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Workplace Situation Reports
Nursing Home Work Situation Report 2025
"
*
" indicates required fields
Section 1: General Information
Name(s) of Employee(s):
Employer:
Number of beds:
Date of Occurrence:
MM slash DD slash YYYY
Time:
Hours
:
Minutes
AM
PM
AM/PM
Shift:
7.5 Hours
11.25 Hours
Other
# Regular Staff:
RN
LPN
PCA
Clerk
# Actual Regular Staff:
RN
LPN
PCA
Clerk
Were you the charge nurse?
Yes RN
No
Staff Shortage Due to:
Sick Call
ELOA
Vacancies
Overtime:
Yes
No
How many staff?
Total hours?
Did This Cause You to Miss Your:
Meal Break:
Yes
No
Rest Period/Break:
Yes
No
Name of Director of Nursing reported to:
Section 2: Details of Occurrence
Provide a concise summary of the occurrence and how it impacted resident care:
Was the safety of the resident or nurse compromised or workload not completed?
Yes
No
(e.g. Insulin or heparin was not double checked; patient rounds not done on an hourly basis, other)
How?
Is this an isolated incident?
Yes
No
Ongoing problem?
Yes
No
Section 3: Nurse/Resident/Environment care factors contributing to the occurrence/concern/issue
Please check off the factor(s) you believe contributes to the workload issue and provide details
Change in patient acuity (e.g. falls)
Change in patient acuity
Change in patient acuity
Number of patients on isolation precautions:
Number of patients on infections precaution:
Number of patients on infections precaution:
Number of admissions, deaths and transfer to hospital
Number of admissions, deaths and transfer to hospital
Number of admissions, deaths and transfer to hospital
# of admissions
# of deaths
# of transfers to hospital
Lack of equipment /supplies /resources /malfunctioning equipment
Lack of equipment /supplies /resources /malfunctioning equipment
Lack of equipment /supplies /resources /malfunctioning equipment
Visitors/Family Members
Visitors/Family Members
Home in outbreak situation
Home in outbreak situation
Doctor’s or Nurse Practitioner orders
Doctor’s or Nurse Practitioner orders
Communication/Process Issues
Communication/Process Issues
Exceptional Resident Factors (i.e. significant amount of time to meet resident needs/expectations)
Exceptional Resident Factors
Visitors/Family Members/complaints follow-up.
Non-nursing duties.
Non-nursing duties.
Other:
Section 4: Recommendations
Please check-off one or all of the areas below you believe should be addressed in order to prevent similar situations:
Recommendations
In-service
Orientation
Review RN/resident ratio
Change unit layout
Change Start/Stop times of shift(s)
Develop workload measurement tool
Adjust RN Staffing
Adjust LPN Staffing
Adjust PCA Staffing
Adjust Clerical Support
Casual pool
Review policies and procedures
Replace sick calls, vacation, paid holidays, other absences
Equipment
Equipment
Recommendations - other
Other:
Other:
Section 5: Employee Signatures and Contact Information
Signature:
Phone # / personal email :
Signature:
Phone # / personal email :
Date Submitted:
MM slash DD slash YYYY
Section 6: Management Comments
Please provide any information in response to this report, including any actions taken to remedy the situation where applicable.
Management Signature:
Date
MM slash DD slash YYYY
Section 7: Recommendations of Professional Practice Committee
The Professional Practice Committee recommends the following in order to prevent similar situations:
Is this issue resolved?
Yes
No
Manager Email
*
NBNU Local President Email
*
Member Email
*