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

1. Audits immunization weekly on all guests.

2. Completes admission chart audit on all admissions.

3. Submits high cost meds report- ex: Lovenox, ARixtra, Epogen, Procrit and Aranes.

4. Ensures narcotic Med Refill and Back up med are refilled and maintenance.

5. Reviews admission order for accuracy.

6. Monitors clinical issues or any staffing issues and all other assigned project as needed.

7. Inputs the 24 hour report electronically on unit. Set up the discharge instructions on all the floors : (11-7 shift only)

8. In-services nursing staff as needed.

9. Completes nursing acuity report daily.

10. Responsible for weekly med room maintenance-returnables expired item,over the counter and monitors refrigerator items.

11. Completes psychotropic summary every 1st Weekend of the month. Follow up with the nurses as needed.

12. Sends wound report in a timely manner. Ensures that follow up documentation is completed and accurate.

13. Performs skin assessment weekly. Ensure that follow up on all documentation and all intervention are in place.

14. Completes infection control report as required.

15. Develops care plan on all guests with facility acquired infection and nosocomial infection.

16. Prepare reports for quarterly meeting as needed.

17. Completes fall incident reports. Follows up with proper documentation and care plan.

18. Prepares investigation report for falls with injury and ensure all documentation is in place as per regulatory agency (State and Ombudsman Standards).

19. Review and corrects all hot files /folder were reviewed by the unit clerk for medical records.

20. Audits High Cost Med list –example Lovenox-duration and submits report.

21. Monitors high cost med usage-Therapeutic Interchange and Per Diem Exclusion List.

I. PERFORMS ASSESSMENTS RELATED TO:

1. Skin

2. Cardiac

3. Respiratory

4. GI

5. Neurological

6. Muscular Skeletal

7. Renal

8. Pain

II. ACCURATELY DOCUMENTS ON THE FOLLOWING FORMS:

1. Ambulation/Restorative care

2. Pyschotropic Monitoring

3. Pain Management

4. Pressure Ulcer Management/skin assessment

5. Fall Prevention Strategies

6. Antibiotic documentation

7. Incidents/accident

8. Nurses Note day 1-5 and day 6 -Discharge Documentation.

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

1. Fall Risk assessment

2. Side Rail screen

3. Braden Scale

4. Bowel and Bladder

5. Elopement Risk Profile

6. Pain Evaluation

7. Smoking Evaluation

8. Data collection

9. Immunization Record Sheet

IV. CONTACTS PHYSICIAN FOR ADMISSION ORDERS:

1. Reconciles medications

2. Documents legibly onto POS

3. Read back and verifies Telephone Orders

4. Make appropriate referrals

5. Transcribes all orders.

6. Fax back (new admissions)

V. RESPONDS TO EMERGENCY CODES:

1. Amber

2. Blue

3. Grey

4. Red

5. Silver

6. Orange

7. Yellow

8. Triage

9. Clear

PART II. FACILITY –WIDE RESPONSIBILITIES & STANDARDS

EMPLOYEE IS REQUIRED TO:

1. Speak English in patient care areas.

2. Attend mandatory and scheduled In-services/meetings.

3. Arrive to work on time as scheduled

4. Demonstrate ability to work with others cooperatively.

5. Demonstrate flexibility in assignment to meet resident/family needs.

6. Wear ID appropriately at all times.

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