• Communicates health/nursing needs and/or recommendations to RN supervisor
• Coordinates admissions, discharges, and follow-up as needed.
• Assists in medical/health appointments as needed
• Ensures the provision of nursing/health services under the direction of the RN and as ordered by the physician, provides direct care as outlined in the Service Plan/Nursing Care Plan
• Takes and records vital signs, weights, wound measurements, etc. Identifies trends outside of parameters, or in need of attention and communicates to RN/physician
• Reports pertinent information and changes in individual health status to attending physician/health professionals and to the Team as needed in a timely manner
• Ensures the provision of needed adaptive equipment
• Medication Administration:
• Administers medications, verifying the correct medications are administered (per the six “rights” of medication administration), and that client’s response to medications is noted and documented along with any noted side effects
• Works closely with home/facility/pharmacy staff in consulting on psychotropic medications, side effects, and medication reviews
• Orders, reviews, monitors, and discontinues medications as ordered by physician. Dispose of unused medication per policy
• Assures that monthly Medication Administration Records (MAR’s) are accurately transcribed in each individual’s record
• Checks the medication cabinet on a weekly basis to ensure medications are administered as ordered, appropriately documented on the MAR, and that missed medications are documented, and required follow-up occurs
• Returns completed med cards at the end of each month, along with expired and unused medications as applicable
• Checks program/service areas on a frequent but not less than a monthly basis to ensure the necessary medical/nursing/medication supplies are available and in ample supply
• Reports client illness, potential communicable diseases or infections and works closely with RN, direct care staff, other programmatic and health care professionals, and family in maintaining a safe environment for clients and staff. Implements isolation precautions as needed
• Ensures health status, care and services are documented accurately and timely per company and state requirements
• Provides supervision and education for non-licensed staff in the provision of care and services and reports any changes
• Complete a quarterly nursing evaluation/review of body systems on assigned individuals per program requirements. Refer to physician any assessment findings needing further review.
• Ensures incidents are recorded, the individual is safe, receives required medical care, communicates to RN, operations leadership timely
• Transcribes physician phone orders and other medically related reports
• Participate in on-call duties to ensure weekend and after-hours access to clinicians by staff and individuals served (participates in on-call rotation as assigned)
• Participates in clinics completed at the operation with PCP, psych, etc. as assigned.
• Participates in quarterly quality improvement activities, weekly team/staff meetings and Interdisciplinary Team meetings (IDT/PDP)
• Work hours may vary – weekends and evening shifts/visits may be required
