Registered Nurse - Days

Description

Position Summary

The Registered Nurse (RN) interacts with the clients and team members throughout their shift, assisting direct care staff in meeting client’s functional needs. The RN collaborates with team members to ensure a safe and therapeutic environment is maintained within the treatment facilities. Position performs various tasks related to the provision of medical care to include taking physician orders, preparing, and administering medications, assessing and document client’s health and mental status, and coordinating health/medical services in accordance with physician orders.

Relationships and Contacts

Within the organization:   Maintains frequent and close working relationships with facility leadership, Director of Nursing, Medical Director, and Medical team including Nurse Practitioners and Physicians Assistants, Clinical Director, direct care team members, and quality/compliance team members.

Outside the organization: May initiate and maintain working relationships with clients, third party providers, pharmacies/suppliers, labs, and vendors, as needed.

Position Responsibilities

Essential Responsibilities

1. Provides a comprehensive nursing assessment identifying client’s medical needs, capabilities, and limitations.
2. Records and transcribes physicians written and verbal orders, conducting or delegating STAT orders immediately.
3. Communicates observations and recommendations for clients’ plan of care, providing input into the treatment team process.
4. Identifies abnormal diagnostic data and brings to the attending physician’s attention.
5. Documents the administration of medication (including PRN) in according to established policies and procedures.
6. Coordinates all pharmacy and laboratory orders, delivery, and refills with the appropriate vendors.
7. Maintains responsibility for the security of all controlled medications kept in the facility and monitors the administration and accurate recording of use.
8. Administers medications/injections according to physician orders and medication administration record.
9. Takes blood, urine and other laboratory samples as ordered by the medical providers.
10. Performs accuchecks, urine drug tests and breathalyzers on clients when needed.
11. Provides, structures, and maintains a therapeutic environment in collaboration with other staff.
12. Documents observations in nursing assessment and daily notes in electronic charting system, Sunwave, in accordance with facility policy in a timely manner, reflecting plan of care outlined in the Master Treatment Plan.
13. Documents ongoing assessment of resident behaviors and feelings as expressed and are addressed appropriately within the program or with referral partner.
14. Prepares clients for discharge through individualized counseling and instruction prior to discharge in a clear and concise manner; providing written instructions if needed.
15. Provides education to clients and families about medications, side effects, contraindications, and physical symptoms through individual counseling and group counseling.
16. Provides review of clinical records for accuracy and quality documentation.
17. Assists in the coordination of admissions, transfers, and discharges to provide a smooth and efficient flow of communication.
18. Coordinates facility infection control program ensuring staff and clients meet policy and procedure requirements.

Additional Responsibilities

1. Functions within the guidelines of the facility’s Code of Ethics and in accordance with corporate compliance.
2. Conducts chart audits following program policy timelines, as requested.
3. Consistently arrives to work on time, rarely missing shifts, and promptly notifies supervisor when absent.
4. Demonstrates an ability to adapt to changes in the facility function, management styles, and facility routines.
5. Reads, understands, adheres to, and models all company policy statements on ethics, conduct, and conflict of interests.
6. Adheres to facility policies, procedures, rules, and regulations, implementing regularly.
7. Maintains positive attitude and acts as a team player with others on the treatment team.
8. Attends and completes all training within assigned time frames as required by the facility.
9. Performs other duties as assigned.

Qualifications

Minimum Requirements

Education and Experience

Must be a graduate of an accredited nursing school and hold a current RN license within the state of Virginia. Previous experience in a behavioral healthcare setting strongly preferred.  

Physical Requirements

• While performing the duties of this job, the employee will be required to communicate with peers, clients and/or vendors.
• Job performance will require the ability to move throughout the building as well as participate in activities outdoors and off facility grounds.
• Performs duties that require the employee to stand and walk for extended periods of time.
• May sit or remain stationary for periods of time.
• While performing the duties of this job, the employee may be required to talk or hear, sit, stand, walk, reach, climb or balance, stoop, kneel, crouch or crawl, taste, or smell.
• Ability to move twenty-five pounds.

Additional Requirements

• Position requires incumbent to have a valid driver’s license and acceptable driving record.
• Clearance of criminal background, TB test, and any other mandatory state/federal requirements.
• Current CPR and First Aid certification

Skill Competencies

• Demonstrates ability to assess suicide/homicide risk and create clinically appropriate interventions.
• Demonstrates an understanding of identifying abuse/neglect in client population.
• Documents timely/thoroughly, follows format, satisfies requirements, and outlines plan of care/therapy issues, assessments, safety issues, and managed in a highly confidential manner.
• Completes comprehensive nursing assessments and aids in the development of a treatment plan.
• Demonstrates the ability to chart vitals, daily assessments, group notes, shift notes, and enters physician orders.
• Demonstrates the ability to perform physical assessments including vital signs and to recognize symptoms and distress of clients in treatment.
• Demonstrates effective verbal/written communication of clinical information during shift hand off.
• Demonstrates the ability to perform an EKG and sends to the appropriate medical team.
• Administers medications; provides education to clients and their families about medications; completes medication orders/refills per physician’s orders. 
• Manages the nursing area including ensuring that medications are secured, and only authorized individuals have access. 
• Demonstrates the ability to properly complete the admission and discharge process.
• Documents assessment of abnormal involuntary movements (AIMS) in clients receiving antipsychotic medications
• Demonstrates proper management of biohazards.
• Demonstrates the ability to perform venipuncture and maintain universal precautions while collecting blood.
• Demonstrates ability to schedule lab pick-up and upload results in chart.
• Demonstrates clinical knowledge of specialized treatment; including established behavioral patterns (including age-related issues), therapeutic treatment methods and dietary/nutritional needs.

Renaissance Healthcare Group dba Pasadena Villa – The Grove provides equal employment opportunities without regard to race, color, creed, ancestry, national origin, ethnicity, sex, gender, sexual orientation, marital status, religion, age, disability, gender identity, genetic information, service in the military, or any other characteristic protected under applicable federal, state, or local law. Equal employment opportunity applies to all terms and conditions of employment. Pasadena Villa – The Grove reserves the rights to modify, interpret, or apply this job description in any way the organization desires. This job description in no way implies that these are the only duties, including essential duties, to be performed by the employee occupying this position. Reasonable accommodations may be made to reasonably accommodate qualified individuals with disabilities. This job description is not an employment contract, implied or otherwise. The employment relationship remains “At-Will.”