The Registered Nurse is responsible for providing the quality medical care within Willow Springs Recovery’ Detoxification and Residential Programs. The Registered Nurse is responsible for the oversight of the onsite LVN’s and participates in the all nursing daily duties. This includes ensuring timely implementation of orders given, reporting of client needs, and documentation. The Registered Nurse will report on a variety of functions including safety, quality improvement needs, and compliance standards of daily client care. The Registered Nurse also performs direct services to clients including medication administration, education of prescribed medications, processing of labs, executes initial detox treatment plans under the supervision of the Director of Nursing and group facilitation as needed. The Registered Nurse’s position is responsible for signing off on all behavioral health services administered by the LVN’s. The Registered Nurse will also attend weekly meetings with the Director of Nursing to be provide information and education to ensure all services are delivered appropriately within each scope of practice.
MAJOR DUTIES AND RESPONSIBILITIES:
- Initial Detox treatment plan generation and discharge planning instructions.
- Adherence to facility policy and procedures, State and Federal law.
- Consults with the physician regarding patient health care plans and treatment.
- Participates in diagnostic test orders to help providers identify and assess the patient’s clinical problems and health care needs.
- Complies with medical records policies regarding the complete and accurate documentation of patient care. Initiates and maintains required records and legal documents.
- Participates in quality improvement activities.
- Educates patients about health and illness’ and promotes health maintenance
- Collaborates with the clinical team regarding the patient’s treatment, health and illness prevention.
- Maintains and reviews patients records, charts and other pertinent information. Posts test and examination results daily
- Administers medications, provides vaccinations and renders treatment to clients.
- Communicates with providers, RN’s, LVN’s, and medical professionals ensuring a continuum of care for each client.
- Considers the age of the client and emotional stability when determining appropriate treatments.
- Respond to inquiries, concerns and complaints from clients and their parents, spouses or guardians as needed.
- Oversee and maintain the tracking of medical supplies and inventory.
- Observe and record client behavior as needed or directed.
- Observing and recording patients’ behavior.
- Conduct nurse to nurse communications with hospitals in the event a client is sent out, ensuring all discharge paperwork is received upon arrival back to the facility.
- Coordinating with physicians and other healthcare professionals for creating and evaluating customized care plans.
- In order to provide emotional and psychological support to the patients and their families, RNs create harmonious environment.
- Diagnosing the disease by analyzing patient’s symptoms and taking required actions for his/her recovery.
- Maintaining reports of patients’ medical histories, and monitoring changes in their condition.
- Guiding and Directing LPN’s in more complex situations.
- Checking the stock on a regular basis for maintaining the inventory level, and placing orders if required.
- Changing patient’s medication as indicated by their conditions, responses and provider.
- Adhering with the protocols, norms, rules and regulations in order to maintain complete medical records.
- Maintaining hygienic and safe working environment in compliance with the healthcare procedures.
- Providing instant care during medical emergencies, like accidents, burns, heart attacks and or strokes.
- Providing necessary guidance on health maintenance and disease prevention.
- Keeping an eye on each and every aspect of patient care that includes physical activity.
ESSENTIAL KNOWLEDGE, SKILLS, AND ABILITIES:
Knowledge: The incumbent will:
- Possess a basic knowledge of administrative functions including, interpersonal communications, office etiquette, and computer skills.
- Advanced knowledge of psychiatric education and treatment of the chemically dependent population.
- Possess strong clinically ethical standards.
- Possess an intermediate knowledge of Microsoft Office suite applications including Word, Excel, Outlook, and Power Point.
- Knowledge of dual diagnosis treatment practices including
- Advanced knowledge of HIPAA regulations and CFR 42 requirements.
- Possess a basic understanding of report generation, and data interpretation.
Abilities: To excel in this position the incumbent should be able to demonstrate the following competencies:
- Problem Solving – Identify and resolve problems in efficient and effective ways.
- Ethics – Treat clients, staff, co-workers, visitors, contractors, and guests of Willow Springs Recovery with respect and dignity; work ethically and uphold the values and standards or Willow Springs Recovery.
- Attendance, Punctuality, Reliability – Arrive on-site, on-time, as scheduled, consistently with a professional disposition. Ensure all work responsibilities are covered in the event of an absence or scheduled vacation.
- Leadership – Constant development co-workers and clients, in effort to achieve each individual’s highest potential.
- Strong Character – Staying calm under pressure is essential. Having an approachable demeanor without compromising Willow Springs Standards of ethics and workmanship.
- Organization – Must be highly organized and efficient in managing the necessary daily client/staff demands and tasks associated with them.
- Patient Care – Excellent bedside manner and communication skills are essential handling clients and their cases.
QUALIFICATIONS AND PREFERENCES: The following requirements and preferences will be evaluated and verified to establish employment eligibility.
- 3-5 Years of nursing experience, preferably in the chemically dependent population.
- 1-3 Year of experience utilizing Microsoft Excel at an advanced level.
- Past experience working with medical records is a plus.
- Bachelor’s degree in nursing preferred.
- Valid registered nursing license in the state of Texas
- Utilization Review experience is a plus.
- Ability to explain treatments and conditions to clients of all ages.
- Working knowledge of healthcare laws and regulations.
Willow Springs Recovery is an equal opportunity employer and prohibits discrimination and harassment of any kind.