Common use of PATIENT CARE FACTORS CONTRIBUTING TO THE OCCURRENCE Clause in Contracts

PATIENT CARE FACTORS CONTRIBUTING TO THE OCCURRENCE. Please check off the factor(s) you believe contributed to the workload issue and provide details: Change in patient acuity. Normal number of beds on unit Beds closed Beds opened during tour Patient census at time of occurrence # of Admissions # of Discharges # of Transfers Lack of/or equipment/malfunctioning equipment. Please specify: Visitors/Family Members. Please specify: Number of patients on infectious precautions Over Capacity Protocol. Please specify: Resources/Supplies Interdepartmental Challenges System Issues Exceptional Patient Factors (i.e. significant time and attention required to meet patient expectations). Please specify:

PATIENT CARE FACTORS CONTRIBUTING TO THE OCCURRENCE. Please check off the factor(s) you believe contributed to the workload issue and provide details: Change in patient acuity. Normal number of beds on unit Beds closed Beds opened during tour Patient census at time of occurrence # of Admissions # of Discharges # of Transfers Lack of/or equipment/malfunctioning equipment. Please specify: Hospital Central Agreement – March 31, 2018 88 Visitors/Family Members. Please specify: Number of patients on infectious precautions Over Capacity Protocol. Please specify: Resources/Supplies Interdepartmental Challenges System Issues Exceptional Patient Factors (i.e. significant time and attention required to meet patient expectations). Please specify:

PATIENT CARE FACTORS CONTRIBUTING TO THE OCCURRENCE. Please check off the factor(s) you believe contributed to the workload issue and provide details: Change in patient acuity. Normal number of beds on unit Beds closed Beds opened during tour Patient census at time of occurrence # of Admissions # of Discharges # of Transfers Lack of/or equipment/malfunctioning equipment. Please specify: Hospital Central Agreement – March 31, 2 020 85 Visitors/Family Members. Please specify: Number of patients on infectious precautions Over Capacity Protocol. Please specify: Resources/Supplies Interdepartmental Challenges System Issues Exceptional Patient Factors (i.e. significant time and attention required to meet patient expectations). Please specify:

PATIENT CARE FACTORS CONTRIBUTING TO THE OCCURRENCE. Please check off the factor(s) you believe contributed to the workload issue and provide details: Change in patient acuity.   Normal number of beds on unit   Beds closed   Beds opened during tour   Patient census at time of occurrence   # of Admissions   # of Discharges   # of Transfers   Lack of/or equipment/malfunctioning equipment. Please specify:   Visitors/Family Members. Please specify:   Number of patients on infectious precautions   Over Capacity Protocol. Please specify:   Resources/Supplies   Interdepartmental Challenges   System Issues   Exceptional Patient Factors (i.e. significant time and attention required to meet patient expectations). Please specify::   Other: (e.g. Non-nursing duties, student supervision, mentorship, etc.) Please specify:  

PATIENT CARE FACTORS CONTRIBUTING TO THE OCCURRENCE. Please check off the factor(s) you believe contributed to the workload issue and provide details: Change in patient acuity. Normal number of beds on unit Beds closed Beds opened during tour Patient census at time of occurrence # of Admissions # of Discharges # of Transfers Lack of/or equipment/malfunctioning equipment. Please specify: Hospital Central Agreement – March 31, 201 86 Visitors/Family Members. Please specify: Number of patients on infectious precautions Over Capacity Protocol. Please specify: Resources/Supplies Interdepartmental Challenges System Issues Exceptional Patient Factors (i.e. significant time and attention required to meet patient expectations). Please specify:

PATIENT CARE FACTORS CONTRIBUTING TO THE OCCURRENCE. Please check off the factor(s) you believe contributed to the workload issue and provide details: Change in patient acuity. Normal number of beds on unit Beds closed Beds opened during tour Patient census at time of occurrence # of Admissions # of Discharges # of Transfers Lack of/or equipment/malfunctioning equipment. Please specify: 88 Visitors/Family Members. Please specify: Number of patients on infectious precautions Over Capacity Protocol. Please specify: Resources/Supplies Interdepartmental Challenges System Issues Exceptional Patient Factors (i.e. significant time and attention required to meet patient expectations). Please specify: