The Registered Nurse demonstrates competence by integrating theoretical knowledge with clinical experience in the care of assigned patients by independently assessing, planning, and evaluating patients and utilizing the systematic approach of the nursing process. The RN utilizes patterns of patient responses to guide practice and provides nursing care as defined by the ANA Scope and Standards of Practice, in accordance with the objectives, policies and procedures of MHRH, the NY State Nurse Practice Act and our philosophy of nursing.RESPONSIBILITIESClinical Skills and Knowledgea--Completes a comprehensive assessment including determination of health literacy, depression screening, determination of readiness for change, assessment of patient's self efficacy related to disease management.a--Follows evidence-based clinical practice guidelines incorporating principles of chronic disease management.a--Develops and implements a plan of care based on evidence based guidelines, incorporating patient centered goals.a--Uses motivational interviewing techniques to determine patient's needs and health goals.a--Evaluates progress toward patient-centered goals weekly and revises plan when needed.Researches and assists in the development of patient educational tools.a--Demonstrates critical thinking skills by recognizing significant changes in the patient's condition and making the appropriate interventions.a--Performs nursing care consistent with policies and procedures of the agency and in accordance with established best practices.a--Completes recertification OASISon site, revising patient's goals and orders to reflect clinical, functional and service needs identified through the OASIS assessment.a--Utilizes telemonitoring for patients with appropriate diagnosis to promote positive outcomes.a--OASIS documentation accurately reflects the clinical, functional and service needs of the patient.a--Patient plan of care includes the appropriate disciplines as identified and supported by the OASIS assessment.Communication/Collaborationa--Communicates hands-off patient information in clear, concise and timely manner via email, telephone and verbally as appropriate.a--Submits completed Start of Care OASIS, including all required elements, within 48 hours of initial visit.a--Conferences with all disciplines after initial evaluation and every 14 days thereafter and documents in the EHR.Communicates to MD SOC information including POC, medications and pertinent assessment findings. Obtains and documents verbal order for SOC.a--Documents patient's progress legibly and according to agency policy.a--Upon transition to a different care setting (SNF, ED, hospital) provides verbal report to the accepting facility. Completes transfer form as needed and submits to Intake Coordinator.Case Management/Leadershipa--Assigns patients to LPN and per diem RN appropriately; prepares packets and updates.a--Assigns home health aide appropriately. Develops plan of care with patient and family. Orients HHA on site per protocol and completes HHA supervision every 14 days or less.a--Participates in multidisciplinary team conferences when appropriate.Initiates multidisciplinary conferences.a--Completes and submits activity sheets and census sheets weekly.a--Prepares patient for discharge from nursing services to case management status communicating to all disciplines and documenting in the EHR.a--Completes discharge OASIS and discharge summary within 5 days of discharge visit. Notifies all involved disciplines of discharge and documents in EHR.a--Completes medication reconciliation on start of care and weekly thereafter.a--Performs and documents disease specific teaching activities including but not limited to medications.a--Performs skin assessment weekly and documents in patient record.a--Measures wounds weekly.Initiates consultation with certified wound specialist for patients with stage 3 or 4 pressure ulcers.Initiates consultation with certified wound specialist for patients showing no improvement in wound status after two weeks of treatment.a--Obtains insurance authorization as required.a--Accepts assignments willingly.Travels to all geographical areasa--Delivers BNI (HHABN, NMN) according to policy.Professional Developmenta--Demonstrates the professional role of the registered nurse role by incorporating best practices and interacting with others in a professional manner.Participates in staff orientation. Serves as preceptor to students and to new staff members. a--Accepts accountability for own practice.Identifies potential learning needs of staff. Researches and assists in the development of staff education.Quality Improvement and Safetya--Administers medications safely including: preparation, pre and post assessment, and monitoring of patient's responses.a--Promotes a culture of safety by fostering an attitude of trust, participation and collaboration among colleagues.a--Provides input to the development and revision of nursing policies. Researches evidence-based practice supporting the policy development/revision.a--Identifies potentially dangerous situations which could cause harm to patients/staff and suggests actions to minimize risk.a--Reports incidents/ errors/critical values appropriately and within the proper time frames.a--Attends unit based QI project meetings. Actively participates and contributes meaningful information.

Experience:

• One year of acute care experience or related experience

Education:

• Graduate of an accredited school of nursing.

Licenses/Certifications:

• Current licensure in New York State as a Registered Professional Nurse.
• Certified in Basic Life Support.
• Other certifications as required in specialty area

Other:

• If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.
• Must possess excellent customer service skills.
• Must demonstrate ability to communicate effectively verbally and written.
• Must demonstrate ability to form effective working relationships with hospital personnel of all levels, to include the multidisciplinary team and both patients and families.

About Us:

MidHudson Regional Home Health