CSRU Hospital Clinical Staffing Complaint Form

Hospital Clinical Staffing Complaint FormComplaint Section

Have you filed a complaint about this issue with the hospital’s Clinical Staffing Committee?

Yes

If NO, you should first file a complaint with the hospital’s Clinical Staffing Committee prior to submitting this form. If you are unable to file a complaint with the hospital’s Clinical Staffing Committee, please select the description that most correctly explains why you are unable to do so.

I do not know what a Clinical Staffing Committee is.

My facility does not have a Clinical Staffing Committee.

My facility’s Clinical Staffing Committee does not have a process to allow for complaint submission.

My facility’s Clinical Staffing Committee has refused to review my complaint.

Other (please specify):

If YES, answer all questions in this section to the best of your ability.

Date on which the complaint was filed with the hospital’s Clinical Staffing Committee:

Please provide the hospital complaint reference number associated with this complaint (if available):

Has the hospital’s Clinical Staffing Committee completed a review of this complaint?

Yes

Unknown

If YES, what were the results of their review?

The hospital’s Clinical Staffing Committee created a specific action plan to address the issues raised in the complaint.

The hospital’s Clinical Staffing Committee did not make any changes based on the complaint I filed.

I did not receive a response from the Clinical Staffing Committee.

Other (please specify):

Is this the first complaint you’ve filed with the hospital’s Clinical Staffing Committee regarding this specific incident?

Yes

If NO or Unknown, including this complaint, how many complaints have you filed with the hospital’s Clinical Staffing Committee regarding this specific incident?

Contact Information

Providing information about you will allow Department staff to contact you should additional information be needed to complete a review. Please select the method of communication you prefer the Department use for all future correspondence related to this complaint:

Direct contact using the information you provide below.

Communication with the Clinical Staffing Committee designee as submitted by the hospital, only.

No contact. Complete anonymity is requested.

It may be necessary to share the nature of your complaint with the facility in order to investigate. It is the Department’s policy to keep your name confidential. Please do not attach any additional information such as medical records, as it will not affect the outcome of the decision.

Contact Information

First Name

Last Name

Email Address

Daytime Phone

Street Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Please choose the option that best describes you:

Hospital Employee

Union representative

Member of the public

Other (please specify):

Hospital Employee

Union representative

Member of the public

Facility Information

Facility Contact Info

Facility Name

Facility Address

Type of Clinical Unit:

Choose an item.

Name of Clinical Unit:

Incident Information

Incident Information
	Date of Incident Specify shift(s) impacted Patient census at time of incident Number of Registered Nurses at time of incident Number of Licensed Practical Nurses at time of incident Type of Ancillary Staff at time of incident Please list all ancillary staff at the time of the incident Number of Ancillary Staff at the time of the incident Please enter total number of ancillary staff at the time of the incident	Item weight

Additional InformationIf able to, please answer the additional information below:

There was a Clinical Staffing Plan posted in the hospital for that shift on that unit.

Yes

Unknown

The ratio of Registered Nurses to patients is lower than in the Clinical Staffing Plan posted in the hospital for that shift on that unit.

Yes

Unknown

Not Applicable

The ratio of Licensed Practical Nurses to patients is lower than in the Clinical Staffing Plan posted in the hospital for that shift on that unit.

Yes

Unknown

Not Applicable

The ratio of Registered Nurses to patients is lower than provided in the hospital’s Clinical Staffing Plan posted on the Department’s website.

Yes

Unknown

Not Applicable

The ratio of Licensed Practical Nurses to patients is lower than provided in the hospital’s Clinical Staffing Plan posted on the Department’s website.

Yes

Unknown

Not Applicable

The ratio of ancillary support staff to patients is lower than in the Clinical Staffing Plan posted in the hospital.

Yes

Unknown

Not Applicable

If yes, provide the titles of the ancillary support staff that were not staffed in accordance with the Clinical Staffing Plan.

Staff that were absent or scheduled off were replaced in accordance with the facility’s adopted Clinical Staffing Plan.

Yes

Unknown

Not Applicable

Staff missed meals and/or breaks due to insufficient staffing to provide coverage.

Yes

Unknown

Not Applicable

If the concerns identified above impacted care provided to a patient, please submit a quality of care complaint to: https://apps.health.ny.gov/surveyd8/email-hospdtc

Please provide any additional information about your complaint that you think would be helpful to share. Please include any additional descriptions of the items above, including but not limited to information pertaining to complaint submission(s) to the Clinical Staffing Committee & timeline of correspondence, date(s) of incident, and relevant staffing guidelines, or any other information that you feel could provide additional context:

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