Registered Nurse or Licensed Practical Nurse- Inpatient

Registered Nurse or Licensed Practical Nurse duties may include:

Behavioral Health Groups:

• Conducts behavioral health groups following agency guidelines and policies.
• Leads groups using effective group facilitation skills that promote participation and interaction among group members.
• Utilizes group process to develop insight, practice skills, and motivate client for change.
• Follows lesson plan or curriculum and connects presented material to individual treatment plan goals.

Children, Youth and Young Adult Services:

• Demonstrates and utilizes knowledge of development in children, youth and young adults.
• Demonstrates and utilizes knowledge and understanding of behavioral health problems in children, youth and young adults.
• Demonstrates and utilizes knowledge of and ability to work with issues of confidentiality, consent and capacity.
• Demonstrates the ability to collaborate and coordinate with family, parents, caregivers and community and natural supports.
• Communicates effectively with children and youth of differing ages and developmental levels.

Inpatient Core Nursing Functions:

• Utilizes the nursing process, providing a systematic approach to client health needs through assessment, nursing diagnosis, planning, implementation, and evaluation.
• Carries out orders as prescribed by staff providers in a concise and timely manner.
• Establishes and maintains professional relationships with clients and families, providing information, education, care coordination, and support.
• Implements prevention strategies for various health conditions as appropriate.
• Actively engages in treatment teams and team-oriented strategies to achieving care objectives.
• Utilizes a variety of resources to increase clinical and professional competence.
• Delegates nursing tasks to appropriate staff members, training and supervising them to ensure accuracy and consistency in care and reporting.
• Represents and promotes professional nursing in all settings.
• Provides support to clients with activities of daily living (ADLs) including but not limited to eating, drinking, dressing, bathing, and toileting.

Crisis Evaluation Intervention:

• Utilizes appropriate crisis intervention techniques for client stabilization.
• Accurately screens for risk to self, others, property and the presence of grave disability and makes appropriate referrals.
• Documents and reports and/or notifies as required by law.
• Applies QPRT (Question, Persuade, Refer or Treat) principles in assessing risk and in safety and treatment planning.
• Develops and documents appropriate safety plans.

Geriatric Services:

• Demonstrates and utilizes knowledge of normal aging process and age related changes.
• Demonstrates an understanding of neurocognitive disorders and their impacts on functioning.
• Demonstrates awareness of how medical issues can affect mental status.

Injections:

• Uses Standard Precautions and performs hand hygiene before and after administering an injection.
• Verifies the medication orders are correct and match the provider’s last note.
• Verifies the medication is available at the pharmacy or the client will be bringing the medication with them.
• Practices the Five Rights of Medication Administration; Right Patient, Right Medication, Right Dose, Right Route and Right Time.
• Demonstrates clean, safe and proper technique with administering and injection; hand hygiene, use of appropriate personal protection equipment (PPE).
• Discards the needle and syringe in the appropriate receptacle.
• Evaluates the client for adverse side effects or reactions following the injection.
• Assesses client’s mood, behaviors, appearance, sleep, appetite and suicidal/homicidal risks factors.
• Reschedules the client for their next injection.
• Documents the injection into the client’s electronic health record.

Medication Administration and Monitoring:

• Safely administers and documents medication according to provider orders and agency policies.
• Conducts and documents ongoing evaluation of intended effects, side effects, adverse reactions and medication non-compliance. Communicates this information to the appropriate parties.
• Implements appropriate interventions regarding medications and side effects.
• Provides medication education to client and family, including purpose of medication, side effects, dosage, frequency and duration.
• Encourages and supports clients in taking medications as prescribed. Promotes illness self-management skills.

