Registered Nurse

Registered Nurse

Initiate physician orders, and administer medications, complete procedures and provide treatments in accordance with care/medical needs, physician orders, policy/procedures, scope of practice and nursing standards of practice. Assess patients and plan, coordinate, and supervise nursing care, including restorative nursing, to ensure compliance with standards of care, policy/procedures. Direct and monitor Medication Aides including responsibility for observing and taking appropriate action regarding any desired effects, side effects, interactions, and contraindications associated with the medication(s) administered by a Medication Aide. Comply with Civil Service policies and regulations, collective bargaining agreements, county policies, and laws to create a cooperative, safe, respectful and quality work environment. Establish effective working relationships with clients, residents, management, employees, outside agencies, vendors, and the public. Perform direct hands-on care in accordance with the plan of care, physician's orders and nursing standards of practice while utilizing independent judgment, critical thinking skills, the principles of nursing care and basic physical assessment skills. Provide patient/resident teaching in accordance with patient/resident needs and standards of care. Develop, document, and implement individualized, interdisciplinary care plans to ensure care/medical needs are being met; complete sections of the MDS (Minimum Data Set) assessment, as requested. Accurately document assessments, care, teaching and observations in the medical record; make informative entries that reflect the medical needs of the individual, the care provided and the response to that care; and ensure that progress notes reflect that the care plan is being followed and updated as needed. Assist with orienting, directing, training, and evaluating the work of subordinate team members. Work cooperatively and respectfully with team members, families, visitors, and volunteers to create a positive and pleasant health care environment. Complete nursing rounds, provide follow-up supervision, and assist/consult with nursing/medical staff ensuring quality nursing care is provided; consult with attending physician as needed for treatments, medications, rehabilitation, etc. Ensure team members are informed of the care needs of each individual; conduct change-ofshift reports utilizing professional expertise in assigning team members based upon their level of training/scope of practice. Serve as a resource person to others, promote a positive work environment, and assist in resolving complaints/conflicts; orient new patients/residents and their families to the facility. Maintain confidentiality of departmental, patient/resident, and employee information; and ensure that communication and documentation are in compliance with all privacy laws including the Health Insurance Portability and Accountability Act (HIPAA) regulations. Promptly inform the Director of Nursing/Nurse Manager/House Supervisor, patient's/resident's Client, and patient's/resident's physician of any change in condition; initiate follow-up to promote safety/care; and immediately report any suspicion/allegations of abuse/neglect/misappropriation of property to the Director of Nursing/Nurse Manager/House Supervisor. Review documented plans of care and discharge plans; participate in updating these plans as needed. Assist in the admission, transfer, and dismissal of patients/residents; complete all related documentation. Serve as a mentor/preceptor to co-workers, students, and agency/outside personnel; follow-up to ensure that they function within their scope of practice; and help others learn by teaching and being a positive role model. Encourage, empower, and support patient's/resident's, whenever possible, in maintaining or regaining their independence; accommodating their individual choices; assisting them in directing their own daily life; and in helping them maintain their personal belongings according to their wishes. Investigate complaints and/or suggestions from patients/residents, co-workers or the public; and take steps to remedy problems. Respond to and assist with medical and psychiatric emergencies and codes at a level of competence. Observe, adhere to, and promote emergency/safety protocols and measures related to hazardous waste, chemical use, fire, weather, internal disasters, elopement, community disasters, and other safety matters. Attend and participate in education programs aimed at increasing personal knowledge and abilities, and those necessary to maintain licensure.