RN

GENERAL STATEMENT OF DUTIES

The Registered Nurse (RN) is a patient care provider. The RN performs a variety of nursing functions

and closely assesses patients for changes in medical or nursing status under the direction and

supervision of a Medical Doctor. The RN provides care to adults who have sustained various forms of

head trauma, and who may or may not have sustained other injuries. The RN will be responsible for

supervision and documentation of the patients' medical/nursing needs until discharge. Among these

duties are observing and documenting patients' behavior, role modeling for the patient, interacting with

the patient, providing training to staff in caring for the patient, ensuring patient safety, and reinforcing

treatment plans and Moody Neuro policies. The RN will uphold the mission, philosophy, and goal of the

organization while maintaining strict confidentiality of personnel and client data and information in the

performance of assigned duties. The RN will act as a liaison between the Medical Director, Program

Director, Clinical Team, and the Residential Department.

ESSENTIAL FUNCTIONS

Major Duties and Responsibilities:

• Specified nursing services as needed by Moody Neuro patients.
• Regularly round on assigned residents in order to assess, monitor, intervene, document, and report the patients social and interpersonal behavior and functional ability to perform as an independent individual in the community setting.
• Perform and document routine assessments to monitor patient specific risk levels, including collaborating with LVN staff as needed to provide input on nursing interventions.
• Carry out patient education such as medication information, comorbidities after brain injury and prevention of recurrence in both individual and group settings.
• Attend team meetings to discuss patient status and goals as designated by supervisor.
• Regularly communicate with other members of the care team and monitor patient information to assess patient status (weights, BP, I/O, blood sugars, etc.) and report trends and concerns to Medical Director.
• Ensures the training and skills orientation of residential staff is successfully completed as directed by the Medical Director or Program Director.
• Assure medical documentation is in accordance with licensing agencies.
• Ensure RN delegation for medication administration is conducted in accordance with accrediting and licensing agencies such as CARF, HHSC, and CRS.
• Oversee medication administration process, including prepping medication for routine administration, passes and discharge.
• Monitor patient self-administration of medications and documentation of ability to perform this function.
• Oversee wound care in accordance with Medical Director and External Wound Care Specialist.
• Schedules and administers an initial TB Test with new employees and patients. Documents result and administer annually.
• Conducts new hire drug screenings and incident follow up drug screenings.
• Follow behavior modification programs recommendations and submit documentation to the clinical team as appropriate.
• Assist in emergency situations including the execution of fire alarm and drill procedures, and the provision of first aid treatment in the case of illness or injury, in respect to triage procedures.
• Will act as medical supervisor as needed and provide documentation of observation of client responses on outings as needed if accompanying patients on field trips.
• Attend in-services, workshops, staff meetings, and seminars, as directed.
• Maintain confidentiality of both client and staff issues.
• Provide safe and secure environment for patients and staff.
• Discharge duties in accordance with Moody Neuro organizational policies, CARF, and other accrediting/licensing bodies.
• Scheduling outside medical appointments assigned by the Medical Director while patients are admitted to Moody Neuro.
• Other duties as assigned.

Organizational Duties :

• Maintain medical documentation, including, but not limited to, medication monitoring sheets, incident reports, and medical consults.
• Act as a therapeutic liaison between the Medical Director, Program Director, and the staff.
• Maintain security procedures according to Moody Neuro policies.
• Maintain appropriate records of on call activity for timecard.

MINIMUM QUALIFICATIONS

Required Knowledge, Skills and Abilities

• Current Texas state license as an RN.
• Knowledge of TBI and related syndromes.
• Ability to work well with other people in a clinical setting.
• Ability to stimulate and motivate people.
• Knowledge of social customs and responsibilities.
• Ability to demonstrate flexibility, innovation, and good judgment.
• Ability to receive and follow instructions accurately.
• Knowledge of philosophical and ethical considerations in rehabilitation practice.
• Ability to communicate accurate and pertinent information through documentation.
• Ability to execute emergency procedures with regard to fire drills, emergency evacuation, and triage.
• Ability to work rotating shifts and hours.
• Ability to assist clients with transfer into/from a wheelchair.
• Ability to obtain NCI certification.

LIFTING REQUIREMENTS - individuals in clinical care positions may be required to assist with transfers up to 150

pounds and should have the ability to lift to 100 pounds without assistance.


EDUCATION

Graduate of an accredited school of nursing.

CERTIFICATION/LICENSURE

Hold a current license to practice as a Registered Nurse in the state of Texas.

CPR certification required

Valid Texas driver's license required

EXPERIENCE

One (1) year of inpatient experience required, rehab and ALF experience preferred. Prefer 2 years post-

graduate experience in nursing, preferably in the fields of rehabilitation, patients with cognitive deficits, or mental health issues.