POSITION SUMMARY: As a member of the Interdisciplinary Care Team (IDT), the Registered Nurse (RN) performs physical assessments and completes health histories; monitors the physical and psychological health of the client; interprets patient information; and makes critical decisions about needed actions. This nurse collaborates with the physician and other healthcare providers and educates clients, families, and staff.
This nurse practices within the scope of Pennsylvania’s Nurse Practice Act and in accordance with Elwyn’s policies and procedures and those of Elwyn’s regulatory agencies.
Duties & Responsibilities
Complete a comprehensive nursing assessment upon admission/readmission and as changing health needs indicate Complete a Quarterly Nursing Assessment every three (3) months that includes a review of systems, full body exam, skin checks, Braden Scale, and Fall Risk Assessment Provide direct nursing care and clinical oversight of care delivery Upon discharge, complete a Discharge Summary that includes all relevant medication, medical follow up, and pertinent health care information to provide for continuity of care Present clinical data obtained through direct observation, interview, physical assessment and other reports to the IDT members; present information in a concise and organized manner Set daily priorities in accordance with professional nursing judgment Develop a health care plan for clients requiring 24/7 nursing care that will include specific nursing goals and directions for meeting the client’s health care needs Review and revise the health care plan at a minimum of every 90 days and incorporate data gathered through nursing assessments and communication with the IDT Collaborate with Day and Work Services to ensure that the health care needs of the client are communicated and the necessary documentation forwarded Collaborate with physicians, physical rehabilitation professionals, therapists, health care professionals and other members of the IDT to plan and implement the therapeutic program of care Refer clients to physicians when assessment indicates further medical evaluation is required; facilitate transfer to the hospital/Emergency Department as needed Complete hospital and Emergency Department transfer sheets including coping and forwarding the annual physical exam, last set of 90 Day Physician Orders, current Medication Administration Records (MARs), and other pertinent information to the receiving facility Monitor weight and blood pressure measurements at a minimum of monthly and more frequently as indicated by nursing judgement or physician orders Administer enteral tube feedings, blood glucose testing, nebulizer treatments, and skin care as ordered by the physician; use discretion during administration to provide as much client privacy as possible Prepare and administer medication as ordered by the physician in accordance with Elwyn’s medication policies and procedures; obtain verbal orders when necessary and transcribe the information as per policy Document administration of prescribed medications and treatments on hard copy MARs or in an electronic format (eMARs); use discretion during administration to provide as much client privacy as possible Instruct direct care staff on the administration and documentation of specific treatments including but not limited to topical creams and other over the counter (OTCs) agents Evaluate the therapeutic effectiveness of medications and treatments and report any observed side effects and relevant laboratory values to the Health Care Coordinator/Charge Nurse; Contact the physician as directed If using hard copy MARs, review the monthly MAR and validate that all medication and treatment orders are correct and update as needed; remove old MARs from the medication binder and replace with new MARs at the start of every month Assess client progress with the self-administration of medication and work to actively promote increased independence in client function; assist with data collection related to medication goals Complete monthly medication exchanges with the pharmacy provider; immediately reconcile identified issues Administer and document immunizations as ordered by the physician; ensure that necessary consents have been completed prior to administration. Prepare clients for medical appointments through communication and maintenance of NPO (nothing by mouth) status, procedural preps, and the administration of pre-sedation medication Validate that all lab work has been completed as scheduled and document in the nursing progress note; if not completed, schedule follow up and document Document all behavioral and physical changes in the client’s status and other pertinent information in the nursing progress notes; document all changes from baseline status; document effectiveness of prescribed behavioral interventions and nursing actions Contact family members/guardians to report any new injuries that require more than basic First Aid or as otherwise requested by the family Communicate health issues to staff in the program’s Alert Log Document all relevant information in the MAR, nursing progress notes, and 24 Hour Change in Status Report Communicate all pertinent client and unit information to