Registered Nurse

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Key/Essential Functions & Responsibilities

• Responsible for provision of nursing services for persons supported in assigned program(s) and/or system(s), working in collaboration with direct support or other applicable staff, including program leadership, to obtain information or updates on persons supported and regularly reporting on-site to engage with persons supported and staff, conducting observations, assessments and trainings.

• Develops and maintains an understanding of regulations applicable to assigned program(s) and/or system(s) as they relate to medical and nursing care, including needs or care for specific medical and related conditions of persons supported and of scopes and standards of nursing practice applicable to state(s) of assignment.

• Utilizes the nursing process with each person supported, assessing their condition, establishing person-centered goals, implementing appropriate nursing interventions and evaluating overall progress, including responses to treatment, to inform updates or changes and improve effectiveness of care.

• Assesses the learning needs of persons supported as it relates to their health care and provides education regarding treatments, special diets, medications, follow-up diagnostic tests and healthy lifestyle information in collaboration with medical providers, if needed.

• Collects data to support assessments of persons supported including taking vital signs, social history, chief complaint(s) and current concerns.

• Triages phone calls from program staff, leadership and/or persons supported during and outside of regular working hours, as applicable to assignment and recommends appropriate actions or destinations (e.g. Urgent Care, Emergency Room etc.), documenting according to protocols; may participate in nursing call list for assigned system(s).

• Observes, records and reports overall condition, reaction to drugs and treatments or complaints received by persons supported to appropriate external medical providers.  

• Documents all calls, correspondence and encounters with people we support in accordance with established guidelines and within appropriate timelines in electronic systems or on paper, as required by applicable regulations

• Writes, reviews and/or updates plans of nursing care, including Plans of Nursing Service (PONS) and other individualized plans of care applicable to assigned program(s) or system(s), for persons supported and regularly completes reports, forms and/or other summary documents in appropriate formats and systems in accordance with all applicable requirements.

• Reviews and documents medical records including diagnostic tests, labs, evaluations or other pertinent clinical information and reports, taking appropriate actions to address health, wellness or medical concerns, sharing medical information with appropriate external providers and interfacing with internal and external parties to support coordination of care in accordance with all established protocols, including during hospitalizations.

• Presents information and responds to inquiries regarding health, conditions and/or status of persons supported in assigned program(s) or system(s) in regularly recurring team or person-specific meetings or as otherwise needed and assists with nursing-related needs in other service settings or systems as requested, which may include participating in meetings, planning, assessments and/or education. 

• Provides oversight of medical care, documentation and systems, including electronic health record (EHR) and medication administration record (eMAR) for assigned caseload through regular training of direct care staff and management regarding individual medical needs including medication information or administration, chronic or other conditions and/or specific care due to current conditions or short-term needs, such as diet or fluid restrictions.

• Provides in-service training and education related to medical treatment and certifications, as well as ongoing oversight of direct care and other staff performing medication administration and assisting with support of complex or specialized medical needs, such as enteral feeding or modified diets, colostomy, ostomy, catheterization, positioning, turning and/or using lifts, for electronic medical record (eMAR) and other nursing-related supports, as required by assigned caseload.

• Participates in intake assessments during the referral process, reviewing medical records and documentation, performing direct observations and/or assessments with the individual and making recommendatio