Nursing Staff Supervisor Rn or Lvn Behavioral Health
3 weeks ago
**Job Duties & Responsibilities**
- Provide nursing care, treatment, and services to HCBTS’s residential withdrawal management clients. Care, treatment, and services provided are individualized, evidence-based, culturally sensitive, and appropriate for the needs of the individuals served. Complete your duties and responsibilities in a timely and professional manner, in accordance with HCBTS Physician/MD instructions/guidance and HCBTS policy/protocols, and within your scope of practice.
- Responsible for completing and documenting the nursing care provided and the client’s condition/status, including but not limited to: initial nursing screening, nurse progress notes, client health questionnaire, suicide risk screening, nutritional risk screening, TB (PPD) screening, and other professional documentation in HCBTS’s EMR system (KIPU) in a timely and professional manner within your scope of practice.
- Observe, screen, and document Client progress and updates to the Client’s status, including but not limited to the following as observed and/or reported: symptoms, reactions, behaviors, vital signs, withdrawal, pain, cravings, physical health conditions/problems, client statements/thoughts/feelings, medication compliance/response, appetite/meals, sleep, personal hygiene, and changes in the client’s condition. Complete EMR documentation in a timely, detailed, and professional manner within your scope of practice.
- Observe, screen/assess, and document Client vital signs and withdrawal management screenings (CIWA / COWS) as appropriate and within your scope of practice.
- Document, monitor, secure, and account for all client medications in the healthcare office in accordance with HCBTS policies and procedures. Document and directly observe each client’s self-administration of medications. Monitor client’s reactions to medications and respond to real or potential adverse drug events/reactions in accordance with Physician instructions/protocols, HCBTS P&Ps, and within your scope of practice.
- Complete your responsibilities for the receipt of client medications, security of medications, and the proper disposal of medications / controlled substances / illegal substances in accordance with HCBTS P&Ps. Closely review medication orders and follow HCBTS physician/MD protocols to verify that medication orders are clearly understood and accurate, as this is critical to reducing the potential for medication errors and the misinterpretation of medication orders.
- Properly utilize Narcan (Naloxone HCL) for known or suspected opioid overdose as appropriate and in accordance with HCBTS’s Narcan protocol. Communicate with the Pharmacy regarding client prescription medications. Perform medication reconciliation documentation, audits, and other medication-related tasks as assigned.
- Complete, monitor, and document client observation rounds in the environment of care.
- Closely monitor, identify, and report clients who are or may be experiencing thoughts of self-harm, harm to others, and/or suicidal ideations/behaviors in accordance with HCBTS policies and procedures. Monitor, identify, and address clients who are attempting to leave treatment ACA. Communicate with the Medical / Clinical / ACA teams for appropriate interventions in accordance with HCBTS policies and procedures. Utilize de-escalation and crisis intervention techniques to calm, comfort and stabilize distressed clients.
- Perform nursing tasks in accordance with the Physician/MD’s instructions and protocols.
- Provide education and instructions to the Client as applicable and appropriate under the circumstances.
- Perform your work in a manner that supports, contributes, and promotes a treatment environment that is safe, healthful, caring, comfortable, supportive, culturally-competent, and therapeutic.
- Communicate and coordinate with other HCBTS team members and departments to provide for an interdisciplinary approach to the provision of care, treatment, and services to HCBTS clients in accordance with the needs of each individual client.
- Complete EMR documentation in a timely, detailed, and professional manner in accordance with HCBTS policy/protocols, evidence-based practices, State licensing/certification laws and regulations, and The Joint Commission standards.
- Plans, prioritizes, manages, and completes work duties and responsibilities in a timely, professional, and effective manner.
- Complete compliance reports and provide support and assistance in the development and improvement of healthcare policies and procedures.
- Participate in the continuous quality management and performance improvement process. Responsible for performing tasks and assignments in support of this process when requested and as appropriate.
- Provide support and assistance for coordination of care and continuing care purposes. Work collaboratively with the clinical team to promote, facilitate, and achieve desired treatment outcomes for clients.
- Communicate appro
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