• Provides direct patient care to maintain each patient’s physical and psychological safety. Examines data to grasp issues, draw conclusions and solve problems. Makes timely informed decisions that taken into account the facts goals constraints, and risks. Resolves difficult or complicated challenges.
o Performs a comprehensive nursing assessment within 24 hours of admission (as schedule allows) in order to carry out plan of care.
o Obtains admission orders and transcribes per policy. Takes off or cosigns all orders within the shift.
- Demonstrates use of a broad range of information, knowledge and skills; and critical thinking in the clinical decision-making processes when providing nursing care.
- Administers prescribed medical procedures and treatments including medications as directed by physician orders.
- Has accurate knowledge of the treatment procedure, rationale for the treatment, and expected outcome.
- Skilled in safely administering the treatment.
- Checks for right patient, right treatment, and right time.
- Documents accurately and communicates to appropriate authority in a timely manner if patient refuses treatment, error is made, or an unpredicted event occurs.
- Ensure vital signs and weights are completed.
- Reviews and monitors therapy and treatment plans for effectiveness, accuracy, currency, and relevancy.
o Demonstrates appropriate and effective utilization of technology, analysis of information, and selection of resources in care implementation.
- Provides ongoing assessment of patient’s status responds appropriately to patient needs.
- Dispense medication in accordance with policy. Diligently attends to details and pursues quality and accuracy in accomplishing dispensing medication tasks.
- Administers prescribed medications as directed by physician orders.
- Skilled in safely administering medication.
Additional Duties and Responsibilities
- Medications documentation is completed in accordance with policy.
- Monitor division/location medication to provide for adequate supply at each location.
- Monitor Pharmacy log to ensure controlled substances are order counted, and record on the controlled substance log. Verify medications delivery status directly with pharmacy.
- Orients new patients to the program as assigned. Formally delivers information to patients. Presents information clearly, concisely, and logically. Focuses on key points. Responds quickly and effectively and provides answers to questions.
- Provides introduction to other patients and staff.
- Reviews the patient handbook to ensure patient understanding.
- Completes the belongings inventory.
- Attends to the nutritional and dietary needs of the patients. Actively promotes and solicits support for meal therapy. Models success behaviors, and encourages improvement.
- Provides support, redirection, and monitoring at meals.
- Checks meals and snacks to assure accuracy.
- Redirecting inappropriate conversations and rituals.
- Provides one-on-one assistance to patients in crisis. Resolves or seeks advice to resolve difficult or complicated challenges. Partners with treatment team to identify and resolve complex or sensitive issues.
- Establishes a therapeutic relationship with patients, including rapport, therapeutic boundaries, and a providing assistance towards with treatment goals.
- Maintains appropriate boundaries with patients refraining from inappropriate self-disclosure, topics of conversation, or physical contact.
- Provides patient support and guidance, manages emergency situation in a prompt and professional manner.
- Upholds and enforces patient’s privileges in accordance with their treatment plan, level of care and program guidelines.
- Assists patients in setting and meeting treatment goals and identifying appropriate coping skills.
- Provides accurate and ongoing assessment of patient’s status responds to and communicates this appropriately through verbal and written communication.
- Accurately documents in shift progress notes and nutritional flow sheets.
- Communicates patient progress and ongoing needs in reports including all complaints at the end of each shift as outlined in the reporting procedure.
- Notifies patient’s treatment team, including therapist, physician, and Program Director as appropriate regarding specific patient concerns utilizing the proper communication procedures.
- Effectively organizes, plans, and distributes unit administrative information to ensure all information is communicated, documented and required action is implemented when necessary.
- Prepare new patient chart as documented in the nursing duties checklist. Ensure charts are updated and include blank Doctor’s DAP note. Transfer patient information into residential binder including Progress notes nightly.
- Chart on all patients and document meals and snacks for assigned patients.
- Prepare vital sheets/group notes daily, on Fridays prepare the sheets for the weekend.
- Verify all patient orders are noted by an RN, accurate, and cosigned.
- Update the white board in the charting room according to Doctor’s orders and Kardex.
- Verify and ensure all Medical and Procedure testing has been ordered, scheduled, paper work completed, log updated and transportation has been arranged.
- Promptly answer all phone calls and file all necessary information in files. Prepare files for weekly staffing.
- Coordinate patients’ discharge and / or transition between levels of care and medication reconciliation.
- Review and verify the order from physicians for continuing care or home medication.
- Works collaboratively with treatment team, and communicate to patients and families to ensure understanding of the discharge medication plan.
- Communicates through email patients’ discharge and /or transition between levels of care with McCallum Place employees.
- Properly reconcile all medication not in use.
- Communicates regularly with Direct Care staff, therapist, physicians, RD regarding specific patient needs. Conveys ideas and facts verbally and in writing using language the audience will understand.
- Actively participates in team meetings.
- Assists staff in understanding patients’ special issues, as well as skills for providing care relevant to these issues.
- Communicates medical safety concerns directly, as well as writing in patients’ Kardexes.
- Contact physicians when clients have medical issues (vital signs, signs/symptoms, injuries, labs out of normal parameters. Obtain and perform orders as directed by physician.
- Demonstrate commitment to advancing clinical skills and professional development through attendance of training.
- Maintains license requirements by acquiring necessary licensure requirements.
- Attends and actively participates in Direct Care meetings, and trainings
- Attends annual safety training.
- Completes McCallum Place required physical and TB Testing.
- Adheres to National Patient Safety Goals.
- Demonstrates professional conduct, concern, respect and compassion toward all patients, families, co-workers and the public as a representative of McCallum Place.
- Demonstrates dependability to include attendance and punctuality.
- Takes initiative and ownership of issues.
- Represents willingness/enthusiasm to create, embrace and facilitate change.
- Maintains confidentiality.
- Familiar with duties and performs them independently, accurately, efficiently, promptly recognizing their importance and relationship to patient care.
- Complete other duties as assigned by Leadership
- Education and Experience Requirement
• Required current RN License
• CPR and First Aid Certified
• Preferred experience with adolescents and eating disorders.
• Minimum three months’ experience working with individuals in a clinical or observational capacity.
• Excellent verbal and written communication.
• Crisis intervention and problem solving skills.
• Health questionnaire, Hepatitis A shot series and Tuberculosis test required within 14 days of hire.
• Required to sit, stand, bend, stoop, walk, climb stairs and drive possibly for extended periods.
• Must be able to lift 40 pounds.
• Work is performed in an administrative office setting, and residential settings
• Must possess the ability to provide physical restraint to the residents.
• Must have visual, hearing and learning capabilities necessary to perform the essential functions described above.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)
Complex Problem Solving