NORTH METRO COMMUNITY SERVICES, INC. JOB DESCRIPTION

Transcription

1 NORTH METRO COMMUNITY SERVICES, INC. JOB DESCRIPTION Position Title: LICENSED PRACTICAL NURSE Supervisor: Residential Nursing Supervisor Date: 4/09 Revised 5/31/2012 Department: Residential Classification: Non-exempt General Summary: Provide medical oversight to consumers in accordance with Division of Developmental Disabilities, Colorado Department of Health and Welfare, State of Colorado Nursing Practice and agency policy and procedure. Act as the liaison between physicians, person receiving services, and their caregivers under supervision of the Residential Nursing Supervisor. Qualifications: Valid Colorado LPN License Valid Colorado Driver s license Good driving record as approved by assigned insurance carrier Prefer experience working in residential setting for individuals with developmental disabilities preferred. Essential Functions: Communicate effectively in oral and written form. Knowledge of reading, writing and speaking English generally acquired through a high school diploma or equivalent. Access and retrieve information from laptop computer and printer Use of personal vehicle in the performance of job duties. Ability to be on call during agency off hours. Ability to go on site or to a medical facility to assess consumer medical needs during non-business hours. Responsibilities: Home Visit and Documentation on Nursing Checklist O Complete Home Visits/Nursing Monitoring's for the LPN caseload on a predetermined schedule and more frequently if needed. O If significant medical concerns arise or any other concerns arise monitoring increases to monthly or more until issues have resolved and then the previous schedule may resume. Assessment: O Provide a systems approach assessment (based on the medical diagnosis's of the consumer i.e. lung disorders should have lungs auscultated, skin conditions and or immobile clients should have bony prominence's checked, etc.) to include VS and PaO2 if on oxygen.

2 o Look at visible skin to look for signs of any abnormality that is "normal" for the consumer (moles, lumps, edema, rashes, etc.) and document your findings on the checklist. O Provide an update from the staff/provider to include any behavioral concerns. Review Master Blue Book: O Verify that the previous nursing checklist is in the book. O Ensure that any follow up from the previous monitoring was completed and document on the current checklist that it was or what the status is at the present time. O Check the adaptive equipment chart for accuracy including that any adaptive equipment the consumer has is on the form (i.e. glasses, hearing aids, splints, wheelchair, shower chair, foot inserts, etc.) Check all adaptive equipment to ensure it is in working order and document findings on the nursing checklist. If equipment is not in working order instruct staff/provider to notify the appropriate supplier/service provider to have it fixed and document this on the nursing checklist. O Review all medical appointments in the Master File are up to date to include annual physical, dental, vision, hearing, psychiatric, neurology, and any other specialties specific to the individual. O Review the medical section of the book and ensure that it is filed correctly and that the paperwork is properly labeled in the top right hand corner to indicate a specialty (cardio, gastro, endo, etc.) if needed. O Check that all specialty appointment follow up is complete, if none is needed document on the nursing checklist. O Ensure that labs are present in the book and that they are up to date ( may have to check this at the office to ensure the most current labs are in the book and if they aren t see that the consumer has labs drawn ASAP). O Check the weight chart to make sure it is up to date and that it matches what is charted on the current MAR sheet. Check weight gain/loss of 5 lbs and follow up with PCP or dietician as needed. O Review Diet order with Staff/HHP. Have concerns addressed by Dietician and/or Physician as needed. O Check the Acute Health Tracking Form and make certain it is up to date and completed. O Look at seizure tracking and be sure that it is up to date and that it is being turned into residential nursing office monthly, even if the consumer is not having seizures. The provider will take a graph of seizure activity prepared by the nursing assistant to the neurologist yearly and or as needed. Check the current MAR sheets to be sure all orders are transcribed correctly including the times to be administered, make sure that there are no open spaces on the MAR and that all non-medicated treatments are documented appropriately. Check through all previous MARs dating back to your last visit to ensure the same is done with them. Check through all PRN MAR sheets for correct documentation and that effectiveness is documented. Review the consumer daily book to ensure no follow up is needed and document on the nursing checklist any follow up that is needed and any instructions that were left with the HHP/staff. Compare all medications on hand to ensure that the labels match the orders on the MAR, that the individuals name is on the bottle correctly, that it is the correct dosage, and

