Registered Nurse – 36 hrs/wk – L’Acadie
Delivers quality nursing care according to the standards within the ANA Standards of Clinical Practice and Maine Nurse Practice Act. Demonstrates competence in nursing assessment, diagnosis, planning, implementation and evaluation. Exhibits leadership skills and teamwork. Promotes patient advocacy and supports learning needs of staff and students. Collaborates with other disciplines to ensure effective and efficient patient care delivery and the achievement of desired patient outcomes. Supports the organization’s vision and mission. Utilizes knowledge of patient’s age and culture in provision of patient care. Maintains organizational and unit requirements. Promotes a collaborative and cooperative environment with emphasis on customer service.
Essential Job Duties:
- Completes admission assessment and recognizes actual and potential health problems.
- Admission assessment completed within 8 hours of admission (If not possible, then provisions made to complete later, and reason documented.).
- Documented nursing assessment reflects review of residents psychosocial, spiritual, and environmental and health education status and data is reflected in the problem list.
- Complete nursing assessment on assigned resident promptly and adequately.
- Assessments done within first hour of work assignment.
- Care is delegated to appropriate caregiver when unable to see resident within an hour, to ensure safety and continuity of care.
- Continuously assesses resident’s response to illness and intervention.
- Documentation of ongoing assessments is appropriate and complete.
- Uses critical thinking skills to assess, anticipate and problem solve.
- Identifies resident and family needs as expressed verbally and through behavior and initiates action to meet them.
- Interprets clinical and diagnostic data with evidence of recognition of deviation from norm.
- Differentiates between clinically significant and insignificant data.
- Takes appropriate action when assessment and/or lab and diagnostic data is abnormal or significant.
- Identifies basic priorities in relationship to work assignment.
- Demonstrates an organized approach to workload.
- Prioritizes individual resident needs and work assignment.
- Initiates problem list and adjusts as needed.
- Problem list is initiated within 24 hours of admission and is appropriate for each resident’s needs, using data obtained from assessments.
Problem list is adjusted as goals are met and/or new problems occur.
- Supports multidisciplinary involvement in the plan of care.
- Collaborates and communicates with the CNO, QIDP and other disciplines to address resident needs, problems, and response to interventions. Documents as appropriate.
- Participates in quarterly Person Centered Planning meetings as assigned by the CNO and QIDP
- Demonstrates a systematic approach to care and treatment.
- Consistently demonstrates and documents a logically planned sequence of actions and activities to expedite intervention.
- Administers care according to established nursing standards and L’Acadie policy.
- Initiates, modifies as appropriate, and implements resident care interventions using critical thinking skills.
- Actions reflect knowledge of nursing science and good judgement.
- Carries out and adapts medically ordered interventions.
- Follows orders when appropriate, withholding actions on questionable orders while seeking clarification in a timely manner.
- Collaborates with CNO and QMRP Manager when questions arise.
- Accountable for safe administration of medication and IV therapy according to nursing standards and hospital/facility policy.
- Medication administered accurately, following the “5 rights” and any safe medication practices implemented (opening unit dose meds at bedside, etc.).
- Patient response observed, reported, and documented.
- IV therapy delivered as prescribed. Site observed and site care given as per policy, and documented appropriately.
- Recognizes adverse/critical changes in patient condition and acts appropriately to initiate intervention.
- Administers supportive care until help arrives and/or orders received.
- Demonstrates correct use of disaster plan and fire alarm system, obtains assistance from staff.
- Able to function (unless medically exempt) as an effective member of the facility evacuation team.
- Evaluates and documents actions, interventions, and outcomes.
- Uses critical thinking skills to evaluate interventions and select new interventions.
- Documents modification in resident problem list necessitated by changing resident needs.
- Nursing notes reflect utilization of current problem list, nursing actions, and resident response.
- Recognizes resident’s right to choose own options for healthcare.
- Accepts the rights of residents/families/guardians to their own beliefs, cultural practices, moral codes, and lifestyles.
- Assists resident/family/guardians in obtaining information on healthcare options.
- Actively involves residents/families/guardians in decision making.
- Supports decisions made by resident/family/guardians.
- Delivers care in a non-judgmental fashion, treats residents and family with respect.
- Displays courteous, respectful, and compassionate behavior towards residents their families, friends, and guardians.
- Accepts the dignity and worth of each resident.
- Assures that informed consent is obtained prior to procedures.
- Evaluates each residents understanding and assesses for questions before procedures are begun.
- Obtains clarification from physician as needed.
