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Performs, interprets, and completes assessment/reassessment, including physical, functional assessment, psychosocial, social, medication history, spirituality, discharge planning, referrals to interdisciplinary team and code status according to unit protocol, policy and the individual needs of the patient.

Provides appropriate pain assessment (in each body system) and management of pain, including reassessment of pain

Assess Patient education needs and barriers to learning.

Initiates/updates patients plan of care based on initial and comprehensive assessment/ reassessment

Knowledge of IV medications, ADR, and blood components, IV catheters site (type, size, location, and verifies patency •Administers medications safely according to policy.

Verifies all monitoring system alarm parameters are active with appropriate limits.

Collaborates with multidisciplinary healthcare team using effective communication, utilizing SBAR when appropriate.

Timely notification to Department Director of potential problems or concerns.

When faced with a problem or concern, is proactive by presenting suggested solutions at the time the Department Director is made aware of the problem or concerns.

Knowledge of and adherence to National Patient Safety Goals as appropriate.

Follows telephone read back policy for all telephone orders by the physician.

Initiate, implements, and revises/updates patient specific plan of care.

Provides an environment conducive to safety and security and implements appropriate precautions/measures.

Documents evidence of nursing care in medical records of patients.

Observes for reactions and /or complications, and report to the physician in a timely manner.

Upholds the basic rights of privacy and seeks to preserve dignity/independence of expression of all patients and families.

Consistently follows medication reconciliation

 

Demonstrates appropriate use of equipment and devices pertinent to the care and safety of the patient.

Maintains fall precautions for patients at risk.

Demonstrates ability to identify and respond appropriately to emergencies (i.e., Code Red, Code Blue, Code Grey, etc.)

Provides an environment conducive to safety and security, implements appropriate precautions/measures.

Demonstrates ability to identify critical events/near misses and takes appropriate action.

Recognizes signs of abuse and reports appropriately per policy

Completes documentation legibly, objectively, accurately and timely.

Ensures physician orders have been acknowledged by the end of the shift, works with Charge Nurse to resolve complex order acknowledgment issues.

Completes documentation of medication given on the MAR and Pyxis.

Practices appropriate measures of infection control using principles of standard precautions (i.e. OSHA blood borne pathogens standards, CDC guidelines)

Demonstrates appropriate use of personal protective equipment (i.e., gloves, gowns, masks, goggles) and handwashing and infection prevention techniques

Adheres to all policies related to seclusion and restraint to avoid/limit the usage.

Maintains suicide precautions following policy.

Respects cultural and religious practices of patients.

Understands and abide by all department policies and procedures as well as well as the Codes of Ethics, HIPAA/Patient Privacy regulations.

Adheres to departmental initiatives related to performance improvement measures.

Is knowledgeable and complies with federal, state, local laws that govern business practices and specific to the position. Complies with all Department of Health Services requirements for the State of California, Joint Commission, and Center of Medicare &Medical Services (CMS) standard that apply to the position.

Participates in Performance Improvement (PI) data collection specific to department.

Defining performance improvement problems solving process (e.g., PDCA) and how its use assists in reaching improving patient outcomes and /or organizational quality and verbalize at least one departmental improvement initiative that has occurred within the last 12 months.

Responsible for 100% review of staff meeting information by attending staff meetings or reviewing staff meeting minutes.

Provides break and meal coverage as needed.

Performs other position-related duties as assigned, depending on assignment setting.

 

Minimum Education: Possession of associate degree in nursing or successful completion of an accredited Registered Nurse Program as evidence by licensure, from a recognized college or university.

Bachelor is preferred.

Minimum Experience: One-year previous telemetry experience preferred. ICU/CCU/ER experience preferred.

Required License/Certifications: Current and valid license as a Registered Nurse issued by the State of California, Current Basic Life Support (AHA), NIHSS Certification and Advanced Cardiac Life Support up (AHA) on hire.

ABM/MAB within 60 days of hire, annual thereafter.

MAB / CPI – required.