3 that it has not expired. o Complete a count of all controlled medications and ensure that the count on hand matches the count indicated on the controlled count sheet. O Check all medications and make sure that the appropriate PRN medications are in the house and properly labeled. O Make sure all medications are stored appropriately to include externals from internals, refrigeration if needed, etc. Also check expiration dates on all medications and remove any discontinued or expired medications from the home for proper destruction. Medical Follow up: All medical follow needs to be completed within a timely manner. Follow up must be completed within one working week from time of visit or document the progress of the follow up in an to the Nursing Supervisor within one week. If the team requests an update then the entire IDT (including RC, Nursing Supervisor, and DPTL). You may utilize the MA to assist in obtaining documentation and follow up from your home visits. Nursing Checklist: Make sure that the checklists are completed in entirety based on each individual and turned in within 4 working days from the visit to the Nursing Supervisor. Document any education provided to staff/hhp on the Nursing Checklist. Ensure that any follow up needed is documented on the Nursing Checklist. Make certain that any directives or treatments that you have requested are documented on the checklist and the staff/hhp understand before you leave the home visit. Bishop Psychiatric Review O Participate in med prep roundtable the second Thursday of every month to get updates for Dr. Bishop review. O Participate in Dr. Bishop review the third Tuesday of every month and read the charts every 3rd month per the schedule. O Review all standing orders, new orders and changes during the review and sign the day review form to ensure the orders are correct. O Answer any questions pertaining to the individual caseload or provide follow up within 2 business days. Lab Review O Review all labs and initial, date, and indicate who to send them to and route to the medical assistant to be faxed, copied, and routed. O Interpret labs and follow up with doctor if needed. O IDT any updates from the doctor regarding labs and route contact note or to home file. Paperwork O Review all paperwork placed in the mailbox, initial, date, copy, and route to appropriate persons/place. O Type up new orders on an agency PO and fax to the doctor. May ask the MA to do this but review it prior to faxing. O New order transcription to monthly PO's done by medical assistant, but nurse must follow up to ensure that this has been done on a weekly basis. New order clarification & relay to staff/provider/tl. O entire team any new orders or condition change (to include RC, TL,

4 Day Program Team Leader, Residential Coordinators, provider, staff facility, guardian, and nursing supervisor). O Route copy to medical assistant to be faxed to appropriate place/person if needed File in the consumers medical book in the nursing office. O Review and print day psychiatric review forms for all individuals that see other psychiatrists than Dr. Bishop and ensure that the form is taken to the appointment with the consumer to include those that see their PCP. If the correct form is not being taken provide education to the staff/hhp the importance and purpose of the day review form to ensure that in the future it is used. TB shots O Administer shots and read results on week assigned if MA not available. O Document and route paperwork when completed to HR and in nursing office file. O Follow up if needed and educate staff. Hep B shots O Sign off on work comp paperwork when staff wish to get the HEP B series if present at the time as needed. Med Testing O Review and educate charting one on one with staff/providers. O Review testing materials one on one with the staff/hhp and go over the disclosure form. O Determine competency through medication practicum. Chart Review O Be present for questions from the pharmacist during chart review every third Thursday. O Review pharmacists recommendations and follow up on it. O Document follow up from recommendations on the PO reviewed and route contact note to home file. O Forward PO s back to the nursing assistant to be sent to PCP for review and signature. Trainings/Classes O G-tube training: provide one on one or class training using the g-tube curriculum from the state to include testing and competency review. Fill out competency documentation and ensure it is in the home file. O Medication Reminder Box training: provide one on one or class training using the MRB curriculum prepared by NMCS to include testing and competency review. O Medication Administration: Provide one on one or class training using curriculum from the state to include testing and competency review when regular instructor is not available every 3 months or as scheduled. O Medication Review: Provide one on one or class training using curriculum from the state to include testing and competency review when regular instructor is not available every 3 months as scheduled. Protocols O Review consumers current medical conditions and create a protocol for staff/provider to ensure medical needs are met to include when to notify the nurse and or 911. O Review protocol(s) quarterly with staff/provider and provide documentation of 100%

