Night Shift RN

Rate based experience and schedule.

QUALIFICATIONS

• Graduated of an accredited school of nursing and licensed by the state of PA as a RN.
• Current CPR or certified within 90 days of hire
• Other certifications may be required for other areas of the organization

POSITION SUMMARY

The Unit Manager assumes responsibility for a specific unit or area within the organization to include assessment, medication, distribution, treatment clinical documentation, and supervision of Nursing Staff and other staff as needed.

PART I: JOB RESPONSIBILITIES AND STANDARDS

• Audits immunization weekly on all guests.
• Completes admission chart audit on all admissions.
• Submits high cost meds report- ex: Lovenox, ARixtra, Epogen, Procrit and Aranes.
• Ensures narcotic Med Refill and Back up med are refilled and maintenance.
• Reviews admission order for accuracy.
• Monitors clinical issues or any staffing issues and all other assigned project as needed.
• Inputs the 24 hour report electronically on unit. Set up the discharge instructions on all the floors : (11-7 shift only)
• In-services nursing staff as needed.
• Completes nursing acuity report daily.
• Responsible for weekly med room maintenance-returnables expired item,over the counter and monitors refrigerator items.
• Completes psychotropic summary every 1 st Weekend of the month. Follow up with the nurses as needed.
• Sends wound report in a timely manner. Ensures that follow up documentation is completed and accurate.
• Performs skin assessment weekly. Ensure that follow up on all documentation and all intervention are in place.
• Completes infection control report as required.
• Develops care plan on all guests with facility acquired infection and nosocomial infection.
• Prepare reports for quarterly meeting as needed.
• Completes fall incident reports. Follows up with proper documentation and care plan.
• Prepares investigation report for falls with injury and ensure all documentation is in place as per regulatory agency (State and Ombudsman Standards).
• Review and corrects all hot files /folder were reviewed by the unit clerk for medical records.
• Audits High Cost Med list –example Lovenox-duration and submits report.
• Monitors high cost med usage-Therapeutic Interchange and Per Diem Exclusion List.

I. PERFORMS ASSESSMENTS RELATED TO

• Skin
• Cardiac
• Respiratory
• GI
• Neurological
• Muscular Skeletal
• Renal
• Pain

II. ACCURATELY DOCUMENTS ON THE FOLLOWING FORMS

• Ambulation/Restorative care
• Pyschotropic Monitoring
• Pain Management
• Pressure Ulcer Management/skin assessment
• Fall Prevention Strategies
• Antibiotic documentation
• Incidents/accident
• Nurses Note day 1-5 and day 6 -Discharge Documentation.

III. ACCURATELYAND TIMELY COMPLETION OF NURSING ASSESSMENT AND DATA COLLECTION UPON ADMISSION:

• Fall Risk assessment
• Side Rail screen
• Braden Scale
• Bowel and Bladder
• Elopement Risk Profile
• Pain Evaluation
• Smoking Evaluation
• Data collection
• Immunization Record Sheet

IV. CONTACTS PHYSICIAN FOR ADMISSION ORDERS

• Reconciles medications
• Documents legibly onto POS
• Read back and verifies Telephone Orders
• Make appropriate referrals
• Transcribes all orders.
• Fax back (new admissions)

V. RESPONDS TO EMERGENCY CODES

• Amber
• Blue
• Grey
• Red
• Silver
• Orange
• Yellow
• Triage
• Clear

PART II. FACILITY –WIDE RESPONSIBILITIES & STANDARDS

EMPLOYEE IS REQUIRED TO

• Speak English in patient care areas.
• Attend mandatory and scheduled In-services/meetings.
• Arrive to work on time as scheduled
• Demonstrate ability to work with others cooperatively.
• Demonstrate flexibility in assignment to meet resident/family needs.
• Wear ID appropriately at all times.

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