Description

Primary Purpose: Delivers care to clients utilizing the nursing processes of assessment, planning, intervention, implementation, and evaluation: and effectively interacts with clients, families, and other ID team members while maintaining standards of professional nursing.

STANDARD REQUIREMENTS:

1. Supports the Mission, Values and Vision of the Agency.

2. Is knowledgeable of client rights and ensures an atmosphere that allows for the privacy, dignity, and well-being of all clients in a safe, secure environment.

3. Supports, cooperates with, and implements specific procedures and programs for:

• Safety, including universal precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs.
• Confidentiality of all data, including client, employee, and operations data.
• Compliance with all regulatory requirements.
• Compliance with current law and policy to provide a work environment free from sexual harassment and all illegal and discriminatory behavior.

4. Supports and participates in common teamwork:

• Cooperates and works together with all co-workers; plans and completes job duties with minimal direction, including appropriate judgment.
• Uses tactful, appropriate communications in sensitive and emotional situations.
• Follows-up, as appropriate, with supervisor, co-workers or clients regarding reported complaints, problems, and concerns.
• Promotes positive public relations with clients, family members, guests, and government representatives.
• Completes requirements for in-service training, acceptable attendance, dress code, personal hygiene and other work duties as assigned.
• Uses computer software for documentation and communication.

ESSENTIAL DUTIES & RESPONSIBILITIES: Responsible for a variety of duties that include but are not limited to:

• Utilizes the nursing processes by demonstrating appropriate assessment, planning, implementation, and evaluation of the clients’ care, as evidenced by client/staff observation.

• Assesses the clients’ health care needs; collects and documents the clients’ current health status.
• Makes accurate and ongoing assessment of clients’ status and responds appropriately.
• Plan/Implement;
  • • Sets priorities for nursing action in a logical sequence according to Clients’ needs
    • Evaluates and analyzes a given situation and makes decisions within the scope of licensed practice
    • Formulates a plan of care
    • Evaluates; performs ongoing assessment and revises plan of care based on new data, clients’ condition.
    • Ensures all clinical activities are carried out in accordance with the Health Care Plan
    • Performs evaluation of new and existing clients to determine priority of suitably of treatment and need for modifications.
    • Documents accurate, legible ongoing assessment of client status.
    • Demonstrates accurate and timely documentation.
    • Documents client care, which reflects nursing intervention, client response to care provided, and client needs, problems, capabilities, limitations, and progress toward goals.
    • Documentation to include evidence of appropriate client/staff teaching and the understanding of the instructions noted in the client’s chart.
    • Maintains up to date information in client’s chart regarding all appointments and procedures.
    • Compiles data for periodic assessment of client’s physical condition and evaluation of the effectiveness of health care procedures.
    • Documents all communication with MD’s, families, case managers program etc. in client’s chart.
    • Notifies and documents changes in client’s condition to all appropriate parties.

• Trains client/staff and others appropriate health information in a timely manner and shares information material, performs direct care utilizing established procedures, policies and standards as evidenced by client/staff feedback.
• Observes and documents clients’ response to pertinent medications.
• Demonstrates necessary skills and knowledge to provide care for clients’ according to their needs.
• Demonstrates ability to handle emergency situations in a prompt, precise, and professional manner.
• Provides personal client care to promote comfort and well-being of the client acknowledging physiological and psychological needs.
• Promotes effective communication with all staff members and communicates pertinent information to the appropriate persons regarding the ongoing health status of each client in a timely manner.
• Ensures and demonstrates accurate and timely documentation.
• Accurately transcribes physician orders according to policies and procedures.

Adherence to Department and Agency Policies and Expectations:

• Demonstrates sound judgment and follows proper reporting procedures for actual or potential accident and/or incidents.
• Participates in ID team conferences; provides input into program planning by interpreting client needs for nursing care and response to therapy.

• Demonstrates knowledge and understanding of all departmental and Agency policies and procedures.
• Demonstrates knowledge and understanding for all Agency, OSHA, and CAL/OSHA safety guidelines and regulations when performing job duties related to but not limited to, blood borne pathogens, hazard communications, needle sticks and other possible exposure incidents.
• Demonstrates knowledge and understanding of HIPAA requirements and agency standards to ensure compliance with HIPAA regulations.
• Consistently demonstrates an ability to take initiative, to make decisions, and respond to changing and challenging situations in a flexible manner, assessing current needs and reprioritizing work as necessary.

CEU’S and License Renewal: HGH does not pay for or reimburse for the cost of Continuing Education Units (CEU’s) for the purpose of License renewal. The RN will be responsible for these expenses.

Equipment/machines used in the performance of this job: Employees must maintain the skills necessary to safely and efficiently operate the following equipment and machines used in the performance of this job.

• Telephone/Fax machine
• Cell Phone
• Computer/Tablet/Printer
• Automobile/Van

Physical Demands/Working Conditions:

• May be exposed to blood borne pathogens, viruses and/or infections.
• Regularly and frequently required to perform physical activity including walking, standing, sitting, reaching, carrying, lifting, bending, twisting, stooping, kneeling; and will assist with lifting, moving and transferring residents from beds, chairs and wheelchairs.

COMPETENCIES:

Education: Valid license as an RN in the State of California.

Experience: Experience providing services to individuals with developmental and intellectual disabilities preferred.

Required Knowledge/Skills/Abilities:

• Ability to read, write and understand the English language.
• Able to establish and maintain effective relationships with clients, co-workers, neighbors, volunteers, vendors and the general public.
• Possess high degree of patience and the ability to tolerate frustrating situations.
• Knowledge of HIPAA Guidelines and Patient Privacy required.
• Current CPR/First Aid certification for Healthcare Professionals is required.
• Ability to multi-task and manage work time efficiently.
• Able to see, talk, hear, walk, bend, stoop, sit, stand, reach, and lift items weighing 30 pounds or less repeatedly during a shift.
• Ability to drive an agency vehicle lawfully and safely in all traffic situations and weather conditions.

Other Conditions of Employment:

• Must be at least 18 years of age at the time of hire.
• Must pass a pre-employment health screening/TB Test prior to date of hire; and annually thereafter.
• Must clear criminal records clearance from DHS and/or DSS (Live Scan fingerprinting).
• Must possess a valid California driver’s license, proof of safe driving record, personal vehicle to drive during workday throughout employment and have 24 months of licensed driving experience upon hire.
• Must provide proof of and maintain proper automobile insurance coverage as required by state law and be an approved driver with HGH insurance company to be eligible for mileage reimbursement.
• Must maintain confidentiality of resident Protected Health Information (PHI) used for treatment, payment, health care, etc. and personal information of residents.
  • Must limit access to restricted Protected Health Information (PHI) to residents under direct care only.
• Must be available as an On-Call Nurse on a rotating schedule.
• Must maintain a valid RN license in the state of California.

Qualifications