09 Jan MHCC – RN (NIGHTS)

Has principle responsibility of the total nursing care, assessment, planning, implementation, and evaluation of each assigned resident. Assures that the plan of care is carried out in a safe environment through performance and supervision of subordinate personnel. Records resident histories, administers medications, follows physicians orders and communicate with physicians and families as needed.

Department: Nursing
Location(s): Memorial Health Care Center
Supervises: Certified Nurse Aides
Chain of Command: RN, ADON, DON, Administrator
Payscale: Discuss with HR about Hourly, Non-Exempt, Call Pay, Shift Differentials, Specialty Pay

Physical and Mental Requirements

• Extended periods of standing or walking
• Manual dexterity
• Pushing and pulling
• Repetitive motion
• Lifting/carrying >=50lbs.
• Kneeling
• Bending
• Stooping
• Visual and hearing Acuity
• Reaching

Work Conditions

Inside and occasionally highly stressful

Hazards

OHSA Blood Borne Pathogens Class I

Types of Clients Served

• Adult 18-55yrs
• Geriatric > 55yrs

Job Qualifications

Education

• Graduate of an accredited School of Professional Nursing

Licensure, Registry and Certifications

• Registered Nurse licensed by the State of Texas.
• BCLS

Personal Job Related Skills

• Effective oral and written communication skills.

Experience

Prior Work Experience

• Two (2) years experience as a professional Registered Nurse preferred

Technical Training

• Current CPR certification.

Essential Duties and Responsibilities

Primary Responsibilities for all halls assigned

Utilizes the nursing process, completes a comprehensive physical and psychological assessment of patients.

• Takes nursing histories to provide a basis for developing patient care plans
• Completes a thorough nursing assessment and history
• Provides a basic assessment needs of residents needs/desires
• Identifies teaching and learning needs with each resident to promote independence
• Provides an ongoing assessment that accurately reflects needs and desires of residents
• Consistently uses input form resident, family, significant other, physician, and healthcare team members
• Supervises and assists staff members providing care while remaining responsible for the delivery of quality nursing care

Implements and monitors appropriate nursing care to meet patient’s needs

• Identifies expected outcomes for planned nursing intervention and insures vital information is passed between shifts
• Administers medications according to policy
• Knows actions, indications, contraindications, precautions, adverse reactions, dosage and route of administration on all drugs prior to administering to patient
• Verifies medication administration accuracy and performs the required checks on the medication administration record
• Assesses residents at the beginning of the shift for acuity of patient needs/problems and establishes priority in which work activities are consistently completed by the end of the shift
• Performs basic nursing competently to include but not limited to: intake and output, vital signs, physical assessment, urine testing, specimens/cultures, dressing changes, neurological assessments, personal hygiene for the patient, skin care, glucose monitoring, airway/suctioning, basic oxygen administration, nasogastric tubes, tube feedings, urinary catheterization, drains and enemas
• Recognizes, evaluates, and interviews appropriately in a life-threatening situation
• Recognizes variance of diagnostic tests, vital signs and assessments that should be reported to the physicians and notifies physicians in a time frames appropriate to the variance
• Functions proficiently in all daily nursing tasks
• Act as liaison between patient, physician, family or RP and other health disciplines

Maintains accurate and timely records according to facility policy and procedures

• Progress notes completed on all appropriate residents at minimum of once, but not limited to, every shift
• Accurately documents on MAR and TAR in the electronic chart
• Completes all quarterly, monthly and weekly observations
• Completes all incident reports as needed and reports them to GNP, Administrator, DON and RP
• Documents on 24 hour report sheet to ensure continuity of care between shifts
• Transcribes and or cosigns physicians orders completely and accurately while reporting changes to RP
• Complete daily assignment forms for all CNAs
• Completes nursing staff sheet every shift

Maintains the required inventory of supplies and equipment

• Assesses the supplies needed and establishes a system for acquisition, storage, control, and issue
• Determines equipment needs and assures equipment is maintained and in good working condition
• Assures medication cart is stocked with appropriate supplies and medications. Reorders medications as needed
• Assures crash cart and AED is  checked daily

Facilitates favorable relationships within the ER , clinics , med surg, therapy and dietary 

• Maintains positive and effective relationships with other departments and the Medical Staff
• Consults with MD/FNP to resolve problems and to obtain and provide patient care input
• Maintains open communication and a problem solving atmosphere with other departments to achieve quality patient care

JOB RELATED FACTORS

• Communicates positively and respectfully to audience (coworkers, patients, physicians, and others)
• Performs required tasks without prompting and adjusts appropriately to situations
• Adheres to the attendance policy
• Follows District and Department Policies
• Attends required meetings and in-services
• Participates in Hospital District Safety Program and QA Programs
• Uses time and resources wisely
• Maintains HIPAA, keeping patient and hospital confidentiality
• Maintains adequate supplies of items needed to perform job, orders, or reports low items to supervisor
• Practices proper phone etiquette, identifying self and department
• Reports adverse events regarding patients, guests, or self to supervisor immediately

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