Nature Trail Health & Rehab Center is hiring nurses for night shift! Make up to $31.05/hr!
PURPOSE The primary purpose of this position is to function as a collaborative member of the IDT, provide Patient quality care, optimal clinical outcomes and assuring resident safety.
KEY JOB FUNCTION:
- Provides accurate assessment, over-sight, and monitoring of Patients for quality medical management and early detection of changes in condition.
- Responds promptly to evaluate and remedy Patient concerns and complaints; manages and documents accordingly.
- Utilizes professional standards in performing clinical assessment and monitoring in accordance with scope of licensure.
- Mentors/collaborates/directs facility LVNs/LPNs in establishing proper clinical management of patient conditions.
- Recognizes AND appropriately responds to emergent and significant change in condition; completes documentation as required.
- Recognizes AND appropriately responds to significant incidents; completes required notifications and investigative documentation as required.
- Utilizes change of condition management practice including referencing care pathways, on-site services, change-of-condition file cards and stop-and-watch tools.
- Maintains familiarity with the use of emergency medical supplies; follows facility practices for monitoring and re-stocking crash carts & other emergency supplies.
- Effectively communicates accurate assessment detail, medical history, advanced directives, and availability of onsite services to physicians.
- Escalates Medical Director involvement when needed to facilitate proper medical care and clinical management of a patient.
- Observes, records, reports to supervisor and physician Patient's change of condition and significant incidents.
- Provides change-of-shift report to communicate changes in condition and unit activities; updates 24 hour communication report when indicated.
- Maintains communication with responsible party specific to changes in condition and notification requirements.
- Develops, implements, evaluates, and updates plans of care accordingly.
- Encourages Patients to participate in prescribed therapies, dietary regimen, and activity programs, as appropriate. Reports, documents, and care plans non-compliance.
- Effectively participates in IDT Walking Rounds and reviews plan of care for assigned Patients; collaborates with MDS for completion of RAI.
- Completes admission, transfers, and discharge processes in an efficient manner; promotes accurate and timely documentation.
- Answers call lights and attends to Patient needs in accordance with scope of practice.
- Supervises/mentors CNAs in providing quality services in accordance with facility policies, state/federal laws, scope of practice, and individualized plans of care.
- Identifies and acts upon unsafe situations (i.e./ oxygen storage, smoking practices, unauthorized medication use, ETOH or drug abuse, unsafe environmental conditions, etc).
- Provides/facilitates appropriate assessment, diagnostics, and management interventions to address psycho-social and behavioral needs.
- Facilitates the proper identification, assessment, and clinical management of skin disorders and pressure ulcers; notifies physician's of new, stagnant, and worsening conditions.
- Monitors and facilitates the proper delivery of therapeutic diets, fluid restrictions, and modified fluids in accordance with physician's orders and care plan.
- Initiates and facilitates proper meal/fluid intake and output monitoring; acts to prevent complications including sig. weight variance, dehydration, fluid overload, and fecal impaction.
- Identifies Patient risk(s) areas and appropriately implements preventative measures as needed (i.e./ at bedside, etc); facilitates compliance with individualized plans of care.
- Monitors and provides appropriate care to clinically complex patients in accordance with facility policies and scope of practice; enteral, dialysis, IV therapy, trachs, etc.
- Maintains familiarity and promotes the use of Patient safety equipment and supplies; mechanical lifts, gait belts, alarms, sensors, floor mats, assistive devices, etc.
- Maintains familiarity and promotes the use of personal protective equipment; follows infection control policies and practices.
- Collaborates / Educates Patients and Families [uses "teach-back" method] as needed to achieve highest level of wellness in accordance with plans of care and discharge plans.
- Identifies functional declines and reports to physician, IDT, and RP accordingly.
- Completes appropriate referrals to other departments and ancillary providers when needed to address patient needs [IDT, therapy, dietary, social services, activities, etc.].
- Regularly monitors documentation/Progress Reports to facilitate point of care ADL documentation and complete intake & output records.
MEDICATION AND TREATMENT ADMINISTRATION FUNCTIONS:
- Takes, transcribes, and carries out complete orders in accordance with professional standards and Covenant Care's order sets.
- Implements and maintains established policies and procedures relative to skin care treatments; communicates formulary availability to physician's accordingly.
- Clarifies incomplete, unclear, or atypical orders and instructions accordingly.
- Facilitates the availability of medications, treatment supplies, diagnostic testing, and equipment to comply with physician's orders; invokes satellite/STAT procedures when needed.
- Properly prepares and administers medications and treatments.
- Complies with professional standards, policies & procedures, and legal documentation principles for administering medications, treatments, enterals, and intravenous therapies.
- Performs shift counts for controlled substances and ensures records reflect accurate reconciliation of shift activities; immediately reports discrepancies to Supervisor.
- Disposes of drugs, controlled substances, and biologicals in accordance with established policies and procedures.
- Checks medications in upon delivery from pharmacy and validates accuracy; reconciles new and re-admission drug regimens accordingly.
- Promptly identifies AND reports medication errors to attending MD, DON, and RP; invokes appropriate monitoring and management of patient condition.
- Maintains proper storage and security of medications and biologicals; medication/treatment carts, controlled storage, medication rooms, and other storage areas.
- Maintains cleanliness and organization of nurses station and drug storage areas.
- Properly labels, re-stocks, and discards items on med/treatment carts accordingly.
