Registered Nurse-PT-73542102

Essential Job Functions

• Participates in the pre-admission evaluation study and plan; the evaluation study, program design and placement of the resident at the time of admission to the residence; the periodic reevaluation of the type, extent and quality of services and programming; and the development of discharge plans and referral to appropriate community resources
• Based on a comprehensive review of the client's overall condition, prepares, continually reviews and evaluates plans of nursing intervention to ensure that such interventions are consistent with the client's comprehensive treatment plan. Ensures, plans of nursing intervention include consideration of the client's cultural and ethnic background, customs, needs, beliefs, and primary language.
• Develop treatment plans, in conjunction with the Interdisciplinary Team, consisting of an evaluation of the nursing needed and selection of nursing procedures and practices which will best serve the residents' health care needs.
• Develops, nursing assessment to reflect holistic needs of each client with consideration of his/her psychological, physiological, social, ethnic, cultural, educational and spiritual strengths and needs.
• Oversees the direct implementation of nursing care to ensure that it is carried out in accordance with the plan of nursing intervention, and overall treatment/service plan, and to ascertain if the needs of the client require modification of the plan.
• Coordinates nursing care activities with other professional disciplines to ensure that the nursing plan is consistent with and integrated with the total treatment/service plan
• Participates at team meetings and provides nursing input on the development and implementation of treatment/service plans.
• Conduct in-service training with regard to personal hygiene, medication administration, family life and sex education. Supervise medication administration practicums and sign off on medication administration monthly.
• Control communicable diseases and infections through: identification and assessment, reporting to medical authorities, and implementation of appropriate protective and preventive measures.
• Record on the residents' medical records nursing observations and action taken, such as nursing care given, medications and treatments given, reactions to treatments, tests, the intake and output of fluids and solids and the resident's vital signs. Record nursing needs of residents.
• Modify the nursing plan, in terms of the residents' daily needs, at least annually for adults in accordance with developmental and medical changes.
• Be available for on-call duty and to work varied shifts as the need arises.
• Work with all consulting and/or contracted medical service providers to in-sure appropriateness of service & to insure that recommended treatments are appropriate and are carried out, integrated and documented into the treatment plan.
• Ensure that the inventory standards for medicines, solutions, supplies and equipment are maintained to meet nursing care needs.
• Account for the issuance of controlled drugs and narcotics and inventories of these drugs.
• Ensures resident protection from health hazards such as transmission of infectious organisms, isolation of infected residents and use of properly sterilized equipment when its use is necessary.
• Provide appropriate information to the resident and family about such areas as sustaining and preventive health care, personal hygiene, methods of family or self-treatments, self-medication and possible side effects of medications.
• Serve as liaison, resident's interpreter with outside health services providers and escort residents to services as needed.
• Train designated staff, by way of demonstrations and written and oral instructions, in the performance of select nursing techniques and the use of nursing equipment, and client specific condition trainings.
• Provides health education/teaching for clients and their families.
• Participates in risk management and quality assurance concerning health related issues.
• Provides emergency care and crisis intervention
• Accesses medications and observes and records effects and side effects.
• Participates in professional activities to improve personal skills and knowledge.
• Provides Nurse Vacation coverage, phone availability during workday hours, and a minimum of one site visit at covering site, for Nurse Responsibility review and weekly reporting.
• IDD Division Nursing Triage Service - After Hours, Weekends, and Holiday’s (5pm – 9am) – On a pre-determined rotation, across all IDD Nurses
• Performs other related duties as assigned.

 

Additional responsibilities of the Residential Nurse in the IDD Division

Consumer Medical Records-Maintain medical record of each individual and ensure all appointments occur as prescribed and on time

• Schedule and coordinate all medical appointments in conjunction with Medical Specialist
• Follow up on all Medical Doctor recommendations following every appointment
• Ensure follow up on all medication changes, making sure the order has been sent to the pharmacy, Medication Administration Review has been updated, medication change log updates, bright colored posting of information has been placed and the information transcribed in the AMAP communication log
• Conducting weekly medical meetings( to occur every Wednesday)
• Review all consults and ensuring compliance with all recommendations
• Ensure the updating of the Appointment Tracking Log as it is a IDD Division System
• Complete Residential Nurse Progress Note and filing all consults once the progress note has been written
• Review and edit MARS Monthly upon delivery

Medication- Responsible for Medication Administration without Error

• Ensure all AMAP Certifications are current
• Schedule and conduct all recertification pouring’s
• Ensure all medication supplies of each consumer is present and labeled according to doctors’ orders
• Ensure the consumer’s Medication Administration Review is updates according with all medication changes, neatly organized with formularies and doctor’s order attached
• At least once per week, conduct a full 100% audit of all consumers’ medication and document results on the IDD Division Medication Regimen Review Checklist. Follow up on any discrepancies immediately.
• Ensuring an adequate refill supply at all times by logging into refill alert and communicating with the pharmacy and medical doctor as necessary

Medical Assessments

• Annual, Semi, Quarterly, Self-medication assessment, 24 hour Nursing Care and Medicaid Certifications as needed

Consumer Weights

• Complete within the first 7 days of the month and follow up on any significant increases or decreases immediately

Bowel Movement

• Ensure Consumers bowel movement are charted consistently and implementing prescribed protocol should any discrepancies be noted

Weekly Medical Reports-

• To be disseminated at the end of each week to the team. Capturing a recap of all appointments from the week and all follow up recommendations.
• Team members include: Manager, Assistant manager, QIDP, Medical Specialist, Senior Vice President, Area Director, Director of Nursing, Behavior Intervention Specialist, Director of Food and Nutrition and Consulting Dietician

Staff Training

• Conducting AMAP refreshers at least quarterly and other in-services of consumer protocols as needed.

 

Essential Knowledge, Skills and Abilities

• Knowledge of professional nursing concepts, principles and practices.
• Knowledge of concepts and principles from the biological sciences that is supportive of nursing practice
• Knowledge of concepts and principles of health promotion and disease prevention.
• Knowledge of abnormal signs and symptoms relating to physical and mental illness, as well as indicators of wellness
• Knowledge of medications and drugs, common dosages, their psychological, physical and physiological effects and possible adverse reactions.
• Knowledge of emergency treatments and interventions.
• Knowledge of teaching and consulting techniques.
• Knowledge of the Agency's routines, procedures and policies.
• Knowledge of cultural, ethnic, and linguistic needs of clients relating to cultural competence.
• Ability to recognize changes in signs and symptoms that warrant the immediate action of a physician.
• Ability to develop, evaluate, implement and modify a plan of nursing intervention to meet the needs of individual clients.
• Ability to secure the cooperation of and work effectively with others. Ability to prepare accurate and timely reports.

Qualifications and Experience

New York State License and current registration to practice as a registered professional nurse, prefer at least one year post RN licensure clinical nursing experience working with individuals with developmental/intellectual disabilities.

 

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