ONA/OSUNO Combined Grievance and Assignment Despite Objection submission. It may be used to document an assignment which is potentially unsafe for the patients or staff and serves as a grievance filed over staffing.EmailThis field is for validation purposes and should be left unchanged. Δ