Overnight LVN

Job Description

Job Description

Description:

Overview.

As an LVN at Restoration Recovery Center (“RRC”), you will be responsible for the nursing assessment, medication monitoring and guidance of non-medical team members as to the medical component of client treatment episodes. The LVN is responsible for both the administrative and medical portion of the client intake process and is the primary in oversight of properly receiving and centrally storing medications and preparing client medications for discharge.

The LVN also has primary responsibility of communicating to non-medical team members regarding changes to medical orders and instructions. While the LVN at RRC has unique medical responsibilities, the LVN is also responsible for learning and being able to achieve all job duties of the Behavioral Technician, without exception.

Responsibilities.

This includes but is not limited to:

· Collaborate with Providers in completing client physical assessment, medical assessment, and assessment of health-illness needs in acute withdrawal care.

· Collect and document in the interdisciplinary notes data such as vital signs, client behavior by physical observations at regular prescribed intervals, client response to medications, nursing care, and medical treatment plans.

· Provide written reports at regular intervals as appropriate regarding client care initiatives, changes, and medical status.

· Demonstrate awareness of client’s physical and emotional state through observation and interaction.

· Maintain medication logs, counts, and client compliance of medications as well as monitor for medication adjustments or complications.

· Ability to act and react accordingly to 911 emergencies and utilize proper and appropriate chain of command in reporting such incidents.

· Complete Incident Reports as prescribed by RRC policies and procedures, including but not limited to reports of safety/risk concerns to appropriate management (Executive Director, Safety Officer, Lead BHT).

· Proficiency in all facets of client intakes and discharges, including ability to follow checklists and flowcharts and proper communication.

o Complete intake process with new admits: conduct body and property search, collect UA, breathalyze clients, complete client consents and interviews, log client’s valuables, and send out intake email (and any other tasks outlined in applicable checklists).

o Complete discharge process: assist with compiling medications (if applicable), preparation of personal property, obtain necessary signatures, including release of client property and valuables, send out discharge email, prepare room for new intake (and any other tasks outlined in applicable checklists).

· Ability to maintain confidentiality of client’s medical and personal information.

· Immediately and accurately receive and transcribe orders from physicians.

· Assist Providers and non-medical team members in creating a positive work environment through clear communication.

· Take vitals and log in a timely manner; ongoing medical assessment of clients.

· Participate in staff and shift change meetings.

· Document and provide shift reports.

· Familiarity with policies and procedures related to self-administration of medications and decision-making authority as to medications.

· Maintenance of nursing supplies and over-the-counter medication supplies.

· Complete nursing documentation audits.

· Complete medication counts as required.

· Client rounds documentation (Observation Logs) as prescribed by Providers and RRC policies and procedures.

· Familiarity with facility rules and ability to provide instructions as to facility’s rules and regulations to new admits - ability to provide brief orientation upon intake.

· Demonstrate adaptability and flexibility to changes in work environment.

· Collaborate with the Medical Director, Providers, Program Director, Clinical Director, Director of Operations as appropriate to ensure continuous quality of client care offered by RRC.

· Execute client care instructions across the disciplines within RRC and support decisions (or plans of action) made by other professionals including Providers, Therapists, Case Managers, and other Management.

· Accurate and compliant medical documentation.

· Conduct accurate and detailed client follow-ups as per RRC policy.

· Dictating and entering medication orders from providers into the EMR.

· Medication administration and accuracy and conduct audits as required.

· Complete daily chores to support upkeep of the facility per shift checklists.

· Perform other related duties as required and/or assigned, including those of the Behavioral Technician.

· Demonstrate effective and good interpersonal skills, communication skills and integrity in offering client-centered care.

· Adhere to policies and procedures / MSBH Employee Handbook.

· Understand and follow policy for Client Rights and Cultural Diversity.

· Uphold and enforce the agency’s standards, policies and procedures, client rights, and professional code of ethics and conduct.

· Additional special projects/duties as assigned for the overall benefit of RRC.

· Current LVN license through the appropriate California licensing Board.

· Valid CDL (no DUI convictions or dispositions within the last 5 years).

· At least one year of licensed experience.

· Experience in residential healthcare facility and SUD field experience preferred.

· Experience in clinical settings and proven experience in providing support in SUD and treatment of co-occurring disorders.

· Experience, knowledge or interest in chemical dependency and abuse.

· Experience in acute withdrawal care.

· Medication administration training and proficiency within 30 days of employment.

· Experience in EMR documentation.

· Excellent verbal and written communication skills.

· Vision, hearing, manual dexterity and hand-eye coordination must be adequate for performance of job duties.

· Able to move about the facility to observe clients and staff.

· Ability to be adaptable and flexible to changes in work environment.

· Superior time management and understanding of priority clients.

· Strong analytical skills and attention to detail.

· Demonstrated problem-solving ability.

· Excellent verbal and written communication skills.

· Must work independently with superior time management and understanding of priority clients.

· Must possess qualities of integrity and patience.

· Computer literate; demonstrated proficiency in Microsoft Office and EMRs.

· Ability to maintain confidentiality - working knowledge of client rights, HIPAA privacy and client confidentiality laws, program services and structure.

· Current CPR and First Aid Certification.

· Current Naloxone Certification.

· Current TB test clearance.