GENESIS DETOX OF BROOKLYN, LLC:
Medically Supervised Inpatient Withdrawal Stabilization Services
RN/LPN JOB DESCRIPTION:
It is the responsibility of a Staff Nurse, under the Supervision of the Medical Director or Nurse Practitioner, to assess, plan, implement, and perform routine care to all our patients, as well as other organizational tasks related to patient care and Unit Operations, providing evidenced based comprehensive safe effective and ethical nursing care to all patients. The nurse is also responsible that medical needs, medication, medication administration and documentation is in compliance with the Genesis Policy & Procedures, Bureau of Narcotic Enforcement, Drug Enforcement Administration and OASAS 816.7 regulations. All core duties and responsibilities are subject to periodic revision.
CORE DUTIES & RESPONSIBILITIES:
- Provides and assures that the provision of direct patient care is consistent with the philosophy and goals of the facility.
- PPE always worn while in the facility, ensuring patients are provided with and utilizing it.
- Responsible for completing nursing assessment and documenting all pertinent health information in the case record.
- Administers CIWA-AR, CIWA -B and COWS and other appropriate screening instruments to determine patient eligibility for admission and during the course of administering detox medication as per facility protocols
- May administer Rapid Antigen COVID-19 tests to incoming or existing patients.
- Review and Document Onsite UDS results
- Communicate accurately all information collected during the Nursing Assessment to the Admitting prescriber.
- Upon admission accurately complete the MAR adding Routine and PRN medications.
- Administer and Document Patient Medication safely and accurately according to facility Policy and Procedure, with knowledge of purpose and adverse effects of the nursing care provided.
- Monitors and assesses patients’ condition and changing needs, making recommendations for additional or modified services in accordance with patient’s total needs. Makes appropriate adjustments as per MD, PA or NP documenting accurately in patient’s case records.
- Reviews any health related information/documentation as supplied by another facility/PCP/hospital.
- Knowledgeable and experienced with the Safe and Proper Utilization of All equipment and current on All Legal Standards as they relate to the delivery of Nursing Care.
- Medication reconciliation done at every shift change, documenting in Narcotics logbook; notifying Supervisor immediately of any discrepancies
- Document as per facility Policy and Procedures that all patient related devices are operating correctly
- Document all prescribed, and OTC medications given to patients in Nursing note
- Nursing shift note completed by every Nurse every shift
- Responsible for overseeing that Unit Aides complete Rounds every hour and participate in rounds as needed
- Wound care as needed
- Nurse on Duty participate in morning case conference (Rounds) conference call daily
- Ensure that all patients are treated with receptiveness, dignity, respect, and practices consistently within the context of the Patient’s Bill of Rights.
- Assure that patient’s Discharge Plans are signed by and given to the patient at discharge
- RN’s only: sign Recovery Care Plans as needed
Leadership & Staffing:
- Identifies and investigates problems and collaborates with the Nursing Supervisor, Nurse Practitioner, Physician’s Assistant or Medical Director in their timely resolution.
- Assists staff in identifying patient problems/issues, and effectively utilizes other members of the Medical/Clinical team to resolve them.
- Demonstrates leadership by delegating tasks/duties to appropriate staff, in coordination with Medical Director, Program Director, or Clinical Director
- Serves as a role model for peers and patients.
- Manages time to perform other duties as assigned by supervisor subject to patient and unit needs.
- Assists the Supervisor of Nursing in the orientation/training of new staff.
- Always exercises good judgment when communicating confidential Patient information with peers, maintaining absolute discretion and confidentiality, according to HIPAA guidelines and Genesis’ Policies and Procedures.
- Effective written and oral communication skills a must, on all relevant information related to patient’s care, environment of care, and timely completion of ALL pertinent documentation.
- Communicates with the Nursing Supervisor, Nurse Practitioner, or Medical Director immediately regarding any arising patient care or safety issues and documents these changes.
- Works collaboratively with all other departments to ensure that daily program schedules are followed and takes direction from superiors in carrying out job functions.
- Always performs ALL duties in a consistent Professional manner; conducts/interacts, communicates in an ethical courteous manner with ALL patients, families, referents, co-workers, supervisors, callers, visitors, and vendors.
Educational and Professional Growth:
- Identify and articulate strengths and areas of improvement as it relates to Organizational and Professional Responsibilities and Competencies, as well as Position Specific and Departmental Responsibilities and Competencies.
- Develop and articulate plan and methods for improving in areas that require improvement, as well as maintaining competence in areas of strength
- Tracks and completes all in-services, courses, and certifications required by organization and/or licensing body providing documentation of completion to HR.
- Track and maintain any license, certification, or accreditation required for specific position.
- Seek out and utilize regular supervision, as well as during crises.
- Participate in semi-annual review, and annual evaluation.
- Graduate of an accredited school of nursing.
Current Licensed Registered/Practical Nurse with New York State.
- BLS/CPR certification required.
One-year minimum nursing experience preferred.
- Experience in alcoholism and substance abuse preferred.
- Computer skills required, EMR a Plus.