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Residential Licensed Practical Nurse

4 months ago

Mays Landing, United States AtlantiCare Full time
Job Description

TITLE:Residential Nurse, LPN

REPORTS TO:Shift RN/Assistant Director of Nursing/Director of Nursing/Nursing Supervisor

DEPARTMENT:Medical/Nursing

REVISED DATE:July 2022

SUMMARY:Under the direction of the Director of Nursing, Assistant Director of Nursing, the LPN Residential Nurse is responsible for the effective operation of the Detox Unit. The Residential LPN performs the duties required in compliance with state and federal regulations

JOB REQUIREMENTS:

Licensed nursing personnel shall, at a minimum, be responsible for the following:

1.Participating in the development of client treatment plans;

2.Providing face-to-face health care monitoring for the facility's clients;

3.Where medically and clinically appropriate, participating on the multidisciplinary treatment team; and

4.Providing required documentation in the client records.

Only a registered professional nurse shall assess the nursing care needs of clients.

All nursing services provided shall be documented in the nursing portion of the client care plan and shall comport with the facility's policies and procedures governing client documentation and with this subchapter. Such documentation shall include, but need not be limited to, the following:

1.Clinical notes;

2.A record of medications administered including, but not limited to:

i. The date the medication is ordered by the physician and the date the medication is to be discontinued;

ii. The name and strength of the medication;

iii. The date and time of the administration of the medication;

iv. Effects of medication (if indicated);

v. The dosage administered;

vi. Method of administration;

vii. The signature of the nurse who administered the medication or identification of the nurse by an entry code if a computerized clinical record system is used. If initials are used, a section shall be included identifying the respective signature and title for all initials; and

viii. The reason the client refused to receive the medication or why the client did not receive the medication at the designated time, if applicable; and

3.A record of medication self-administered by clients shall be maintained in the nursing portion of the client care plan and the medication administration record. Such documentation shall include:

i. Whether medication was taken orally, injected, inserted, topically or otherwise administered by a client to himself or herself;

ii. Verification of the dose with the prescriber's orders;

iii. Verification that the client took his or her own individual dose;

iv. If self-administration is observed, a recording of the observation that the client has taken his or her own medication orally, by way of injection, topically or insertion in nursing portion of the client care plan and medication administration record; and

v. Signature of the nurse who observed the client's self-administration of medication or identification of the nurse by an entry code if a computerized clinical record system is used

JOB RESPONSIBILITIES:

1.Performs physical, mental and addiction withdrawal assessments of detox clients as per protocol and reports acute changes to medical provider

2.Administers and documents the correct medication when client exhibits signs and symptoms of withdrawal.

3.Refer all clients that do not meet criteria for detox to ACMC for medical evaluation

4.Reviews admission protocol to include medical, surgical and family history and ensures that client's laboratory and urine drug screening are completed within required timeframe

5.Maintains a safe, therapeutic, client-focused environment in the detox unit. Treats all clients with dignity and respect.

6.Monitors meals and provides proper nutrition for clients in detox process.

7.Responsible for shift assessment; ensuring vital signs, medication administration records, withdrawal assessment scores and progress notes for assigned clients are completed and documented correctly in EMR. Ability to supervise and monitor documentation required by Medical Assistants

8.Maintains confidentiality of all client information in accordance with state and federal regulations

9.Responsible for maintaining medications, medication rooms and carts, keeping them clean, neat and orderly at all times.

10.Responsible for verbal or written shift report before and after every shift.

11.Responsible for proper narcotic counts before, after every shift or if there is any staff changes during a shift.

12.Monitors emergency equipment checks for expirations, proper maintenance for equipment. Monitors nursing unit and common areas and addresses any spills, trip hazards or housekeeping needs of facility

13.Able to respond to medical emergencies throughout building on all units, including Detox, Short Term and Long Term Residential. Ability to document and communicate to medical providers any changes in client's status and obtain verbal orders

14.Maintain CEU as required for LPN license in state of New Jersey and to enhance skills as addiction/detoxification nurse

15.Participate in departmental meeting, treatment teams and facilitate educational in-services for clients and staff as needed for health and wellness of facility. Responsible to facilitate training for client orientation, Narcan training, and state department of health issues as needed.

16.Must attend at least 6 staff meetings per calendar year

17.Perform other related duties as assigned by immediate supervisor and other management as required

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1.Ability to actively engage in conversation with clients in order to clearly understand their needs.

2.Ability to use appropriate communication method to fit the situation.

3.Ability to perform assessment for signs and symptoms of dependency and withdrawal

4.Ability to express oneself clearly when presenting ideas or concerns with respect to all cultures, ethnic or gender specific backgrounds

5.Capable of adapting to changing environments, policies or administrative procedures

6.Ability to establish and maintain a positive and cooperative working relationship with all employees. Reports to proper chain of command any urgent concerns, violations, or client or staff safety concerns

7.Demonstrates knowledge of health related issues regarding addiction, detoxification, chronic diseases, communicable and infectious diseases.

8.Knowledge of universal precautions and ability to educate staff and clients on standard protocols

9.Knowledge of medication administration, potential interactions and proper storage and security of all classes of medications.

10.Knowledge of nursing assessment, physical exam and ability to identify acute mental or physical changes

11.Ability to maintain medical or clerical supplies and report needs to supervisor as needed

12.Ability to participate in treatment team meetings as needed and assigned by supervisor

SUPERVISION RESPONSIBILITIES

Medical Assistants

QUALIFICATIONS

Graduate of an accredited school of nursing

Licensed Practical Nurse in the State of New Jersey

Minimum of one year experience in detoxification

The Institute reserves the right to revise or change this description and the duties and responsibilities herein as the need arises. This description does not in any way constitute a written or implied contract of employment.