Staff Nurse-PRN

Job Description

Job Description

GENERAL STATEMENT OF DUTIES: Administers medication, assist the Nursing Services Manager. in administering the Health Care Services to the residents inside the Clinic and on the campus. These functions must remain within the boundaries allowed by law, to an L.P.N. or R.N. as applicable.

EXAMPLES OF ESSENTIAL DUTIES: (This list may not include all of the duties assigned)

• Administering medications and treatments, and is responsible for staying current on changes to either.
• Assesses common illnesses and complaints. Initiates standing orders as approved by the physician and outlined in standing orders and report to the D.O.N and physician as needed.
• Assist physicians in Dental, Neurological, and other clinics as needed.
• Provide bedside nursing care to assigned clients in the clinic and document every 2 hours.
• Assist with preparing patients for doctor visits within and outside the premises of St. Mary’s.
• Take T.P.R. and blood sugar, weekly weights and BP’s if needed on assigned clients.
• Requests needed supplies and stocks supplies as needed. Order medicines and TX’s as needed or changed.
• Investigates any report of illness and takes proper action, including admission to the clinic when illness so requires. Complete clinic admit form and document admission in nurse notes.
• Receives physician’s orders and executes said orders according to pre-established procedures.
• Informs parents, guardians and visitors of established policies and procedures.
• Write shift summary report at end of shift and email to all nursing staff – include illness, new orders, appointments, incidents, labs, etc.
• Prepare quarterly reports and attend staffing on assigned clients.
• Complete and document quarterly nursing assessments on assigned clients.
• Complete charting prior to leaving campus at the end of shift; i.e., med changes, illness, appointments, any phone calls concerning clients, staffing, orders, orthotics, etc. any occurrences during your shift.
• Sees that all safety procedures are followed. Must be familiar with the pre-established procedures in case of fire, bomb threat, disaster and in the pre-established system of patient evacuation in case of an emergency requiring such action.
• Complete health records and nursing assessments as assigned.
• Take prompt action in case of medical emergency as required by the pre-established policy and procedure; including orders for O2 during seizures..
• Cleans and assembles equipment for sterilization when necessary
• Inform parents and guardians of all doctor appointments and result; and admission to the clinic.
• Adheres to all safety policies.

DAILY RESPONSIBILITIES

• Shift change in clinic-check communication book
• Report to assigned dorm.
• Check email at start of shift and at regular intervals during shift
• Medication administration.
• Body checks q shift on designated clients.
• Night nurse-nightly chart checks on clients who went out on appts/MAR checks; flag any that need corrections/completion.
• Order medication refills/supplies.
• Round in clinic every 2 hours if clients from your dorm are in clinic and chart in progress notes.
• Daily filing of information in charts for your dorm.
• Thin charts as needed (see list of approved documents that can be removed, it is posted in chart room).
• Q shift, document follow up on minor injury reports (clinic care assessments) whether you initiated or not. When complete (healed) return the form to the clinic nurse and document healed wound in progress notes.
• Keep your work area clean and neat.
• Interact with clients.
• Complete quarterly nursing assessments and staffing reports as indicated.
• Night nurse-refrigerator temp checks and documentation on dorms and clinic. On weekends, this should be completed by the day nurse.
• When new monthly MARS come out-pull charts and check MAR against MD’s orders to assure all orders are current; this includes diet, meds and med times, treatments, labs,dx (each med should have a dx), etc...lastly, check against the current MAR make any corrections on new MAR and in chart if needed; pull yellow copies and put in pharmacy bin in clinic for them to pick up. Place new MAR in your MAR binder. Check lab spreadsheet to assure labs are scheduled correctly.
• Labs-the clinic nurse and coordinator will order routine labs, get results and fax to MD when indicated; the clinic nurse will notify the dorm nurse when any orders come in concerning labs; dorm nurse to take off orders, execute, and file completed labs and orders; document in nurses notes; if dorm nurse receives an order for labs, fill out initial lab req. and notify clinic coordinator of orders.
• Outside appts-assist with preparing client and paperwork for appts; dorm nurse will be notified when client returns from appt; dorm nurse to execute any new orders and notify clinic coordinator if any further appts need to be scheduled. Assure that education is given to direct care staff if needed, regarding care of client after return from appts. If client is to remain in clinic, follow clinic admission procedure and utilize CNA communication book to get information to all clinic CNA’s (direct care staff)
• Day shift dorm nurses-maintain a logbook/calendar with your client’s lab orders and due dates so you can follow up on them.
• Dorm nurse will be notified if any new orders come into clinic on your clients.
• If you administer a TB test in the clinic on a staff member, document in TB logbook as well as test form.
• Review notes from Dr Hill clinic-get consent for new meds if needed, make changes to MAR. Any new lab orders are put in DON and Clinic Coordinator’s box to handle.
• Check for Clinic Care Assessments that need follow up Q shift. When wounds are healed off, turn CCA in to Nurse Manager. Document healed wound and DC wound care in chart.
• Email end-of-shift report to “nurses”
• Any other duties as assigned by Nurse Manager or Director of Health Services.
• Nurses are responsible for clients and charts on their assigned dorms. Please assure that the documentation is complete on all charts for your dorm.
• Performs all other duties as requested by the Director of Health Services, Nursing Services Manager and/or Administrator.

For 70 years, St. Mary’s Residential and Community Services has been a premier home for individuals with developmental disabilities, offering personalized care that helps each resident reach their full potential. Nestled on 55+ acres in Central Louisiana, we welcome residents as young as 3, providing a nurturing environment focused on social development, emotional well-being, and community inclusion through comprehensive onsite services.

Company Description

For 70 years, St. Mary’s Residential and Community Services has been a premier home for individuals with developmental disabilities, offering personalized care that helps each resident reach their full potential. Nestled on 55+ acres in Central Louisiana, we welcome residents as young as 3, providing a nurturing environment focused on social development, emotional well-being, and community inclusion through comprehensive onsite services.