Shift assessment, intake RN assessment/admission full and screening, and d/c assessment, obtain, assess and disseminate necessary information, incident reports based upon interviews as needed, nursing assignments, peer evaluations to assist RN Shift Supervisor.
The Registered Nurse is responsible for identifying client alterations in health, assessing the client's responses to actual and potential health problems and prescribed treatments, and providing appropriate nursing interventions to return the client to baseline health with appropriate physician orders. Whenever possible, the client, family/significant others is integrated in the care provided. The RN functions within the interdisciplinary team model to provide a safe, therapeutic environment and support the client in reintegration to the community. OSHA Statement: This position has potential for exposure to blood and body fluids.
Clear/Active license to practice as an RN in the State of Florida. Experience in an inpatient psychiatric unit preferred.
Qualifications to determine pay:
· 3 years of experience with Mental Health population, Crisis Units, Corrections or psych settings will be eligible for higher end of pay scale. Substance abuse experience will count for Residential/OTP/Detox only. Experience must be met while utilizing respective license, this must be verified.
· Employment of Agency work or PRN elsewhere will not count toward total length of service experience. PRN at Meridian DOES count towards experience if working as RN.
Shift assessment, intake RN assessment/admission full and screening, and d/c assessment, obtain, assess and disseminate necessary information, incident reports based upon interviews as needed, nursing assignments, peer evaluations to assist RN Shift Supervisor
The RN performs assessments and other activities as recognized by the Board of Nursing and supervises and directs the care provided by CNA's, LPN's and unit clerks in activities appropriate to their licensure and experience. The RN coordinates the care provided by the interdisciplinary team.
Willing to be an active participant in client restraints, as needed.
*Must attend CSU Staff meetings once a month*
· Performs initial physical assessments and performs ongoing re-assessment.
· Assesses and collects data to determine client stability, safety, and pain status on admission
· Integrates assessment findings with previously reported or documented information to determine changes in the client's status
· Assesses client cultural and religious practices, education level, readiness to learn and utilizes the information to plan care
· Recognizes interrelationships between assessment findings, medications, and lab findings
· Follows up abnormal assessment findings, changes in status, and lack of response to therapy
· Initiates Treatment Plan and Nursing Care Plan.
· Plans and coordinates initial and ongoing care based on assessments and re-assessments
· Treatment goals are client-centered, specific, and measurable
· Incorporates the client, family/significant other, developmental and age-appropriate needs
· Provides client and family/significant other education and discharge preparation as appropriate
· Implements care based on assessment of client status and progress toward desired outcomes.
· Implements the Treatment Plan and Nursing Care Plan
· Initiates, verifies, and carries out physician orders transcribing to the Medication Administration Record as appropriate
· Initiates independent nursing actions that demonstrate accountability for progress toward outcomes
· Provide support to the client, family/significant other as needed
· Implements appropriate interventions for changes in client behavior
· Assumes leadership role in crisis or emergency situations
· Provides education on milieu, medication, adaptive and coping techniques, and discharge needs
· Documents all assessments, evaluations, and interactions as per policy and procedure
· Evaluates care based on the client's progress toward desired outcomes.
· Evaluates client condition related to identified problems and goals of treatment
· Identifies unexpected responses to treatment or other alterations in client condition that requires treatment and communicates with appropriate physician
· Revises treatment plan as necessary based on assessments
· Collaborates with other members of the team to assess progress toward goals.
· Organizes assignments based on client needs and available resources and provides leadership to the nursing team
· Identifies clients whose needs require constant monitoring
· Facilitates adjustments in assignments according to acuity and census
· Delegates tasks appropriately and follows up to ensure completion
· Works with Nurse Manager and HR Staffing to provide appropriate staffing based on census and acuity
· Contributes to a safe and therapeutic environment for clients, visitors, and staff
· Identifies clients at risk for self-harm or harm to others and institutes appropriate measures to reduce risk
· Manages milieu to promote safety
· Assesses and corrects or reports environmental safety hazards
· Responds to client or family/SO concerns promptly and completes Client Concern reports
· Completes Unusual Occurrence reports and/or Medication Variance Reports as needed and appropriate
· Demonstrates professional development, accountability, and leadership in the performance of professional nursing
· Keeps current with continuing education as required by license or as required by the position
· Utilizes resources as needed to accomplish goals
· Participates in QI activities and incorporates results in daily practice
· Ensures compliance with HIPAA
· Transcribes verbal or telephone orders received from the physician and verifies such by "read-back".
· Transcribes physician orders to the medication administration record(MAR).
· Performs Nursing Physical assessment.
· Performs breath testing for alcohol.
· Performs vital signs.
· Performs finger stick for glucose evaluation.
· Evaluates point-of-care urine drug screens.
· Administers medications as ordered by a physician.
· Provides wound care as ordered by a physician.
· Educates and orients client and family to the unit milieu and structure.
· Provides confidentiality in all interactions with clients, to the extent possible, in the clinical setting.
· Provides for interactions with family, to the extent possible, under HIPPA regulations.
· Ensures that necessary safety precautions are taken based on the client's condition and facility policy.
· Intervenes as necessary to prevent injury to staff or other clients.
· Provides accurate documentation of client interactions and interventions.
· Initiates upon admission, and updates EMR & Shift Report.
· Utilizes seclusion and restraint as warranted and provided for in the Baker Act.
· Staff is required to stay over shift until appropriate and sufficient staff has arrived.At times, in circumstances of staff call-outs, increased client acuity or supervisor requests, staff is required to stay until dismissed by RN Shift Manager, Staffing Department or Administrator on-call. Violation of this may result in disciplinary action, up to and including termination.
General Organizational Responsibilities:
· Greets clients as soon as possible after screening and provides welcoming atmosphere.
· Provides confidentiality during assessment/injection.
· When not engaged in work-related tasks or activities, keeps personal conversation quiet to avoid being misinterpreted by clients.
· Treats all customers - clients, staff, other departments - with courtesy.
· Documents clearly and effectively utilizing appropriate forms.
· Seeks information as needed.
· Attends staff meetings.
· Coordinates breaks with other staff members as appropriate.
· Requests time off with required notice and notifies the Staffing Department as soon as possible if calling off for illness or emergency and adheres to the Absenteeism/Tardy Policy.
· Orients and mentors new staff members as needed and as appropriate.
· Considerate of other team members.
· Channels questions, suggestions, and constructive criticism appropriately.
· Works with the team to identify opportunities for improvement.
· Flexible. Adapts well to change.
· Reports communicable illnesses in clients to the Nurse Manager and Infection Control Practitioner(CNO).
· Practices effective hand hygiene, hand washing, and cough etiquette.
· Reports to Employee Health for pre-employment tuberculin skin test and annual skin testing.
· Enforces Standard Precautions and Transmission-based Precautions in all aspects of client care.
Knowledge, Skills, Abilities:
Specific competencies required are identified on a department/program specific basis and identified in each employee's Competency Checklist. The following are general and apply to all positions with this title.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.