- Demonstrates competency in professional standards for safe medication administration.
- Maintains proper hand washing and infection control practices during med pass and treatment; including disinfecting CoaguCheck, blood glucose monitors, iSTAT.
- Appropriately monitors, assesses, documents, and medicates pain throughout the shift; follows company practices for recording pain characteristics; levels using 0/10 pain scale.
- Monitors and reports adverse drug reactions, side effects, enteral, and intravenous therapy complications as appropriate.
- Administers and safely monitors Coumadin Therapy.
CHARTING AND DOCUMENTATION FUNCTIONS:
- Completes required documentation and assessments timely; retains and files legal documentation accordingly.
- Completes daily Medicare assessments and supportive skilled service narratives.
- Encourages attending physicians to review treatment plans, record/sign orders, progress notes, etc. in accordance with established policies and best practices.
- Records nurses' notes and SBAR COC's in an accurate, complete, informative, and descriptive manner reflecting care provided and outcome/response.
- Follows Covenant Cares incident management standards; completes appropriate SBAR's/COC and associated documentation, notification, and care plans.
- Documents complete and accurate skin assessments upon admission, transfer, discharge, and COC; Completes accurate and timely documentation and re-evaluations.
- Develops, reviews, and amends care plans accordingly.
- Completes, and follows legal standards for entering, signing, dating, and correcting (errors/late entries) in the Patient's medical record.
- Demonstrate key competencies as required by the position and in accordance with State/Federal regulations.
INTERPERSONAL / LEADERSHIP FUNCTIONS:
- Cooperates with others to achieve department objectives and maintain good employee, interdepartmental, and public relations.
- Works cooperatively with IDT, nursing staff, and families to achieve the best possible outcomes for Patients.
- Provides exceptional customer service to Patients, families, physician's, and facility partners; practices "family serving families" philosophy.
- Greets newly admitted patients/families upon admission. Orients new patients and families to facility, staff, and routines.
- Timely greets and makes rounds with physicians when they come to facility; proactively collaborates and communicates with confidence.
- Utilizes a positive, can do' approach when interacting with patients, Physician's, family members, colleagues, caregivers, case managers, etc. and assignments / work.
- Interacts with everyone in a friendly, courteous, kind, respectful manner that recognizes everyone as a unique, special human being.
- Maintains HIPAA Privacy & Confidentiality of personal protected health information.
- Reports occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures.
- Recognizes and reports abuse, unethical behavior, attendance/HR issues, and code of conduct infractions.
- Practices high standards of nursing care and follows facility policy & procedures; federal and state laws, Nurse Practice Act.
- Records absences, tardiest, and relief coverage for assigned shifts as required; reports staffing concerns immediately to Administration.
- Follows HR practices for documenting progressive disciplinary actions of supervised staff. Participates/completes annual performance reviews as required.
- Takes initiative and identifies potential issues, problems, and challenges for management/QMP review; collaborates on the development of practical solutions.
- Serves on, participates in, and attends various facility -based committees (e.g. Quality Management/Safety/IDT) as desired or required.
- Organizes work day according to accepted routines and prioritizes activities to accomplish shift activities in a timely manner.
- Maintains a skill set in teach back methods and educational programs for Patients and family members discharged to home; understands/articulates proper disease management.
- Attends/participates in annual mandatory training programs for OSHA, hazard communication, exposure control, blood borne pathogens, abuse, HIPPA/Privacy, etc.
- Attends and participates in continuing education and enhanced learning programs offered by the facility; maintains knowledge and skills to practice safe/competent care-giving.
- Follows the federal/state laws and company policy related to reporting suspected injury or suspected abuse.
- Understands and complies with Code of Conduct, HIPAA, reporting practices, and applicable company policies.
- Maintains required licenses and certifications.
- Abstains from chemical and substance abuse.
- Maintains professional boundaries with patients, families, physicians, and colleagues.
MINIMUM QUALIFICATIONS (Specific Requirements, Education, Certification, and Experience)
* Must be a graduate of an accredited school of nursing. * Must posses a current, unencumbered, active license to practice as a Registered Nurse in the State in which you are employed.
* Must be able to read, write, speak and understand the English language. * Must posses the ability to make independent decisions when circumstance warrant such action * Must be knowledgeable of nursing and medical practices and procedures, as well as law, regulations, and guidelines that pertain to long-term care.
* Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
* Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care. * Must be able to relate information concerning a Patient's condition. * Must not pose a direct threat to the health of other individuals in the workplace. * Must meet the general health requirements set forth by the policies of the facility or department which may include a medical and physical examination.
ENVIRONMENTAL CONDITIONS AND PHYSICAL REQUIREMENTS
* Artificial lighting.
* Safety equipment required: Closed toed, non-skid shoes; application of universal precautions and use of appropriate PPE as indicated.
* Typically 8 hour shifts with weekend coverage; first, second, and third shift. * Paced based on individual patient care demands and nurse assistant to patient ratio. * Flooring: Tile, carpet.
* Medium to heavy physical demands including, occasional to frequent lifting, up to 100 pounds. * Frequent standing, bending, and reaching.
* Occasional squatting, kneeling, twisting, and extending. * Subject to call-back emergency situations (i.e., severe weather, evacuation, and post disaster, etc.). * Possible exposure to infectious waste, hazardous chemicals, diseases, including TB, AIDS and Hepatitis B viruses.
* May be subject to hostile residents (patients) and/or family members.