Registered Nurse RN

Aachele Home Care and Hospice, LLC

Home Care Registered Nurse (RN) Job Description

Position Title: Home Care Registered Nurse (RN)

Department: Home Care / Skilled Nursing

Reports To: Administrator / Director of Nursing / Clinical Supervisor

Employment Status: Full-Time, Part-Time, PRN, or Contract, as assigned

Service Area: Client Homes and Other Approved Community Settings

Position Summary

The Home Care Registered Nurse (RN) provides professional, compassionate, and individualized skilled nursing services to clients in their homes. The RN is responsible for assessing client needs, developing and implementing the nursing plan of care, providing ordered treatments, monitoring changes in condition, educating clients and caregivers, coordinating services with physicians and other members of the healthcare team, and completing timely and accurate clinical documentation.

The RN is expected to provide care in accordance with the client's physician/provider orders, agency policies and procedures, applicable professional standards, and federal and Georgia requirements applicable to the services being provided.

Essential Duties and Responsibilities

Skilled Nursing Care

• Perform comprehensive and focused nursing assessments.
• Complete initial/admission nursing assessments when assigned.
• Obtain and document vital signs and other appropriate clinical measurements.
• Assess pain, mobility, nutrition, hydration, skin integrity, safety, medication use, and functional status as appropriate.
• Provide skilled nursing interventions according to physician/provider orders and the established plan of care.
• Monitor the client's response to treatment and identify changes in condition.
• Provide medication education and medication reconciliation as appropriate.
• Provide disease-process education and self-management teaching.
• Perform wound assessments and wound care according to provider orders.
• Measure, photograph, and document wounds when authorized and clinically appropriate.
• Monitor wounds for signs of infection, deterioration, or improvement.
• Perform other skilled nursing procedures within the RN's scope of practice and agency policy.
• Notify the physician/provider and clinical supervisor of significant changes in condition.
• Assist with preventing avoidable emergency department visits and hospitalizations through early identification and reporting of clinical concerns.

Admissions and Start of Care

• Complete the initial nursing assessment within the timeframe required by the agency, payer, referral source, or applicable regulation.
• Review the client's diagnoses, medications, allergies, physician orders, recent hospitalizations, and current healthcare needs.
• Identify immediate safety and clinical concerns.
• Verify that required orders are available for skilled services.
• Establish or contribute to the client's individualized plan of care.
• Educate the client and/or caregiver regarding services, medications, treatments, emergency procedures, and when to contact the agency or physician.
• Coordinate necessary follow-up with the physician/provider and agency clinical team.
• Complete all required admission documentation accurately and timely.

Plan of Care

• Follow the physician/provider-approved plan of care.
• Review the plan of care for continued appropriateness.
• Recommend changes when the client's condition or needs change.