Registered Nurse (RN) or Licensed Vocational Nurse (LVN) - Full Time Night Nurse

Summary/Objective:

Will be clinically competent while delivering care to patients utilizing the nursing process of assessment, planning, intervention, implementation and evaluation. Effectively interact with patients, families and other health team members while maintaining all standards of professional nursing.

Duties & Responsibilities:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Perform/document nursing assessments and screenings including reviewing client histories and documenting a nursing clinical summary on all clients admitted to Origins.
• Assess individual client care needs, initiate medical treatment plan and competently process/implement all care according to physician orders and standards of nursing practice.
• Utilize safe and effective practices of medication ordering and management as defined by policy and standards of nursing practice.
• Accurately administer and monitor the effects of medications and conduct accurate controlled medication counts.
• Processes physician orders in a timely and accurate manner
• Collect and process lab specimens following proper infection control procedures.
• Provide appropriate client education as determined by client assessments/needs and treatment plans.
• Delegates some duties and coordinates care with other direct-care staff to ensure continuity of client care, staff relations, and efficiency of service.
• Prepares and maintains client medical records including appropriate and timely documentation.
• Accurately and thoroughly documents in the medical record utilizing approved medical record language and abbreviations adhering to the medical record policies and procedures.
• Provide thorough and accurate shift report to ensure continuity of client care.
• Work a flexible schedule based upon service demands.
• Attend all mandatory trainings as identified by Origins policy.
• Complete yearly training requirements and mentor new employees.
• Effectively communicate medical/ nursing issues to clinical/case management team and serves as a resource.
• Uphold all Origins of Texas Policies and Procedures.
• Maintain client/potential client confidentiality in accordance with Origins’ Policy.

Additional Responsibilities:

• Be responsible for the health, safety, and welfare of clients.
• Ensures the privacy and confidentiality of all clients and their medical records.
• Completes duties in a professional and timely manner.
• Reports all alleged incidents of abuse or neglect in accordance with all state standards and accrediting bodies.
• Ensures that all records are available for all state and accrediting bodies staff inspection.
• Ensures and coordinates with the clinical staff’s functioning, so as to avoid scheduling conflicts for clients, between Administration, Clinical, and programmatic needs or requirements set-forth by the Standards.
• Stands "On Call" at designated times, and;
• Reports directly to the Nurse Manager and completes orders in a professional and timely manner.