JOB SUMMARY:
Responsible for performing a variety of duties to provide quality nursing care to patients including coordination of total nursing care; implementation of specific procedures and programs; participation with the Director of Nursing in establishing specific goals; assisting with work procedures and expediting work flow; ensuring compliance with all policies and procedures, Texas Department of Health regulations and Federal Health Care Administration regulations; communicating care with appropriate staff and entities; and providing daily reports and other periodic reports; and performing all the duties of a staff and managing nurse when required.
ESSENTIAL JOB FUNCTIONS:
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Coordinates all nursing and nursing-related activities in the facility while on duty, including medication administration.
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Keeps the physician medical providers informed of patient conditions and needs, monitors the nursing team care of patients, and organizes medical care based on patient needs.
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Perform/document nursing assessments and screenings, including reviewing patient histories and documenting a nursing clinical summary for all patients admitted to CLR.
- Assesses individual patient care needs, coordinates with provider to initiate medical treatment plans, and competently processes/implements all care according to physician orders and standards of nursing practice.
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Utilizes safe and effective practices of medication ordering and management as defined by policy and standards of nursing practice.
- Accurately administers and monitors the effects of medications and conducts accurate controlled medication counts.
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Processes physician orders in a timely and accurate manner.
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Collects and processes lab specimens following proper infection control procedures.
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Provides appropriate patient education as determined by assessments/needs and treatment plans.
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Performs duties and coordinates care with other direct-care staff to ensure continuity of care, staff relations, and service efficiency.
- Works with department heads in other facility areas to provide nursing assistance when needed.
- Prepares and maintains 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.
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Provides thorough and accurate shift reports to ensure continuity of patient care.
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Works a flexible schedule based upon service demands including mentoring of new employees.
- Attends all mandatory training as identified by facility policies.
- Attend multi-disciplinary treatment team meetings on a regular basis.
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Maintain accurate suboxone/Subutex and other controlled substance quality control logs.
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Orders or directs the ordering of drugs, solutions, and equipment after communication with the Director of Nursing.
- Investigates and resolves complaints or refers to administrators as appropriate.
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Effectively communicates medical/ nursing issues to clinical/case management team and serves as a resource.
- Upholds all facility Policies and Procedures.
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Maintains patient/potential patient confidentiality per facility policy.
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Maintains and assists with the nursing schedule
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Plans and coordinates medical/health education classes for patients and staff.
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Assist with Infection Control observations and reporting.
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Other duties as assigned.
JOB SKILLS AND ABILITY
- Knowledge of resident rights and provision of treatment that promotes resident dignity, independence, individuality, strengths, privacy, and choice.
- Able to meet the unique needs of our resident population, taking into consideration diagnosis and trauma-informed care.
- Ability to maintain appropriate boundaries with residents.
- Ability to communicate effectively, using non-judgmental words and behaviors, using person-centered language, and engage in active and reflective listening.
- Recognizes, respects, and adapts to diversity, differences, and cultural traditions of residents.
- Knowledge and application of confidentiality requirements and HIPAA.
Completes duties in a professional and timely manner.
- Reports all alleged incidents of abuse or neglect per all state standards and accrediting bodies.
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Ensures that all records are available for all state and accrediting bodies’ staff inspection.
- Ensures and coordination with the clinical staff’s functioning to avoid scheduling conflicts for clients between Administration, Clinical, and programmatic needs requirements set forth by the Standards.
- Ability to remain "On Call" during designated times as needed.
- Strong understanding of addiction treatment, preferably with experience working with age-specific client populations.
- Proficient in using personal computers, including basic software applications.
- Familiarity with Microsoft Office products and network systems.
- Excellent verbal and written communication skills.
- Highly organized with the ability to manage multiple tasks effectively.
- Ability to ensure family, referral, and client satisfaction through proper documentation and effective communication.
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Commitment to maintaining compliance with all state regulations and accrediting body standards, demonstrated through accurate documentation.
EDUCATION AND EXPERIENCE:
- Must be graduate of an approved nursing program with a current, unencumbered nursing license from the Texas Board of Nursing.
- Experience as a staff nurse preferably in the field of chemical dependency and/or behavioral health.
Associate (ADN) or Bachelors (BSN) degree, preferred.
- Must be currently licensed as an LVN. RN is preferred
- Previous supervisory experience preferred.
