Registered Nurse (RN)

Job Title

To deliver nursing care and provide active treatment for people with intellectual and/or developmental disabilities requiring long-term supports.

Essential Functions

1. Works under the direct supervision of the Director of Nursing and/or Assistant to Director of Nursing using the state-specific Nurse Practice Act, Policies and Procedures, and nursing judgement.

2. Delivers nursing care to residents requiring long-term supports.

3. Completes Assessments within time-frames and guidelines of residents in assigned caseloads

4. Collects resident data, makes observations, and reports pertinent information related to the care of the resident.

5. Implements resident’s health related active treatment program plans and evaluates the resident responses.

6. Maintains knowledge of necessary documentation requirements.

7. Maintains knowledge of equipment set-up and maintenance.

8. Maintains confidentiality and resident rights, regarding all resident/personnel information.

9. Provides resident/family/responsible party education as directed.

10. Works rotating shifts, holidays and weekends as scheduled.

11. Initiates emergency support measures (i.e., CPR, protects residents from injury).

12. Performs other duties as deemed necessary and appropriate, or as may be directed by the Director of Nursing.

13. Documents observations and ensure it is complete and reflects knowledge of unit documentation policies and procedures.

14. Nursing history is present in the medical record for all residents.

15. Changes in resident’s physical/psychological condition (i.e., changes in lab data, vital signs, mental status), are reported appropriately

General Resident Care

1. Resident is approached in a kind, gentle and friendly manner. Respect for the resident’s dignity and privacy is consistently provided.

2. Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.

3. Independence by the resident in activities of daily living is encouraged to the fullest extent possible.

4. Treatments are completed as indicated.

5. Make rounds every two (2) hours of your unit to assist in the hydration needs of residents deemed by the Interdisciplinary Team as high-risk to dehydration and constipation.

6. Ensure residents who are at risk for pressure sores are repositioned at the time intervals documented on Resident Repositioning form which is located in the residents' closet. Initial Repositioning Form to verify resident has been repositioned. Wheelchair residents should be placed on floor mats in the activity area.

7. Make periodic/random checks to assure that prescribed and/or preventive treatments (i.e. facility’s preventive foot-care program) are being properly administered by designated personnel and evaluate the resident’s physical and emotional status.

8. Safety concerns are identified and appropriate actions are taken to maintain a safe environment.

a. Siderails and height of bed are adjusted.

b. Restraints, when used, are maintained and documented properly.

c. Rooms are neat and orderly.

9. Resident identification bands and allergy bands (if applicable) are present.

10. Functional assignments are completed.

11. Emergency situations are recognized and appropriate action is instituted.

12. All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguisher, etc.).

13. Carryout restorative and rehabilitation programs, to include self-help/self-medication/sex education, and ensure appropriate data collection of programs.

14. Catheters are monitored and changed according to facility policy.

Medication Administrations

1. Adheres to state-specific Nurse Practice Act for administration of medication and parenteral therapy.

2. Dates that medications are started or discontinued are documented.

3. Medications are charted correctly with name, dose, route, site, time, and initials of nurse administering.

4. Pulse and blood pressure are obtained and recorded when appropriate.

5. Medications not given are circled, reason noted and physician notified if applicable.

Coordination of Care

1. Tests are scheduled and preps are completed as indicated.

2. Co-workers and QIDP’s are informed of changes in resident conditions or of any other changes occurring.

3. Information is relayed to other members of the health care team (i.e., Administrator, QIDP’s, physicians, facility consultant’s, social services, etc.) and family/responsible party.

4. Facility activities are coordinated (i.e., changing resident’s rooms for admissions, coordinating transfer/discharge forms, etc.).

5. Work with Social Service to ensure notification of the residents’ next of kin/legal guardian/responsible party when there is a change in resident’s status.

6. notes are written for medications not given and actions taken.

7. Notify the attending physician of automatic stop orders prior to the last dosage being administered.

8. Name and title of nurse administering medications are documented.

9. Resident’s medication record is labeled with full name, room number, date, and allergies.

10. The procedure for administration and counting of narcotics is followed.

11. Name, date, and time are documented on medication punch card when card is started (first punch on card).

Professionalism

1. Decisions are made that reflect knowledge and good judgement and demonstrate an awareness of resident/family/responsible party/physician needs.

2. Awareness of own limitations is evident and assistance is sought when necessary.

3. Dress code is adhered to.

4. Committee meetings (if assigned) are attended. Reports related to the committee are given during staff meetings.

5. Responsibility is taken for own professional growth. All mandatory and other inservices are attended.

6. Organizational ability and time management is demonstrated.

7. Confidentiality of resident is respected at all times (i.e., when answering telephone and/or speaking to co-workers).

8. Professional behavior is demonstrated.

Human Relations

1. A positive working relationship with residents, visitors and facility staff is demonstrated.

2. Authority is acknowledged and response to the direction of supervisor is appropriate.

3. Time is spent with residents rather than other personnel.

4. Co-workers are readily assisted as needed.

Cost Awareness

1. Supplies are used appropriately.

2. Minimal supplies are stored in the resident’s room.

3. Discharge medications are returned to the pharmacy or destroyed in a timely manner.

4. Follow established procedures to ensure an adequate supply of floor stock medications, general supplies, incontinence supplies, and equipment are on hand to meet the nursing needs of the resident.

Communication

1. Change of shift report is complete, accurate, and concise.

2. Incident Reports are completed accurately and in a timely manner.

3. Staff meetings are attended, if on duty, or minutes read and initialed if not on duty.

Marginal Functions

1. Participates in the identification of staff educational needs.

2. Serves as a preceptor, as delegated, for new staff.

3. Maintains patient/resident care supplies, equipment and environment.

4. Participates in the development of unit objectives.

5. Provides input in the formulation and evaluation of standards of care.

Exposure Risk

The Registered Nurse(Vocational) Nurse is at moderate to high risk for exposure to blood and body fluids or other potentially infectious materials.

Supervision Received

· Administrative supervision from the Director of Nursing, Assistant to the Director of Nursing and/or Administrator.

· May receive functional programming supervision from the Program Services Director or Associate Administrator.

Supervision Exercised

None

Minimum Qualifications

1. Graduation from