Inpatient Medication Assisted Treatment Nursing Functions:

• Demonstrates an understanding of substance use disorders and their treatments and risks; promotes recovery through medication assisted treatment.
• Notifies the Addiction Treatment Team via email that an active OTP client has been admitted.
• Reviews any take-out-doses the client has on hand and either stores or destroys per policy SD-031.
• Completes chain of custody form with OTP Nurse when doses are delivered.
• Properly stores medication consistent with Controlled Substance Distribution Administration policy MM-008.
• Practices safe medication administration outlined in policy MM-016.
• Appropriately documents in MAR and on OTP tracking form, SD-002.
• Notifies Addiction Treatment Team of declined doses via email.
• Coordinates with Addiction Treatment Team on discharge planning.
• Follows program policies for medication spills or waste.

Nursing Assessment and Planning:

• Completes all required intakes and assessments following agency guidelines and polices for content, format and timeliness.
• Obtains and documents essential clinical data as well as person-specific data.
• Applies assessment, evaluation and reassessment data to the formulation of treatment planning.
• Formulates measurable, achievable goals and treatment recommendations within the scope of treatment that the setting provides and in collaboration with the client.
• Communicates observations, planning and recommendations clearly and effectively to fellow nurses and other members of the treatment team.

Program Screening:

• Conducts in program screening processes according to program guidelines.
• Collects all pertinent clinical information.
• Facilitates effective and professional communication during screening and intake processes.
• Documents screenings and admission decisions as appropriate.

SERVICE NOTES:

• Completes all required service notes according to Comprehensive Healthcare’s guidelines, policies and procedures regarding format, content and timeliness.
• Language used in service notes is respectful, clear, descriptive, concise and client-centered.
• Service notes accurately depict treatment modalities and interventions provided within the clinician’s scope of practice and according to treatment plan.
• Service notes accurately reflect and depict client status and progress consistent with assessment and reassessment data, problem statements and treatment plan goals and objectives.

Seclusion & Restraints:

• Adheres to policies and procedures regarding use and application of seclusion and restraints to ensure safety for clients and staff.
• Adheres to techniques and approach to managing violent and aggressive behavior as per the facility’s crisis intervention training modality.
• Documents specific client behaviors and staff interventions leading to safe use of seclusion and/or restraint, according to policies and facility protocols.
• Demonstrates proficiency in the use of skills in accordance with agency approved crisis intervention and de-escalation techniques such as those taught in PROACT and Psychiatric Emergency Response Team (PERT) training.

Symptom & Medication Response Monitoring

• Conducts and documents ongoing assessment of client symptoms and their response to prescribed medications.
• Provides support and education to encourage clients to take medications as prescribed.
• Promotes illness self-management skills to assist clients with medication adherence, identifying warning signs and symptoms, and symptom management skills.
• Monitors medication side effects and facilitates access to, and communication with, medical staff as needed.

VEVIPUNCTURE:

• Verifies active physician order.
• Demonstrates understanding of the equipment and the ability to gather the needed equipment to obtain samples.
• Demonstrates clean, safe and proper technique with hand hygiene and personal protective equipment.
• Can safely obtain a sample following agency policies and procedures.
• Discards of needle, syringe and all other equipment in appropriate receptacle.
• Appropriately labels tubes immediately after obtaining sample.
• Demonstrates an understanding of how to use a centrifuge and what samples require spinning.
• Demonstrates an understanding of storage and shelf-life samples.
• Understands available resources, including maintaining access to LabCorp Link.
• Demonstrates the ability to schedule a courier for sample pick up.

Treatment Planning:

• Completes all required treatment plans following Comprehensive Healthcare’s guidelines and polices for content, format and timeliness.
• Applies assessment, evaluation and reassessment data to the formulation of treatment plans.
• Supports recovery principles by incorporating the individual’s and their family’s (when applicable) strengths, barriers and needs into the plan components.
• Documents problem statements and treatment goals/objectives/ discharge plan that are written in clear and understandable language and includes client’s own voice.
• Formulates measurable, achievable goals and objectives within the scope of treatment provided in collaboration with
• Describes clinical modalities/interventions that are reasonable and provided according to applicable Comprehensive Healthcare’s protocols.
• Reassess treatment effectiveness and adapts treatment plan as needed in collaboration with the individual client.

Schedule:

Thursday- Saturday 7PM-730AM