Assesses, plans, implements and evaluates the nursing care of patients and residents within the skilled nursing and intermediate care setting. Responsible for ensuring continuity of care of the patients/ residents during and between shifts by providing direct care as well as supervising the care given by CNAs, LPNs and support staff members. Participates in resident and family teaching and is responsible to assure that complex treatments are provided and evaluated. Maintains role as patient/resident advocate with a focus on the facility's mission.
DUTIES AND RESPONSIBILITIES:
Assesses paitents/residents on admission and as needed, as well as when conditions change. Documents appropriately to meet the requirements of the MDS. Assists with and coordinates all campus admissions and discharges.
Admits new patients with the assistance of the all unit Nurses and assures that the medications are reconciled with the Ambulatory Pharmacy.
Utilizes Vigil System and/or Vocera and serves as the primary resource for the initial connection and monitoring of staff response where appropriate. Utilizes the Vocera to access staff and management.
Performs all formal nursing assessments, including the comprehensive skin and pain assessments required of the Utilizes appropriate pain management techniques and consults with Pain Team for non-pharmacological pain management. Educates the resident, family and CNA regarding complex pain management. .
Performs all campus oversight of clinical admissions, treatments and discharges and contacts the Manager, Director of Nursing and/or Administrator as needed.
Works closely with the MDS Coordinator.
Documents and reports changes in resident's condition and nursing care on progress notes and plan of care, helps determine significant change in status per MDS protocol. Contacts Providers as needed for additional orders and/or needs to transfer patient/resident to a higher level of care.
Performs waived testing (point-of-care testing) per Clinical Laboratory's and the resident care unit's policies and procedures as necessary. Draws ordered labs and communicates with the Lab regarding critical values.
Ability to interpret results of Lab waived tests; access Radiology reports in Meditech, and take appropriate action on waived tests or other diagnostic results.
Performs functions that will optimize resident safety and reduce the likelihood of medical/health care errors.
Submits documentation in timely, clear, concise and pertinent manner.
Notifies Provider of changes in resident's condition and follows through until appropriate action is taken.
Understands situations which require notification to DPHHS, with appropriate investigation and follow through, with the assistance of the manager and DON.
Notes and carries out physician's orders in a timely manner. Monitors orders for completion.
Rounds with the Provider(s) as needed to provide updated care needs and/or changes in condition.
Participates in walking rounds and documenting appropriately any issues that are found.
Follows through, as needed, on information given by shift repor/huddle regarding resident, family or resident concerns.
Directs care assignments and staffing in the absence of the Manager. Coordinates Staffing throughout a 24 hour period in collaboration with the Manager, Staffing Tech, and/or other Campus Resource Nurses.
Provides complex care and treaments to patients/residents, such as but not limited to Wound Care and IV Therapy. Acts as the Wound Nurse in weekly Wound Rounds.
Works every other weekend and alternates holidays as scheduled to assue coverage. May have a direct patient/resident assignment to meet staffing needs on assigned unit(s).
Leads the Care Team by serving on Committees and Task forces related to Quality Assurance and Performance Improvement QAPI).
Monitors the plan of care and makes changes as appropriate.
Helps direct the care provided to improve the quality of care rendered.
Assists with the department's continuing education and in-service programs.
Demonstrates competence in technical, manual and critical thinking skills, according to the scope of practice for RNs.
Functions as a patient/ resident advocate by protecting the resident's rights.
Administers medications, following the five (5) medication rights and reduces the potential for medication errors.
Demonstrates creativity in solving problems and looking at situations in new and innovative ways.
Interacts with residents, families, co-workers, managers and other departmental personnel in a kind, knowledgeable and friendly manner.
Consistently involves patient/resident and family in planning for care, treatment, teaching needs and discharge plans.
Participates in the performance improvement functions by collecting and verifying data, Performs CMS Audtis.
Participates in the completion of the MDS.
Functions as a resource to all Staff.
Participates in orientation of new personnel.
Follows proper infection control/prevention procedures and supervises supportive staff in infection control procedures. Completes infection control audits and reports them to Unit Manager and to QAPI as appropriate..
Demonstrates ability to remain calm in emergency and/or stressful situations and gives everyone a feeling of confidence that the situation is under control.
Consistently follows the policies and procedures of the facility.
Exhibits genuine interest in and appreciation of adults in later years of life.
Motivated and independently competent to organize workload so that all functions are completed efficiently.
Identifies potential stressors and acts as a change agent to manage transition of patients/residents and/or work environment.
Assesses all patient/resident Falls, Medication Errors, and Employee Injuies and reports all serious safety events.
Maintains healthcare and life safety standards and participates in Mock and Annual Surveys by CMS.
Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.
Adheres to dress code.
Completes annual educational requirements.
Maintains regulatory requirements.
Wears identification while on duty.
Maintains confidentiality at all times.
Attends department staff meetings and Resource Nurse Meetings as required within the department.
Reports to work on time and as scheduled; completes work in designated time.
Represents the organization in a positive and professional manner.
Actively participates in Quality Assurance and Performance Improvement (QAPI) activities.
Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards
Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.
Complies with Benefis Health System Organization Policies and Procedures.
Complies with Health and Safety Standards and Guidelines.
Graduate of an accredited College of Nursing.
Current licensure as a Registered Nurse in the State of Montana.
Current BCLS certification, healthcare provide and maintains certification per per Benefis policy.
As a not-for-profit community health system, Benefis is driven to provide the highest level of care. We serve nearly 230,000 residents across a 15-county region that is bigger than Connecticut, Massachusetts, New Hampshire and Vermont combined. Benefis is the largest non-governmental employer in the Great Falls area, with more than 3,000 employees.Benefis has 530 licensed beds (that includes 146 beds in long-term care, 71 in assisted living and 20 beds at Peace Hospice of Montana) and partners with over 250 area physicians.Our hospital has been recognized for its exceptional work in quality care by providing a wide range of programs and services to help you live the best life possible. We’re here to help you “Live well.”Benefis Health System came about when two Christian-based hospitals became one. Our founders believed in providing good care to all in need, and trusted that this would be accomplished. The Benefis name was derived using Latin root words: "Bene-" meaning good, and "fis-" for faith and trust. It’s these same root words that make up such terms as ‘beneficial’ and ‘confidence’.Benefis has been a trusted provider of care for more than 125 years. And our name speaks to o...ur commitment: good care one can put faith in.Benefis is consistently ranked among America’s top hospitals by the nation’s leading healthcare ratings organizations for a range of services, including cancer care, joint replacement, stroke treatment, wound care and home health.To learn more about our services, continue looking through our website at WWW.BENEFIS.ORG or call 406.455.5000.