Provides normalized, therapeutic and preventative nursing care to clients in a given assignment at Beechwood within the scope of the Pennsylvania Professional Nursing Law and in accordance with licensing standards and Woods Services Policies and Procedures.

Assessment:

• Assesses client’s health status on admission, when health needs indicate and on discharge.
• Refers clients to campus nurse/physicians when further assessment indicated. Differentiates between the need for emergency care or the need for physician follow-up.
• Assists physicians with rounds in units and clinics as necessary.
• Attends psychotropic medication reviews and actively participates.

Medication Administration:

• Prepares and administers medications as ordered by Woods/Beechwood’s physicians in accordance with Woods’ Medications Procedures. Receives verbal orders as necessary from Woods/Beechwood’s physicians/dentists.
• Evaluates therapeutic effectiveness of medication with pertinent data and reports any observed side effects or relevant laboratory values to Woods/Beechwood’s physicians.
• Reviews medication sheets and quarterly physician order sheets from pharmacy and makes corrections as necessary, communicating with pharmacy.
• Administers immunizations as required.
• Documents all relevant information according to Woods/Beechwood’s Medication Procedure Manual on MAR sheets, physicians’ orders and nurses’ notes.
• Assists clients with the self-administration of medication goals as indicated by the SAM assessment and RSP.
• Accurately administers and documents treatments as ordered by Woods/Beechwood’s physicians.
• Instructs, supervises, and insures documentation of any treatment in which direct care staff may be involved.

Communication Responsibilities:

• Documents assessments in the medical chart and on all appropriate reports, forms, graphs, etc.
• Documents the health needs of specific clients in residential logs on a daily basis, where applicable.
• Prepares assessments for annual physical examinations, GYN, neurological reviews, RSP, consults on and off campus, and completes hospital and emergency room transfer sheets.
• Completes division of paperwork form and is responsible for same.
• Relays pertinent health concerns (i.e. seizures, elevated temperatures, unusual behavior, rashes) to the campus nurse as necessary and on a daily basis at the end of the shift.
• Coordinates appointments with Health Services for clients.
• Participates in the Interdisciplinary Team process, as necessary, functioning as an integral member of the team. Documents monthly progress on identified goals.
• Coordinates lab work.
• Notifies family/guardians/agencies/Residential Manager/Administrative Managers/Supervisors of health issues as necessary. Contacts families/guardians/agencies for non-routine testing, consultations after clarifying insurance/funding.
• Other communication needs as assigned.

Continuing Education:

• Participates in continuing education relevant to the area of nursing.
• Obtains inservice training as required by Beechwood standards and relevant legal and nursing regulations.
• Obtains CPR certification yearly, First Aid certification every three years, and other mandatory inservices.
• Conducts inservices as a resource person regarding health issues for other staff persons.
• Provides health teaching to clients as necessary.
• Attends nurses’ meetings/inservices and serves on committees when requested.

Other Responsibilities:

• Assumes responsibilities as assigned after complete orientation.
• Covers units other than scheduled assignment when necessary.
• Assists with emergencies.
• Maintains medical equipment in units, assesses functioning of emergency equipment monthly and after use, and reports any malfunctioning equipment immediately.
• Assists in orientation of new nursing employees.
• Performs other duties as assigned.