RN Registered Nurse

Job Description

Job Description

Position Summary

The Registered Nurse (RN) is responsible for providing professional nursing care to participants enrolled in the Community-Based Adult Services (CBAS) program. The RN performs comprehensive nursing assessments, develops and implements individualized plans of care, coordinates interdisciplinary services, monitors participants' health status, administers treatments and medications, provides education to participants and caregivers, and ensures compliance with all applicable California Title 22 regulations, CBAS standards, Medi-Cal requirements, and organizational policies.

The RN promotes participant independence while maintaining a safe, therapeutic, and person-centered environment.

Essential Duties and Responsibilities

Participant Assessment

• Perform comprehensive nursing assessments upon admission and at least every six (6) months, or more frequently as participant condition warrants.
• Evaluate physical, cognitive, psychosocial, nutritional, and functional status.
• Identify changes in participant condition requiring intervention.
• Complete ongoing health assessments and document findings timely.
• Participate in the interdisciplinary team (IDT) assessment process.

Nursing Care Planning

• Develop individualized nursing care plans based upon assessment findings.
• Update care plans as participant needs change.
• Collaborate with physicians, therapists, social workers, dietitians, pharmacists, and other disciplines.
• Ensure participant goals are measurable, individualized, and person-centered.
• Participate in interdisciplinary care conferences.

Clinical Care

• Administer medications and treatments according to physician orders.
• Monitor medication effectiveness and adverse reactions.
• Perform wound assessments and wound care as ordered.
• Monitor chronic medical conditions including but not limited to:
• • Diabetes
  • Hypertension
  • Congestive Heart Failure
  • COPD
  • Dementia
  • Parkinson's Disease
• Perform blood glucose monitoring.
• Obtain vital signs and other clinical measurements.
• Respond appropriately to participant emergencies.
• Coordinate emergency medical services when indicated.

Care Coordination

• Communicate participant status changes to physicians, families, and interdisciplinary team members.
• Obtain physician orders as necessary.
• Coordinate outside medical appointments and follow-up recommendations.
• Assist participants in accessing community resources.
• Collaborate with case managers and managed care organizations.

Infection Prevention

• Follow infection prevention and control policies consistent with Title 22.
• Monitor participants for communicable diseases.
• Implement standard and transmission-based precautions.
• Ensure proper use of personal protective equipment (PPE).
• Participate in infection surveillance and reporting.
• Educate staff and participants regarding infection prevention practices.

Medication Management

• Administer medications safely following the Five Rights of Medication Administration.
• Monitor medication storage and security.
• Document medication administration accurately.
• Report medication errors according to policy.
• Reconcile medications as needed.

Documentation

Maintain accurate, timely documentation including:

• Nursing assessments
• Care plans
• Progress notes
• Medication administration records (MAR)
• Physician communications
• Incident reports
• Participant education
• Nursing interventions
• Health monitoring records

Documentation shall comply with:

• Title 22 regulations
• CBAS standards
• Medi-Cal requirements
• HIPAA
• Organizational documentation policies

Participant and Family Education

Provide education regarding:

• Disease management
• Medication administration
• Nutrition
• Fall prevention
• Skin integrity
• Infection prevention
• Healthy lifestyle practices
• Chronic disease self-management
• Advance care planning when appropriate

Emergency Preparedness

• Participate in emergency drills.
• Assist in implementing emergency response procedures.
• Respond to participant medical emergencies.
• Maintain current CPR certification.
• Participate in disaster preparedness activities.

Quality Improvement

• Participate in Quality Assurance and Performance Improvement (QAPI) activities.
• Monitor clinical outcomes.
• Assist in policy development.
• Participate in chart audits.
• Identify opportunities for improving participant care.

Regulatory Compliance

Maintain compliance with:

• California Title 22 Community-Based Adult Services regulations
• California Department of Aging (CDA) requirements
• California Department of Health Care Services (DHCS)
• Medi-Cal regulations
• HIPAA
• OSHA
• Infection Prevention Standards
• Adult Protective Services reporting requirements
• Elder Abuse reporting laws
• Organizational policies and procedures

Supervisory Responsibilities

May provide clinical direction and supervision to:

• Licensed Vocational Nurses (LVNs)
• Certified Nursing Assistants (CNAs)
• Medical Assistants
• Home Care Aides
• Nursing students
• Volunteers (as appropriate)

Minimum Qualifications

• Current California Registered Nurse (RN) License in good standing.
• Minimum one (1) year of clinical nursing experience.
• Current CPR/BLS Certification.
• Ability to pass required background clearance.
• Current TB clearance.
• Ability to meet CBAS employment requirements.

Preferred:

• Experience in Adult Day Health Care (ADHC) or CBAS.
• Experience with geriatrics and adults with disabilities.
• Case management experience.
• Wound care experience.
• Diabetes management experience.
• Dementia care experience.

Knowledge, Skills, and Abilities

Knowledge of:

• California Title 22 regulations
• CBAS Program requirements
• Nursing process
• Geriatric nursing
• Chronic disease management
• Infection prevention
• Medication administration
• HIPAA
• Emergency response procedures
• Documentation standards

Ability to:

• Perform comprehensive nursing assessments.
• Develop individualized care plans.
• Prioritize multiple responsibilities.
• Respond appropriately during emergencies.
• Communicate effectively with interdisciplinary teams.
• Maintain accurate clinical documentation.
• Educate participants and caregivers.
• Exercise sound clinical judgment.
• Maintain confidentiality.

Physical Requirements

• Frequent standing, walking, bending, and reaching.
• Ability to lift, transfer, and assist participants (up to 50 pounds with assistance).
• Manual dexterity sufficient for clinical procedures.
• Ability to respond quickly during emergencies.
• Visual and auditory acuity necessary for participant assessments.

Working Conditions

• Community-Based Adult Services (CBAS) Center.
• Frequent interaction with older adults and adults with disabilities.
• Exposure to communicable diseases and bodily fluids.
• Occasional stressful situations involving medical emergencies.
• Requires adherence to universal precautions and infection control practices.

Performance Expectations

The Registered Nurse is expected to:

• Deliver safe, compassionate, participant-centered nursing care.
• Demonstrate professionalism and ethical practice.
• Maintain compliance with Title 22 and CBAS regulations.
• Collaborate effectively with the interdisciplinary team.
• Promote participant dignity, independence, and quality of life.
• Complete documentation accurately and within required timeframes.
• Maintain required licensure and continuing education.
• Support Legacy's mission of providing high-quality, person-centered care in a safe and respectful environment.