PRINCIPLE RESPONSIBILITIES

• Evaluate client’s needs, review all medication, and involve other disciplines as appropriate. Complete a comprehensive assessment as needed.
• Collaborate with Clinical Manager, RN Supervisor/ Administrator, physician, client, client representative (if any) on an individualized Plan of Care based on client’s current health, psychosocial, functional, cognitive and environmental needs, and make appropriate revisions as the client’s condition changes. Collaborate with Administrator/Clinical Manager/RN Supervisor and the client/client representative (if any), to establish appropriate realistic measurable goals for the client to achieve and evaluate progress toward these goals.
• Provide services requiring professional nursing skill, including administration of oral, IM, IV, and rectal medication, in acceptance with standard nursing practice and performance of nursing duties/procedure deemed competent on the documented competency form including but not limited to catheter insertion and care, ostomy care, tube feeding, wound care, staple removal, and PICC line care. Nurses should not administer drugs with which they are unfamiliar.
• Initiate appropriate nursing procedures.
• Observe and report signs, symptoms and progress of client to Administrator/Clinical Manager and physician.
• Coordinate services, informing the physician, client representative (if any), and other inter-disciplinary team members of changes in the client’s condition and needs.
• Instruct/counsel client, client’s representative (if any), and family in meeting client’s needs, promoting self-care and independence, including safe and effective use of medications and observation of side effects.
• Keep current and adequate records showing assessment of current status, the client's response to treatment, teaching and training, and the treatments provided. Abides by the Agency’s Documentation of Services policy.
• The nurse may accept verbal and telephone orders from the physician involving any changes in original treatment plan, but they must be sent to the Administrator/Clinical Manager for physician signature or may be obtained during a doctor’s visit.
• Participate in client Care Conferences, In-service Education, and Public Education as required and teaches other nursing personnel.
• Consult with specialists for client care problems.
• Assists with orientation of new nurses to their client to assist in evaluating their nursing competencies.
• Responsible for participating in QAPI activities.
• Responsible for monitoring for and reporting any suspected abuse to the supervisor immediately.