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Patient Care Registered Nurse
2 months ago
Key Responsibilities:
Execute physician directives, administer prescribed medications, perform medical procedures, and deliver treatments aligned with patient care requirements, medical directives, institutional policies, and nursing standards. Evaluate patient conditions and orchestrate, coordinate, and oversee nursing services, including rehabilitative care, to guarantee adherence to care standards and protocols.
• Supervise and guide Medication Aides, ensuring proper monitoring and appropriate actions regarding any effects, side effects, interactions, and contraindications related to medications administered by them.
• Adhere to civil service regulations, collective bargaining agreements, organizational policies, and legal standards to foster a collaborative, secure, respectful, and high-quality work atmosphere. Cultivate effective relationships with clients, residents, management, staff, external agencies, vendors, and the community.
• Provide direct patient care in accordance with care plans, physician orders, and nursing standards while employing independent judgment, critical thinking, and fundamental nursing skills.
• Deliver patient education tailored to individual needs and care standards. Develop, document, and implement personalized, interdisciplinary care strategies to ensure all medical needs are addressed; complete sections of the Minimum Data Set (MDS) assessment as required.
• Accurately record assessments, care provided, educational efforts, and observations in medical records; ensure entries reflect the medical needs of individuals, the care delivered, and their responses; and confirm that progress notes indicate adherence to and updates of care plans as necessary.
• Assist in the orientation, direction, training, and evaluation of subordinate team members.
• Collaborate respectfully with team members, families, visitors, and volunteers to foster a positive healthcare environment.
• Conduct nursing rounds, provide follow-up supervision, and collaborate with nursing and medical staff to ensure quality care; consult with attending physicians as necessary for treatments, medications, and rehabilitation.
• Ensure team members are informed of each individual's care requirements; conduct change-of-shift reports utilizing professional expertise to assign team members based on their training and scope of practice.
• Act as a resource for others, promote a constructive work environment, and assist in resolving complaints and conflicts; orient new patients and their families to the facility.
• Maintain confidentiality regarding departmental, patient, and employee information; ensure communication and documentation comply with all privacy regulations, including HIPAA.
• Promptly notify the Director of Nursing, Nurse Manager, or House Supervisor, as well as the patient's physician, of any changes in patient conditions; initiate follow-up to ensure safety and care; and immediately report any suspicions or allegations of abuse, neglect, or misappropriation of property.
• Review documented care plans and discharge strategies; participate in updating these plans as necessary.
• Assist with the admission, transfer, and discharge of patients; complete all associated documentation.
• Serve as a mentor and preceptor to colleagues, students, and external personnel; follow up to ensure they operate within their scope of practice and facilitate learning through positive role modeling.
• Encourage and empower patients to maintain or regain their independence, accommodating their individual preferences, assisting them in directing their daily lives, and helping them manage their personal belongings according to their wishes.
• Investigate and address complaints or suggestions from patients, coworkers, or the public; take appropriate steps to resolve issues.
• Respond to and assist with medical and psychiatric emergencies and codes competently.
• Observe, adhere to, and promote emergency and safety protocols related to hazardous materials, chemical use, fire, weather, internal disasters, elopement, community disasters, and other safety concerns.
• Attend and engage in educational programs aimed at enhancing personal knowledge and skills, as well as those necessary for maintaining licensure.
Required Documentation:
• BLS Certification
• RN License from the state of NE
• Covid Vaccination Card or Exemption Form