on l? 21115 (3011th of Wood 

 

 

 

 

 

DISCIPLINARY ACTION FORM . 
HUMAN 

Name: Rosemary Carlson Department: Crossroads/TBI
Type of Action Taken:
Counseling Verbal Written El Final Written Discharge
Session (Optional) Reprimand Warning Warning

Continued infractions of performance or policy may lead to additional discipline, up to and including, termination of employment.

State subject or code of conduct rule violated.
Medication 

Administering 02 at a liter/minute above what was prescribed without getting a new order

Date of Violation 9/28/16 Number of prior written warnings on file 1

 

Describe in detail information you have available which supports taking the above course of action. List witnesses to incident

if possible. State what action will be taken if problem persists.
Medication orders cannot be changed without a MD order, whether verbal, telephone, or written. This is the 3rd medication error since

hire. Subsequent errors will be subject to discipline up to and including termination.

 

State what corrective action you feel the employee may take to eliminate the above problem area.
Employee will obtain orders before making any medication changes and document orders per protocol.

Employee will be more diligent in ensuring that orders are followed as written, any questions in orders will be brought to the HRN or
MD

 

Employee Comment:

 

Appeal Rights: If you feel this action violates a Wood County or departmental policy or procedure or violates a state or
federal guideline related to your work, you should consult the ?Complaint Resolution Process? policy in the Em gloyee Policy
Handbook, or contact Human Resources. Failure to initiate your complaint in a timely manner may result in your complaint

options being denied.

I have received the above notification and acknowledge that I received
a signed copy. I

Road Qouim Meir 1/ Meow/?)

Emlployee Signature Date Supervisor Sigthui Date

Giro/(Lo

Rev. 03-2013 Belgium, mcut QHeaigSignaturc Date

 

 

If the above pertains to a suspension or discharge, the Department Head must also signf?f