Clinical Responsibilities
- Coordinates and implements nursing services for Adult Residential Services – North Region or Mobile Bay Region
- Completes the assessment/admission process for individuals including: Medical Checklist/Physical Health/Nutritional screening, Infoscriber/Chartmeds/MAR, height/weight, AIMS, TB skin testing, vital signs, and other assessments as applicable
- Assists with maintaining medical records to include documentation of acute health changes to provide a clear picture of the course of illness or injury
- Provides individual, family or group education regarding individual’s psychiatric illness and/or intellectual disability or developmental disability
- Administers medications, observing the Seven Rights of medication administration Monitors individuals for potential side effects of medications and reports findings to the physician
- Provides medication education for the individual and family, including uses and potential side effects
- Reviews Medication Administration Records and monitors for errors
- Identifies psychiatric and medical needs and communicates effectively with physicians to include completion of medical consultations and reconciling any orders. Accompanies residential staff and individuals to doctor’s visits as needed and assists with recommendations
- Interfaces with the multi-disciplinary/person centered plan team and actively and cooperatively participates in development of the interdisciplinary treatment plan and/or person centered plan
- Monitors laboratory results and performs CLIA waived testing as applicable, and reports all abnormal findings to the Provider
- Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation including providing emergency care as needed (CPR, MindSet, PRN Medications)
- Identifies and monitors nursing deficiencies (through peer reviews, trainings, chart audits, etc.) in the residential program and implements corrective measures
- Ongoing compliance with Nurse Delegation Program, including recertification requirements and taking MAS call
- Primary delegation within NDP to MAC workers. Implementation of NDP practices and assessments to include verification and monitoring of MAC worker competence
- Accepts calls from staff about emergencies or critical issues after normal work hours and on weekends
Administers appropriate Human Resource functions:
- Assists with interviews of nursing applicants when necessary and completes necessary forms as outlined by HR Policy and Procedure
- Provides positive and effective leadership
- Objectively completes employee performance evaluations on program staff and routes to Human Resources department on a timely basis
- Completes Time & Attendance biweekly within set timeframe given by payroll department
- Is knowledgeable and applies HR policies and procedures on a consistent basis
- Provides staff with consultation and supervision individually and in group staff meetings
- Training and general orientation of the facilities, policies and procedures, and program operations
Supervision and Consultation
- Seeks clinical supervision and consultation needs
- Accepts and employs suggestions for improvement
- Actively works to enhance clinical skills
Clinical Record Keeping
- Documents in a timely fashion per AltaPointe policy
- Documents in a clear, concise manner, nursing services provided to the individual and general observations
- Documentation shows that forms, notes, logs, and other applicable written information are completed promptly, accurately and updated when appropriate
- Documents legibly
Courteous and respectful towards individuals, visitors and co-workers
- Treats individuals with care, dignity and compassion
- Respects individual’s privacy and confidentiality
- Is pleasant and cooperative with others
- Assists individuals and visitors as needed
- Personal values don’t inhibit ability to relate and care for others
- Is sensitive to the individual’s needs, expectations and individual differences
- Is gentle and calm with individuals and families
Administrative and Other related duties as Assigned
- Actively participates in Performance Improvement activities
- Actively participates in AltaPointe committees as required
- Completes assigned tasks in a timely manner
- Accesses appropriate community resources according to consumer needs
- Follows AltaPointe policies & procedures
- Maintains current State license and requirements for renewals (i.e. CEUs), and attends to required in-services and workshops
- Any other duties as assigned by supervisor or designee