the incoming nurses through written reports Provide significant clinical and informational updates to the Charge Nurse throughout the shift; contact the Charge Nurse by phone (1) hour prior to the end of the shift to provide verbal report Contribute nursing knowledge to the development and maintenance of a safe and therapeutic living environment; inspect the general living areas for present and potential hazards and report to the Unit Director, Health Care Coordinator, or Charge Nurse Monitor for potential infectious disease among clients and staff and report to the Health Care Coordinator/Charge Nurse who will then report to the Director of Nursing, Campus Provide response to emergencies and oversight of medical issues in the role of Charge Nurse as assigned Provide clear and concise direction to Elwyn staff during a medical emergency and direct medical care provided; transfer care to the Emergency Medical Technicians (EMTs) upon their arrival Order medical and nursing supplies for assigned unit; restock supplies upon arrival Maintain medical equipment in proper working order in each assigned medication dispensary; clean equipment at least monthly and facilitate equipment repair as necessary Assist with the training and orientation of new nursing employees Provide nursing coverage to all units as needed; demonstrate flexibility, adaptability, and team work when nursing assignments must be modified In the absence of the Health Care Coordinator, provide nursing leadership to the unit staff for medical issues that arise including but not limited to seizure episode, 26666 call, falls, Ensure timely reporting of all injuries or occupational exposures to blood, body fluids, infectious materials and hazardous chemical in accordance with the facility’s policies and procedures and OSHA guidelines; collaborate with Risk Management as needed Adhere to Elwyn’s policies and procedures related to HIPAA and the disclosure of health protected information Complete all Elwyn mandatory educational requirements by the annual due date Attend nursing meetings and in-services as required Perform cardiopulmonary resuscitation (CPR), and crisis intervention using agency-trained protocols Submit new/current Nursing License, CPR card, Driver’s License, physical exam, and contact sheet on or before the actual due dates Perform other duties as assigned
IMMEDIATE SUPERVISOR: Health Care Coordinator
DIRECT REPORTS: None
CONTACTS: Elwyn individuals, personnel, families/guardians, physicians, health care providers, and service agencies such as pharmacies, hospitals, skilled nursing facilities, and hospice program personnel
Licensed as a Registered Nurse in the Commonwealth of Pennsylvania One (1) year general nursing or medical surgical experience required; Developmental Disabilities nursing experience preferred Demonstrated skill using an electronic medical record system Ability to work in a fast-paced environment and manage and prioritize multiple, often competing, priorities Demonstrated strong attention to detail Demonstrated strong time management and organizational skills Demonstrated excellent judgment with the ability to independently solve problems and make decisions with little or no need for direct supervision Demonstrated ability to anticipate future needed changes or identify problem areas and take effective actions Excellent planning, communication, customer interaction, collaboration, and documentation skills required Current CPR certification Demonstrated ability to work effectively as part of a team Must be able to perform CPR and crisis intervention techniques using agency-trained protocols Demonstrated basic experience with Microsoft Office applications, including Word and Outlook Must have current, valid driver’s license in state of residence, 3 years driving experience in the United States, and acceptable driving record
PHYSICAL DEMANDS/ENVIRONMENTAL PROFILE: See Physical Demands Checklist below which represents the general physical demands and environment conditions to which the employee holding this position must meet, in addition to the duties and responsibilities listed above, to successfully perform the essential functions of this job. Elwyn will engage otherwise qualified candidates for this position whose disabilities may require reasonable accommodations to enable an individual to perform the essential functions.
Elwyn reserves the right to revise or change job duties and responsibilities as needed. This job description is not meant to be an all-inclusive statement of duties and responsibilities of the job nor does it constitute a written or implied contract.
Elwyn is an Equal Opportunity Employer. Elwyn does not discriminate on the basis of race, color, religion, creed, ancestry, pregnancy status, medical condition, gender, gender identity or expression, genetic information, sexual orientation or identity, age, national origin, citizenship, handicap status, marital or family status, mental or physical disability, perceived disability, military or veteran status, political activities or affiliations, or any other characteristic protected under applicable federal, state or local law, ordinance, or regulation.
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