Registered Nurse at Family… · New York

JOB DESCRIPTIONSummary/ObjectiveUnder the supervision of the Nursing Supervisor, the Registered Nurse (RN) is responsible forthe overall oversight and supervision of the healthcare needs of the people we support. The RNwill work in conjunction with medical providers to ensure the delivery of the highest quality ofintegrated health and continuity of care to the people supported across the FREE network.Essential Job Functions• Review, modify and update the individual’s plan of nursing care in accordance withmedical diagnoses and treatment plan. Ensure nursing care plans are updated annuallyand whenever a new diagnosis is added.• Ensure staff are trained on individual plan of nursing service.• Spot check medication count to ensure that the records for narcotics control andneedle/syringe supply are accurate.• Ensure supplies of medication and first aid materials are adequate and not expired, thatmedication is stored and disposed of according to agency policy. Complete monthlymedication storage.• Ensure individual-specific formulary is present for all medication administered to eachindividual.• Validate the Medication Administration Record on a weekly basis for requiredinformation: medication given as ordered and started in a timely fashion; no blanksignatures, record is initialed on front and signed on back, PRN symptoms are chartedand result stated, note reason for any discontinued medications.• Check that doctor’s orders and prescriptions are current, medication formularies are inplace for each medication, and MARs are printed and completed correctly. Grab and Gobooks have current information.• Ensure that procedures for new medication orders are accurately completed (are dated,signed, noted in Formulary and copied to all appropriate parties).• Check that all medication administered has a matching label, order and medication sheetentry.• Monitor effects of medication; document as needed.• Track and document all medical appointments; illness or accident; current medication;medication changes; current diet (weight loss and gain) and all charts required by theindividual’s nursing care.• Ensure that all physician appointments and follow ups are scheduled as ordered. Reviewincoming physician summaries for instructions, medication changes and treatment ordersand implement all changes. Ensure that all emergency room/hospital dischargeinstructions are followed up and documented.• Maintain a tracking log for all individual’s for all appointments; ensure that recurring andannual appointments (vision; hearing; nutrition; dental exam and cleaning; special needs)are scheduled and attended.• Complete all necessary nursing assessments per agency policy (quarterly, bi-annually,annually), including, but not limited to, as Fall Risk assessment, Nursing Visuals, Self-Administration of Medication Evaluation, and Tardive Dyskinesia Screening. BradenScale for predicting pressure under risk semi-annually.• Perform physical observation of individuals (skin/nails/hair/overall health).• Review incident reports and occurrences; counsel and/or re-train staff as needed to ensureaccurate reports.• Validate accuracy and timeliness of entries in all required individual’s charts.• Conduct Nursing In-service training of residential/day service to include: recognition ofillness or dysfunction, disease, infestation and indicators of injury that warrant medical ornursing intervention; taking vital signs; addressing consumer-specific health problemsand needs (e.g. diabetic/daily foot care); administering any necessary treatment (e.g.warm soaks); performing first-aid on occasion of accidents (injury); making a diagnosis;following proper emergency procedures; writing incident reports. Add topics asnecessary.• Maintain a record of dates when required in-service sessions for residential/day programstaff/ were conducted.• Teach AMAP Certification/Recertification classes as well as the required curriculum forAgency orientation.• Supervise AMAP staff during certification/recertification for accurate pouring and vitalsigns.• Participate in meetings regarding the care and concerns of the individuals, includingISP’s, Interdisciplinary Team Meetings, Project Management and House Meetings.• Maintain communication with physicians, Day Programs and family members regardingthe individual’s care.• Ensure that program nursing staff maintain communication log for each other; informday/residential program nursing staff as appropriate.• Review nursing communication log for summary of doctor’s visit; ensure thatinformation is complete, accurate, and documented in the individual’s records including:results of tests and recommendations for necessary follow up.• Report possible violations of individual’s rights promptly, and complete and submitincident reports in accordance with New York State regulations and Agency policy.• Participate in any investigation into incidents occurring within the program as requestedand maintain confidentiality in regard to such investigations.• Maintain the confidentiality of any information relating to the individual’s in the programas per HIPAA guidelines.• Complete required documentation (paper and/or electronic) in a timely, accurate fashionand as per compliance regulations.• Ensure all required documentation is maintained in records in the prescribed manner.Duties and Responsibilities• Report ongoing problems and suggest solutions to improve working/environmentconditions.• Receive and communicate effectively on feedback from management, peers, other staffand consumers in a cooperative manner.• Handle program equipment, consumable materials and resources in a cost-consciousmanner.• Keep updated and review any regulation changes in State or Federal policy and/orAgency procedures.• Provide your projected weekly schedule to your supervisor.• If position includes being “on call”, ensure timely response to calls from the residence,day program, family members, etc.• Obtain/maintain certification in CPR and SCIP as needed per Agency policy.• Maintain copy of your current license with the Human Resources Department.• Follow the Code of Conduct and Agency Standards as outlined in the EmployeeHandbook.• Accurately and positively communicate Agency philosophy and administrative decisionsto other staff in a timely and professional manner.• Attend and complete training in accordance with New York State regulations and AgencyPolicy.• Assist in maintaining Agency property in a neat, orderly and safe manner and report allrepair needs in a timely manner as per site-specific needs.• Observe Agency policy and procedures for building security and identification ofauthorized personnel.• Follow HIPAA and OSHA regulations, including universal precautions.• Check that the following are posted and used correctly: Poison Control number,emergency numbers, pharmacy telephone numbers, medical providers, and nursing oncallinformation.• Provide transportation as required.• Report all violations and/or accidents in Agency or personal vehicle in accordance withNew York State regulations and Agency policy.• Address emergency situations as they occur in the program according to establishedpolicies and procedures, and ensure communication of such situations in a timely manner.• Provide coverage in emergency situations until relieved of the responsibility.• Ensure the physical safety and security of the individual by taking precautionary andpreventative measures against conditions in the environment which might cause physicalharm.• Ensure the appropriate protective and preventive measures for both staff and consumersin the control of communicable and infectious diseases including identification,assessment and reporting of same.• Ensure that the individual’s needs are met and intercede on the individual’s behalf asnecessary.• Treat each individual with dignity and respect in accordance with New York Stateregulations and Agency policy.• Complete and submit occurrence forms and incident reports in a timely, accurate fashionand as per agency policy and State regulations; counsel or re-train staff as neededregarding reporting procedures.• Utilize information acquired through training, meetings, education and experience tobenefit individuals.• Perform additional responsibilities as requested and/or necessary, including supportingalternate locations when assigned.Education, Work Experience, and Competencies• NYS Licensed Registered Nurse.• Associates in Nursing or related field.• Bachelors in Nursing or related field preferred.• Experience working with the differently-abled population preferred.• Knowledge of OPWDD, DOH, or OMH state and federal regulations preferred.• Ability to manage multiple priorities and ability to be flexible to meet the needs of adiverse population in a variety of settings.• Strong verbal and written communication and organizational skills.• Valid NYS Driver’s License.Work Environment• Duties are performed in a classroom or residential environment. The noise level in thework environment varies.• The job risks exposure to disease/pathogens; blood and bodily fluids; medications; andtoxic or caustic chemicals.Physical Demands• The employee must frequently lift or move items weighing up to 10 pounds. Occasionallifting, pushing, pulling, transferring, carrying and/or moving adult individuals receivingservices.