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REGISTERED NURSE (full-time)

SCO1005SCOF

Brentwood, NY, United States6d ago

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Skills

cfainfection controlinternal auditmedical recordsmedication administrationoshapatient assessmentrecord keepingtreatment planningvital signs

About the role

  • Oversees all medical aspects of the person supported health:
    1. Has at least one face to face contact on a weekly basis with each person supported to ensure physical well-being.
    2. Ensures the required medical appointments for each person supported are scheduled based on his/her individual needs and as per regulatory requirements.
    3. Ensure all nursing assessments are completed accordingly.
  • Ensures that there is an adequate supply of medication for each person supported by completing a medication storage at minimum at least once per month.
    1. Ensure persons supported are receiving prescribed medications, treatments and diets as ordered.
  • Reviews all routine, pre- and post-surgical, and Urgent Care/ER visit summaries in their entirety. Document findings/assessments/recommendations accordingly in a nursing note, if applicable.
  • Serves as an advocate for the person supported during their medical care with the Prescriber.
  • Maintaining a high level of professionalism with the ability to lead professional settings such as audits and participate in conferences representing the agency.
  • Visits the people supported during hospitalizations or nursing rehab admissions to ensure their healthcare needs are being met at a minimum of once a week, or as needed based on the medical necessity and acuity of the person supported.
  • Provide RN Coverage of other I/DD sites deemed necessary.

CLINICAL RESPONSIBILITIES:

  • Actively participates as a member of the person supported program planning team.
    1. Ensures that all health and medical-related issues are discussed with the Team to foster awareness and develop a plan of care.
    2. Participates in program planning/goal development as it relates to the person supported's health/medical needs.

RECORD KEEPING RESPONSIBILITIES:

  • Maintains all mandated medical records:
    1. Nursing notes (minimum of once a month)
    2. Medical visit summaries
    3. Discharge summaries from Urgent Care/ER/Hospitalizations
    4. Prescriber's order/script
    5. Plans of Nursing Services (PONS)
  • Complete all medical reports for the person supported (CFA, ICFs only, or ISP, IRA only) in a timely manner. Participates in these meetings to provide a medical update to the Team and circle of supports.
  • Responsible for the oversight of person supported charts, including:
    1. MAR/Treatment Records (minimum of once a week)
    2. Updated Prescriptions/Formulary
    3. BM Charts (minimum of once a week)
    4. Medical Books
    5. Flowsheets including, but not limited to: Vital signs, Blood Sugar Records, Body Check, Head Injury, Seizure, Repositioning, Controlled Substance Count, etc.
    6. PONS (updated annually or when there is a change in diagnosis or treatment plan)
  • Participates in the internal auditing process utilizing the Chart Audit Tool on a quarterly basis.

STAFF TRAINING RESPONSIBILITIES:

  • In-service staff at scheduled staff trainings, staff meetings and shift meetings on:
    1. General health issues, including but not limited to Illness Detection, OSHA/Infection Control, First Aid, Diets, Diabetes, Seizures, Epi-Pen, AMAP, Hygiene Issues, etc.
    2. Person Supported specific needs, including the procedures/issues that are occurring, the purpose of the procedure/treatment, precautions, and possible side effects of the procedure/treatment.
    3. PONS training will occur annually of if there is a change in a diagnosis or treatment plan.
  • Train AMAP staff on responsibilities regarding medication administration.

OVERSIGHT RESPONSIBILITIES:

  • Ensure that health and safety procedures are being followed according to State and Federal regulations.
  • Triage health concerns of the individuals via telephone and provide directives to the staff as necessary.
  • Direct the staff to utilize Telehealth services when deemed necessary to decrease Urgent Care/ER visits.
  • Supervises the AMAP's dispensing of medication and treatments as per the prescriber's orders.
  • Ensure that medication errors are reported accordingly and the AMAP is trained on ways to prevent medication errors in the future.

PERFORMANCE:

  • Maintains a standard of high quality of work and productivity.
  • Has overall knowledge of the person supported:
    1. Program Plans
    2. Medical Status
    3. Day Program
  • Follows through on issues in a timely manner.
  • Demonstrates good judgement and decision-making.
  • Is a good role model for both staff and person supported.
  • Has a good attitude and team spirit.
  • Is flexible and takes initiative.
  • Has good attendance.
  • Responds to directives as per the Nursing Supervisor.

QUALIFICATIONS:

  • Licensed RN
  • One year of experience working with people supported with an intellectual development disability preferred
  • Respect for the person supported and embodies the importance of person-first language & the Justice Center's Code of Conduct
  • Valid N.Y.S Driver's License