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REGISTERED NURSE (RN)
DIRECTOR OF NURSING
Variable days and hours, including weekends and holidays.
Conducts patient assessments and provides nursing interventions to patients as assigned.
Maintains a safe and efficient working and treatment environment per facility policies and procedures.
Communicates effectively with the treatment team to ensure safe, quality care is provided to all patients.
Provides supervision to Licensed Practical Nurses and Mental Health Technicians. Assumes role of Charge Nurse when assigned.
This job description reflects management s assignment of essential functions. It does not prescribe or restrict the tasks that may be assigned. Nothing in this job description restricts management s right to assign or reassign duties and responsibilities to this job at any time.
Graduate of an accredited nursing program.
Current State Licensure. CPI/CPR Certified per policy.
Two years as Registered Nurse with one year acute psychiatric experience preferred.ERGONOMICS / WORKING CONDITIONS
% TIME SITTING
25% (medical record documentation and review, treatment team, facilitating groups, written reports, telephone coverage).
% TIME STANDING
25% (medication administration, direct patient care, patient observations).
% TIME WALKING
50% (direct patient care, patient observations, environmental/safety rounds).
% TIME BENDING
Up to 50% (patient care, access files and supplies).
65 pounds (patient care, supplies, equipment).
Ability to: administer medications; provide direct patient care; assist with activities of daily living including ambulation, transfers, grooming and toileting; use medical equipment; perform physical interventions; document clearly in the medical record; use the fax, telephone, computer keyboard and security door key pad or keys.
Ability to: effectively read, write and process information accurately; input/retrieve information to/from the computer, fax, phone, patient records and from regulatory and licensing materials; see objects and persons near and at a distance.
Ability to: communicate effectively with others; give, take and process information; use the telephone extensively; hear patients and staff on the unit so response can be timely and appropriate to needs; hear alarms or other sounds that may indicate a safety concern.
Exposure to: infection from disease-bearing specimens; blood-borne pathogens, body fluids and wastes; chemotherapeutic agents; occasional exposure to unpleasant patient or departmental elements; occasionally subjected to irregular or prolonged hours; occasional exposure to high risk behaviors from patients or visitors that may result in agitation, aggression or violence; exposure to critical incidents and sentinel events.ESSENTIAL JOB FUNCTIONS
Complete admission nursing assessment per policy and as assigned.
Complete nursing reassessments per policy, as assigned, and any time a change in status is observed or reported by team members.
Identify the need for additional assessments and/or specialized treatment, including but not limited to: dietary, rehabilitation services, and/or infectious disease through the initial and ongoing assessment process. Communicate the identified need to the attending practitioner or the consultant, per policy.
Assess patients for risk of danger to self or others at time of admission and ongoing through hospitalization. Document assessments and communicate concerns to the attending practitioner and team members through verbal and written methods.
Conduct patient rounds on assigned patients at the beginning of the shift to ensure all patients are present and to identify if there are any immediate needs that need addressed.
Oversee all aspects of patient care and complete assignments as assigned by the Charge Nurse.
Perform ongoing observation of the patients and milieu to ensure active treatment is provided and patients are participating.
Respond appropriately and timely to patient requests.
Intervene appropriately with patients experiencing a behavioral crisis situation, i.e., suicidal, threatening behavior, elopement and/or other situations. Exhibit leadership by providing clear direction to the team and communication of the patient s status to the practitioner.
Initiate emergency medical care when indicated. Exhibit leadership by providing clear direction to the team and communication of the patient s status to the practitioner.
Provide support and direct assistance to patients who are unable to attend to their activities of daily living by assisting them with meals, daily grooming, ambulation and toileting as needed.
Participate with the treatment team in implementation of the individualized plan of care. Report factors that may impede successful accomplishment of the treatment plan to the Charge Nurse.
Provide patient educational information for identified learning needs.
Facilitate educational/activity groups as assigned or when indicated using approved materials. Recommend alternative activities based on patient functioning level and treatment plan.
Attend and actively participate in treatment team meetings as assigned.
Ensure compliance with infection control protocols and/or policies by patients, visitors, and staff.
Review assignment sheet, Kardex, and facility designated communication tools each shift, i.e. communication log, bulletin boards, etc.
Review practitioner orders, MAR, laboratory and test results, and treatment team documentation daily to ensure the treatment plan is current and fully implemented.
Review all laboratory and test reports and transfer records from hospitals and other providers.
Establish and maintain therapeutic and safe environment through role modeling, supervision and feedback.
Remain on-duty until nursing coverage for subsequent shift arrives on unit, receives verbal report and conducts rounds on assigned patients.
Ensure all patient valuables retained at the hospital during inpatient stay are recorded and stored per policy.
Ensure patients are discharged with all personal belongings, medication, prescriptions, discharge and referral information.
Comply with all National Patient Safety Goals and provide immediate feedback if non-compliance is identified.
Complete Charge Nurse duties when assigned including assignment sheet, verification that staff assignments are completed and providing ongoing supervision as needed to the assigned nursing staff.
Obtain clarification on medication orders that are unclear, do not include all the required elements or include DNU abbreviations.
Read Back and receive confirmation on all telephone orders.
Provide medication education on all new medications and respond to additional questions or concerns the patient may have regarding medications.
Document medication variances and/or adverse drug reactions on the appropriate form and notify the patient, practitioner and facility leadership as directed per policy.
Control access to the medication rooms and/or medication dispensing machines in accordance with facility policy.
Ensure medication room and equipment is clean, including no personal belongings in the medication room.
Interact with patients, family members, external entities and internal staff professionally and respectfully.
Work collaboratively with all treatment team members to create a treatment environment that supports the facility s mission to provide exemplary patient care and customer service.
Act to preserve patient and family dignity and safety.
Documentation for medical records and reports is timely, legible, thorough, and in required format.
Document as required including assessments, treatment plan, nursing notes, medication administration, education, discharge planning, incident reports and medication variances.
NON-SUPERVISORY CORE COMPETENCIES (SKILLS)
Update and revise treatment plan as assigned and per policy.
Ability to provide excellent service to internal and external customers.
Ability to effectively listen, process received information, and express ideas verbally and in writing.
Ability to initiate action, take personal responsibility, suggest improvements, and solve problems within scope of job without being asked.
POLICY AND PROCEDURE COMPLIANCE
Ability to understand and comply with government regulations, regulatory and accreditation requirements and hospital policies.
Ability to record, report, and maintain confidentiality of information and respond to requests for information.
Ability to complete assigned work in an acceptable manner, in the time allotted, with minimal prompting or reminders.