5 competency in the home file and on the nursing checklist. O Update protocol(s) yearly and place a new copy with signatures and date in the home file and nursing protocol book in the nursing office. O Route protocol(s) that need doctor's signatures to the doctor and then to home and nursing files. Service Plan Meetings O Attend each consumers SP yearly unless there is a conflict in the working schedule. Notify the Nursing Supervisor of the overlap and your rationale prior to attending and or not attending an SP. O Provide accurate medical information for the team and represent NMCS in a professional manner. O the team with any nursing follow up requested by the SP within one week. If the information is not yet available update the team on the follow up status weekly until completed. IDT's (interdisciplinary team meeting) O Attend consumers team meetings that are related to medical concerns and behavior concerns if the client is on psychotropic medications. O Be prepared with information for the discussion/concerns. O Provide accurate medical information for the team and represent NMCS in a professional manner. O the team with any follow up requested during the IDT with in one week. If the information is not available, update the team on the follow up status weekly until completed. Monthly MAR's & PO's O Review PO's monthly to ensure all medication orders on the current PO match the standing orders in the clients file at least 4 days prior to the last working day of the month. O Make changes as needed to the consumers PO's. O Contact the pharmacy with any discrepancies found on the PO to ensure cycle fill will be accurate 5 days prior to the 1st of the month. O Route completed PO's to the MA and assistant for routing and MAR completion. O Answer any questions related to the MAR from the MA or assistant. Monthly team meeting at Apartments/Group Homes O Attend the monthly team meeting(s) of your assigned staffed facility. O Provide accurate medical information and represent NMCS in a professional manner. O Educate staff as needed during the meeting and or get back with them on any questions or follow up asked for at the meeting with in one week. Quarterly Caseload Meetings O Meet quarterly with Residential Coordinator and team leaders to review caseloads O Provide accurate medical information for the team and represent NMCS in a professional manner. Long term medical paperwork O Review, correct, and sign PMIP paperwork from Resource Coordination for consumers on your caseload then give to assistant to route back to RC. Hospital discharges

6 O Coordinate consumer care during and after a hospitalization or surgeries. Evaluate the client s physical and emotional ability to return to their home environment. O Be present for hospital discharges to ensure all orders are clearly written, that the orders match previous orders, and ensure that staff/providers understand any new orders or treatments. O If unable to attend a discharge, get approval by the Nursing Supervisor to perform a discharge over the phone and document the conversation to be routed to the home file. Attend doctor appointments with clients as needed O Attendance at certain medical appointments may be required to discuss in depth medical concerns and potential treatment plans for the consumer. Nursing Files O Purge green books on each caseload yearly at time of SP meeting (must be done during the month of the SP). O May have the MA purge the book but must review the paperwork prior to it being shredded to ensure that important paperwork is not extracted from the file. Professional Communication O Perform all duties and communication with others while on the clock in a professional manner. O Communicate with medical offices and other medical professionals via telephone with good customer service skills. O Communicate with HHP/staff in a professional manner and establish appropriate and professional boundaries. O Communicate with members of the IDT in a professional manner. O Communicate with coworkers in a professional manner. O Communicate all medical concerns with team leaders and Nursing Supervisor in a timely manner. On Call O On call rotates as predetermined in the schedule set between the nurses (typically once every 3 weeks (for entire residential), some holidays (for entire residential), and M-W 24 hours a day and Thursday until 5 pm on your case load). O It is expected that you return all phone calls within 15 minutes, except when driving. If you continue to get phone calls and you are going to be driving for a long period of time please pull over and return the call to ensure a timely response. If it is not urgent instruct the caller that you will return their call when you reach your destination. O Document all phone calls in the nursing on call book and fill out appropriate paperwork for individual consumer files. O Give accurate weekend report at Monday morning debriefs to the residential department. O Speak directly with the appropriate nurse about any follow up requested during on call. Continuing Education O Complete a minimum of 8 continuing education credits per year: 2 credits must be in Nutrition, 2 credits must be directly related to individuals with intellectual disabilities, 4 are of your choice.

7 O Must keep CPR and First/Aide for the Professional training up to date. Required agency training (one time only): O Abuse/Neglect, Incident Reporting, Legal Rights/ Confidentiality. Complete incident report follow up documentation as needed. Provide additional in-service training as requested. Complete Medication /Charting Error Report as follow up to medication errors. O Complete the nursing paperwork within 4 business days and route. Ability to lift/push/pull/carry various objects, not including people, of pounds frequently and pounds occasionally. **I have reviewed and understand the requirements of my job duties as described above. Signature Supervisor signature Date Date