REGISTERED NURSE

Job Summary:

Responsible for delivery of patient care through the nursing process of assessment, planning, implementation, and evaluation. Directs and guides patient teaching and the activities of ancillary personnel while maintaining standards of professional nursing. Understands and adheres to GCMC's Compliance Standards as they appear in GCMC's Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy. Keeps abreast of all pertinent federal, state and GCMC regulations, laws, and policies as they presently exist and as they change or are modified.

Experience:

* Entry level-graduate per Education requirements
* Specialty Units-At least 1 year of medical-surgical nursing preferred. (i.e. ICU, Maternity, Psych)

Skills:

* See core competencies and unit specific competencies

Licensure/Certificates/Certification:

* Current NYS license to perform as a registered professional nurse
* Current BLS-CPR certification required (or within first 30 days of employment)
* Specialty Unit - Maternity - Neonatal Resuscitation Certification within 6 months of employment
* Specialty Unit -ICU- ACLS within 6 months of hire

Essential Job Functions:

Accordingly, employees may be asked to perform duties that are outside the specific functions that are listed.

Assessment-Performs patient assessment and documents accurately in a timely manner per nursing and department policy.

* Performs nursing admission assessment thoroughly and within timeframe. Documents the admission assessment accurately and completely.
* Performs skin risk assessment accurately and reassessment per policy and protocol.
* Performs pain assessment and reassessment per policy and utilizes hospital approved pain scale and documents appropriately.

Patient Monitoring-Monitors patient as appropriate for condition, status and safety according to nursing department policy.

* Monitors patient's vital signs and systems per protocol and documents on appropriate forms.
* Recognizes change in patient's condition or status and reports to charge nurse or physician as appropriate.
* Calls CAT team for patients who meet criteria.
* Works to ensure patient safety is maintained in all aspects of patient care, by following all policies related to National Patient Safety Goals, etc.
* Raises concern about patient care and utilizes the Chain of Command as needed to prevent patient harm.

Medication Administration-Performs safe administration and complete documentation of medications, IV fluids, and blood products in accordance with nursing policy.

* Follows medication administration policy using e-Mar, bar coding and scanning of medications and has at least an 85% scan rate.
* Insertion of IVs under aseptic technique and follows IV policy by changing site, tubing and dressing and documents accordingly.
* Always follows hospital policy when administering blood products.
* Maintains security of electronic signature with Omnicell and accounts for all narcotics removed from automated dispensing system through proper waste/return administration documentation.

Patient and Family Education

* Assesses and addresses educational needs of patients and families to include disease state, care and treatment.
* Documents educational needs.
* Distributes appropriate teaching sheets.
* Includes evaluation of learner's understanding post-teaching.

Safe Discharge/Discharge Planning

* Contributes to or initiates discharge plan upon day of admission and participates in interdisciplinary planning.
* Completes all pre-discharge checklist items.
* Always gives patient correct forms and discharge instructions by using 2 patient identifiers.
* Provides patient a safe discharge and appropriate follow-up information and community resources are in place.

Assist Providers-Assist providers in performing procedures and treatments per unit, department specific and hospital policy.

* Assist physicians/providers with beside procedures and remains competent with unit-specific procedures.
* Performs read back of critical values and telephone orders when interacting with physicians as warranted.
* Uses SBAR when giving physicians report on change in patient condition.

Equipment Use

* Demonstrates knowledge and ability to use equipment safely and effectively.
* Utilizes hospital equipment per policy (i.e., guardrails for IV pumps, alarm settings).
* Uses patient lift equipment per policy at all times.

Nursing Clinical Skills- Demonstrates the ability to perform nursing treatments and procedures.

* Demonstrates competency, knowledge, and ability to perform nursing treatments and procedures safely and effectively.
* Conducts Hourly Rounds on patients using 4 P's and documents on appropriate forms.
* Regularly uses patient room white boards to communicate information to patients and families.

Emergency Preparedness-Demonstrates working knowledge and understanding of emergency preparedness plans and operations.

* Aware of and actively participates in emergency preparedness procedures and operations.
* Aware of and actively participates in Code Blue, Green, Pink, Orange, White, and Silver drills and actual events.

Documentation-Completely and accurately documents patient care activities and response in a timely manner in accordance with department and hospital policy.

* Documents on a regular, real time basis all patient care activities in accordance to hospital policy.

Nursing Promotion-Promotion of professional nursing to include participation in PI/QI, Customer satisfaction, community involvement, committee activities and nursing continuing education.

* Actively sits on and attends at least 1 team or committee, or participates in unit PI activity or department team or projects
* Attends at least 75% of all staff meetings.
* Attends at least 1 clinical update and all mandatory in services.
* Participates in unit specific or hospital wide PI/QI activity.

Infection Control-Provide safe and effective patient care in accordance with hospital Infection Control policy and procedures.

* Wears appropriate PPE as warranted.
* Follows hand hygiene protocol.
* Follows all isolation procedures.

Utilize nursing process-Identify patient needs and problems through assessment. Implement nursing interventions based on nursing diagnosis. Develop individualized patient care plan. Provide appropriate discharge instructions to patient and family.

* Initiates individualized patient plan of care for all admissions.
* Edits Plan of Care on a regular basis per policy.
* Document's interventions every shift based on nursing diagnosis.

Assist and provide for participation in clinical learning experiences.

* Participates in learning experiences for orientees, nursing and ancillary staff and students by serving as a preceptor.
* Participates in Nursing Grand Rounds at least quarterly by either attending a session or assisting in preparing for unit topic.

Provide for continuum of care-Assure safe patient hand off through effective communication of the treatment status of each patient.

* Participates in interdisciplinary care/discharge planning.
* Uses SBAR for patient handoffs.
* Uses Ticket to Ride and communicates important information to other departments.

Other Duties as Assigned

Employees may be asked to perform duties that are outside the specific functions that are listed.

The pay range for this position is $37.50 - $53.06 per hour.

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