Registered Nurse - Casual

OVERALL PURPOSE OF JOB:

This position is responsible for providing nursing care in the Windber Hospice at Somerset facility and teaching patients and families the skills necessary to care for themselves at home. This position is also responsible for meeting patient/family needs effectively and efficiently through all life stages and ages. This position also provides direction and oversight to other staff members regarding patent care.

CASELOAD:

Provide patient care throughout all life stages from infancy through geriatrics.

ESSENTIAL FUNCTIONS OF JOB: (other duties may be assigned)

• Actively participate in patient care.

• Communicate information orally and written on a daily basis to physicians, patients, caregivers, and coworkers.
• Monitor and report changes in patient’s and caregivers conditions daily.
• Assist patients, caregivers and significant others with decision-making.
• Maintain confidentiality of patient’s personal, medical and financial information.
• Use order entry process as necessary in the EHR
• Initiate standing orders as necessary.
• Address teaching needs as needed with patients and families
• Receive incoming Hospice calls

• Advise caregivers, give emotional support, document responses
• Initiate/reorder medications as necessary.
• Update /Teach / Inform/ Utilize MD or HC staff as necessary.
• Document calls, orders, chart appropriately in the EHR
• Administer medication and treatment daily as ordered by physician with proper documentation.

• Follow the five patient rights: right medication, right patient, right route, right dose, and right time.
• Complete documentation immediately following medication administration in patient’s chart.
• Sign and date all documentation.
• Administration of respiratory treatments and medications after hours and off-shifts
• Proper administration of IM injections, SQ injections
• Perform appropriate documentation regarding narcotics administration.
• Coordinate IV therapy.

• Ensure peripheral IV site and tubing is changed every 72 hours.
• Ensure Heparin/saline locks are changed every 96 hours.
• Document site and tubing changes on IV log sheet immediately following changes.
• Observe site for any signs of infiltration or infection and record on IV log sheet.
• Sign and date all documentation.
• Maintain 100% compliance with all Hospital policies and procedures.
• Use and access of mediports
• Use of TAR-IV/ blood administration document properly in EHR
• Complete initial and on-going patient assessments to define individual patient needs.

• Review assessment data and identify patient problems.
• Develop patient plan of care and update daily.
• Maintain concise documentation in nursing notes of all patient care that is provided every shift or as needed.
• Complete nursing care plans daily.
• Evaluate patient response to therapeutic interventions and document in nursing notes.
• Document appropriately via computer system
• Provide clinical oversight of the nursing care process.

• Serve as a resource for staff including the licensed practical nurses, nurse aides, and other ancillary staff.
• Delegate nursing care duties as appropriate for the scope of practice of assignee.
• Observe staff with patients regularly to ensure patient satisfaction.
• Direct staff as needed to ensure 100% compliance with all Hospital policies and procedures.
• Evaluate patient care provided by other staff members through coaching.
• Reinforce Hospital policies and procedures to ensure staff continually deliver quality patient care.
• Assist in orientation of new staff and transferred staff for three months as needed.
• Provide staff with direction in day to day duties of patient care & care planning.
• Assist physicians in the daily rounding.
• Ensure the most appropriate level of care for admissions/transfers.
• Assist Hospice Director with shift schedules.
• Coordinates with Hospital Supervisors for adequate staffing and report
• Teach various techniques to patients, care partners, and other staff members as needed within scope of practice.

• Evaluate patient, care partner, and other staff member’s understanding of techniques by successful demonstration.
• Document procedure upon completion of demonstration.
• Offer pre/post testing with new techniques.
• Assist in identifying the educational needs of the Unit.
• Coordinate patient discharge planning.

• Begin planning patient discharge upon admission.
• Complete discharge summary plan as outlined on physician discharge orders.
• Review discharge plans with patient and/or care partner.
• Ensure patient and/or care partner understands discharge instructions.
• Document discharge planning and patient and/or care partner understanding in patient chart legibly.
• Collaborate with staff, physicians, social worker, Nurse Liaison, Homecare Coordinator, and Homecare staff in determining issues and discharge disposition.
• Respond to emergency codes as needed.

• Respond to all blue, red, black, pink, disaster drill, and utility failure codes immediately.
• Ensure staff follow appropriate Hospital policies and procedures.
• Complete documentation following all codes and ensure documentation is accurate and legible.
• Coordinate staff use of equipment; dynamaps, SCD’s, IV pumps, BGM, whirlpool, hoyer lifts, bed alarms, chair alarms, feeding pumps, etc.

• Demonstrate proper use of equipment.
• Supervise staff in the use of equipment.
• Document proper use according to patient response.
• Assist in directing the operations of the Department.

• Assist in developing departmental goals and standards in accordance with WMC/Hospice philosophy.
• Monitor operation of the department for effectiveness and assist in resolving problems as they arise.
• Monitor medication use consistent with end-of-life care.
• Oversee the activity of the staff to ensure care is being provided according to established procedure.
• Assist with departmental evaluation and improvement of nursing practices.

• Participate in quality improvement, fire safety, infection control, etc.
• Support change to improve patient care through suggestions offered by patient response forms.
• Participate in departmental committees or projects, attend as assigned.
• Accept and respond to constructive criticism by improving performance
• Maintain 100% compliance with all Hospital policies and procedures.
• Patient safety regulations and goals will be followed.
• Keep up-to-date on CEU’s and licensure

13. Must remain up to date, knowledgeable, and compliant on all DOH and other applicable regulatory related to your department and area.

• Patient safety regulations and goals will be followed (i.e. using 2 patient identifiers, reporting critical values, medication reconciliation, etc)
• Perform appropriate documentation regarding narcotics administration (i.e. second signature for count and waste, etc.)
• Follow the regulations regarding restraint and seclusion, sentinel event notification, etc.
• Attend appropriate educational programs related to regulatory standards, updates, and initiatives.
• Education/Training/License/Certification:

Valid/current Pennsylvania Registered Nurse License required.

Cardio-Pulmonary Resuscitation Certification required.

Certification in Hospice nursing within 2 years of hire, preferred

• Work Experience:

One year related experience is required.

• Driving Record:

If deemed a driver in your position, a valid Driver’s license and proof of insurance are required. Motor Vehicle Record checks will be performed upon hire, in addition to annually thereafter.