- Demonstrates knowledge of cultural factors, risk factors, preventative health measures, and complications associated with the age group of resident population served.
- Evaluates and documents pertinent observations, concerns, and issues relating to the age, culture and life stage of each resident.
- Recognizes common age related and cultural issues and modifies care to prevent complications or improve outcomes.
- Formulates and/or updates teaching plan for resident/family/guardian that is appropriate to their needs and level of understanding.
- Readiness to learn, learning style, and learning needs assessed.
- Family/Guardian must be included in teaching.
- Teaches methods identified during Person Centered Planning process and follows through
- Participates in orientation of new personnel.
- Demonstrates familiarity with orientation procedure for new staff and actively participates as assigned.
- Supports and welcomes new staff, while assisting with learning resident and facility specific needs.
- Recognizes individual learning needs of coworkers and provides opportunities for them to practice and observe.
- Arranges opportunities for coworkers who wish to practice skills or procedures (inserting IV’s, foleys, colostomy care, portacath, etc.).
- Includes students in teaching opportunities.
- Functions effectively in the charge role.
- Ensures that staff is assigned according to level of experience and scope of practice.
- Ensures that routine shift checks are completed and documented.
- Ensures that narcotic count is performed and documented completely.
- Modifies resident assignments in response to resident needs, desires, changes in acuity, and changes in staffing ratio.
- Responds appropriately to workload changes during the shift.
- Recognizes when own workload exceeds time/ability to complete and makes arrangements to obtain assistance delegates tasks as possible, asks for assistance from coworkers, etc. so that continuity of care is maintained.
- Offers assistance when able and steps in to assist coworkers (Includes Nursing staff and Direct Service Staff) whose workloads exceed time/ability to complete tasks.
- Establishes priorities based on unit needs, takes responsibility for assuring that safe resident care is maintained.
- As Nurse on duty, anticipates staffing needs, assists in filling in open scheduling slots etc. for the present and oncoming shift and plans accordingly.
- As Nurses on duty, collaborates with facility manager to assure adequate staff for the present and oncoming shift.
- As Nurse on duty, communicates with other nurses from the other shifts to maintain awareness of Hospital transfers, outings, and staffing needs.
- Assists Developmental Trainers manage breaks and meal times to ensure they do not disrupt resident care.
- Obtain coverage for resident care when leaving the unit for more than a brief period of time.
- Coordinates activities with other departments to ensure smooth transition from one unit to another unit.
- Collaborates with hospital based units during discharges to hospital, transfers, outpatient services, facility medical director, and social services.
- Encourages social support among coworkers.
- Utilizes and assists coworkers in using a teamwork approach.
- Seeks to support colleagues and develop trusting relationships with them.
- Assists with open communication and proactive approaches towards problem solving or conflict.
- Communicates pertinent information at shift report.
- Shift reports are organized and complete.
- Uses allocated time (not to exceed ½ hour).
- Actively participates in evaluating the quality of nursing care provided and resident care
- Completes audits as assigned or per protocol (restraint, fall protocol, chart audits, etc.).
- Participates with other staff members to evaluate and improve the standard of care provided to residents.
- Contributes information to potentially improve workflow or the work environment.
- Recognizes own needs and takes initiative to set measurable goals for professional growth and development.
- Sets professional goals and target dates at annual review or as needs arise.
- Communicates educational needs to manager as they occur and suggests plan for completion
- Demonstrates knowledge and skill in the use of facility utilities.
- Utilities frequently used in the resident care environment.
- Special applications, emergency procedures, disaster plan.
- Procedures for reporting failures and/or emergency shutdowns
- Demonstrates responsibility and accountability.
- Assumes personal and professional responsibility for decisions made and actions taken.
- Assumes personal and professional responsibility for maintaining requirements and for following policy.
- Follows through with requests from CNO/facility manager in a timely manner without multiple reminders.
- Maintains work commitment.
- Utilizes prescribed form, channels, and time frame when requesting time off and/or exchanging time, per policy.
- Other than unscheduled absences and earned benefit time taken, works at least 97.5% of employment commitment.
- Demonstrates capability of performing position responsibilities.
- Maintains a current professional Maine registered nurse license with no lapse in re-licensing
- Maintains responsibility in following through on license due dates and renewal process.
- Meets a minimum of 15 hours per year of continuing education (hours submitted to the Health Education Department for recording).
- Meets the unit’s annual competency training requirements.
- Complies with local, state and federal laws and regulations.
Licenses and Education:
Maintains current BLS Health Care Provider Coarse.
Maintain all required education for ICF/IID/Nursing facilities