Registered Nurse

Physical and Environmental Demands

Visual acuity and manual dexterity are needed for required paperwork. Frequent talking and hearing are required when communicating with co-workers, families, and other service providers. Physical demands are light with walking, standing, and occasional stooping. Possible exposure to communicable diseases during contact with individuals released from various locations i.e. jails, hospitals, unsanitary conditions, rehabilitation centers, etc.

Job Responsibilities

• 1.
• Able to provide quality customer service to personnel, persons served, families and stakeholders.
• 2.
• Helps maintain the health, safety and welfare of personnel, person served and stakeholders.
• 3.
• Be a leader and example in medical team by demonstrating the highest level of compliance and exemplary performance.
• 4.
• Participate in quality assurance by monitoring quality of medical care, documentation, and client interactions they provide.
• 5.
• Maintain current licensure and certifications.
• 6.
• Identifies client care requirements by establishing rapport with potential and actual clients by maintaining an open-door policy.
• 7.
• Follow detox protocols per organization policies and procedures.
• Including, but not limited to completing frequent face to face assessments (minimum of once a day), COWS/CIWA scales when applicable, administering ordered medication, etc.

• 8.
• Complete daily rounding of detox clients at bedside.
• 9.
• Promotes client’s independence by establishing client care goals; teaching client to understand their condition, medications, and self-care skills, answering questions.
• 10.
• Assures quality of care by adhering to therapeutic standards; measuring health outcomes against client care goals and standards, making, or recommending necessary adjustments; following agency and nursing division’s philosophies and standards of care set by State Board of Nursing, State Nursing Practice Act and other governing agency regulations.
• 11.
• Maintains safe and clean working environment by complying with infection-control policies and procedures.
• 12.
• Protects clients and personnel by adhering to medication administration and storage procedures, controlled substance regulations, and disposing of unused/abandoned medications per organizations policies and procedures and state regulations.
• 13.
• Complete inventory of supplies and stock medications and notify appropriate staff to obtain necessary supplies.
• 14.
• Works with other medical and program staff to complete initial intake rapid COVID testing and report results to appropriate team members.
• 15.
• Obtain lab specimens per Medical Provider (MD/APRN/PA) orders, report results to Medical Provider within a timely manner, and document results in electronic medical record.
• 16.
• Complete initial Nursing Assessments with each client per CARF requirements.
• 17.
• Document client care services by charting in client and department records.
• 18.
• Documenting client progress in nursing progress notes in electronic medical record.
• Charting by exception (ER visits, new symptoms/complaints, noticeable progress, etc.).
• 19.
• Documenting communication with Medical Provider (MD/APRN/PA) and new medications or treatments ordered.
• 20.
• Initiate new orders from Medical Provider (MD/APRN/PA) within a timely manner.
• 21.
• Assess client concerns on an as needed basis, triage needs, provide appropriate care within scope of practice, and notify Medical Provider (MD/APRN/PA) for further orders as needed.
• 22.
• Assist in preparing clients to see Medical Provider (MD/APRN/PA) for initial evaluations (I.e., obtain list of client's current medications, allergies, health concerns, and most recent vital signs).
• 23.
• Complete “Shift Report” with off-going and on-coming medical staff through email and in person communication.
• 24.
• Ensures and maintains client confidentiality and adheres to HIPAA regulations.
• 25.
• Assist with training non-licensed personnel in medication administration upon hire, annually, and when retraining needs are identified.
• 26.
• Provides feedback and education to all clients in collaboration with clinical and programming teams.
• 27.
• Respond to screening approval emails in a timely manner.

• 28.
• Serve as a liaison for the Medical Provider (MD/APRN/PA) and Pharmacy(s).
• 29.
• Complete phone screenings and send them to appropriate team members for approval in a timely manner.
• 30.
• Assist with Health and Safety policy development and implementation when requested.
• 31.
• Prepare Plans and follow-ups in accordance to CARF Standards.
• 32.
• Other duties as assigned.

General Standards

• 1.
• Exemplify Core Values 2.
• Follows the Ethical Code of Conduct 3.
• Follows the Chain of Command 4.
• Maintain Confidentiality of all client information.
• 5.
• Maintain a safe environment for recovery 6.
• Maintains all requirements for job duties to include but not limited to TB skin screening and any continuing education requirements necessary.