Registered Nurse

SUMMARY

The Registered Nurse (RN) at CLEARFORK ACADEMY is responsible for assessing clients in an inpatient drug and alcohol treatment program and administering medication according to state, accreditation, and facility policies and procedures. The RN works directly with Behavioral Health Techs and other clinical staff and medical staff to ensure nursing components of the organization are appropriately coordinated. The RN is also responsible for performing advanced indirect and selected direct patient care duties in support of the clinical process in a competent manner and completing any associated clerical functions.

AGE/PATIENT POPULATION(S) SERVED

Age of Patient Population Served: Adolescent and Young Adult Males/Females

Population Served: Persons meeting DSM 5 criteria for substance use disorders with or without co-occurring psychiatric illness.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Assessment of clients with addiction and mental health conditions and assisting in ascertaining clinical medication management with other Registered Nurses, Nurse Practitioner, Physician Assistant, Psychiatrist, and Medical Doctor. 
• Performing, completing, and validating assessments, utilizing proper grammar, spelling, and complete sentences without using unapproved abbreviations. 
• Provide nursing care adapted to the individual patient needs based on the nursing process, which includes assessment, planning, implementation and evaluation. 
• RN responds promptly in medical and emergency situations by carrying out appropriate intervention as evidenced by successful completion of procedure reporting of incidents and completion of documentation. 
• Direct patient care, including the reporting of observed changes in mental status and/or physical condition, response to emergencies, safety risks.
• Administering and documenting vital signs, CIWAs, COWS, fall assessments/precautions, seizure precautions, suicidal/homicidal assessments, nutritional assessments, pain scales, anxiety scales, craving scales, self-administration of medication assessment, and infection control precautions. 
• RN performs and records an AIMS Examination on each client exhibiting suggestive first time Tardive Dyskinesia. 
• Attends weekly treatment team meetings and brings forward information that would prevent crisis situations and client needs to assure safety. Collaborates with other members of the treatment team to solve clinical care problems as they occur. 
• Informing personnel (i.e. UR, psychiatry, kitchen) of new admissions when appropriate. 
• Works jointly with providers to assure protocols are being followed 100% of the time, medications are filled, and labs are followed up on. 
• RN assumes accountability when using independent clinical judgement and established protocols.  
• Lead, manage, and maintain accountability for all LVNs and supportive medical staff. Reviewing LVN notes and may assign LVN or MA daily tasks. 
• Phlebotomy 
• Observation, documentation, audit functions, education, and record keeping of all observed/inventoried/destroyed/prescribed medications. 
• Administering medications via oral, sublingual, intramuscular, subcutaneous, inhalation, auricular, topical, and rectal routes and performing scheduled and PRN vitals as appropriate. 
• RN completes medication reconciliation on each client and completes documentation. 
• RN acts according to the Nurse Practice Act for all written and verbal medical orders. RN enters medication orders into the electronic health record. 
• Manages the Medication Observation Record, documenting efficacy, and first response. 
• Train medical and non-medical staff on safety, infection control, medications, injuries, and appropriate delegated tasks.  
• Provides direct patient care to a diversified patient population, across continuum of care. 
• Collaborates with staff in assessing patient, family age-specific nursing needs and develops plan of care for complex high-risk patients. 
• Actively promotes wellness-oriented lifestyle behaviors for clients served as evidenced by nursing progress notes. 
• Communicates with DON regarding complex clinical or ethical issues. 
• Provide assistance to Utilization Review in communicating pertinent nursing information. 
• Designs teaching programs for patients/families and provides assistance to staff in program implementation. 
• Work closely with physicians to provide education and counseling for clients and other organizational health care providers on optimal use of medicines (e.g., proper use, avoidance of over medication). 
• The RN maintains necessary medical supplies at the facility for medications and infection control procedures.
• Carries out measures to prevent exposure to and transmission of pathogens in accordance with facility standards on infection control at all times. 
• Documents nursing incidents, infection control issues, and medication errors appropriately.  
• Ensures to use the utmost of care in protecting the confidentiality of client records in accordance with state and federal laws. 
• Keeps abreast of all pertinent federal, state and CLEARFORK ACADEMY regulations, laws, and policies as they presently exist and as they change or are modified. 
• Attends scheduled nursing meetings and disseminates information to the appropriate members of the treatment team.
• RN will maintain continuing nursing education units to comply with the standards set by the Texas Board of Nursing, as evidenced by proof of attendance. RN will provide completion of outside trainings to the HR department. 
• RN will complete all Clearfork Academy’s training requirements within the first 30 days of employment and will not allow more than a 30-day lapse annually. 
• Maintains a professional and ethical code of behavior. 
• RN always maintains neat and professional appearance. 
• Performs other duties and tasks as required.

AGE SPECIFIC COMPETENCIES (ADOLESCENT AND YOUNG ADULT MALES/FEMALES) 

• Demonstrates ability to systemically collect, record and analyze data and other relevant interactive social systems, including mental status, special precautions (suicidality, homicidality, elopement); physical problems/medical acuity (withdrawal and nutritional needs); and ethnic concerns (social, religious, or cultural needs).
• Uses assessment data to identify problem list and other interactive social systems.
• Initiates/develops a treatment plan with specific goals and interventions unique to the needs of the patient.
• Intervenes as guided by the treatment plan to implement appropriate interventions that promote, maintain, or restore physical and mental health, prevent illness effect rehabilitation, and restore developmental progression in adulthood.
• Provides health teaching for adult/family through individual and group interactions.
• Recommends special precautions for adults, as needed.
• Evaluates the response of the adult/family to interventions in order to revise the plan, including discharge criteria.
• Demonstrates an understanding of the developmental milestones of adolescents and young adults.
• Identifies trauma, abuse/neglect or exploitation a client may have experienced. 

MINIMUM JOB REQUIREMENTS

Education, Training, and Experience Required:

? Current and active Registered Nursing license from the State of Texas Board of Nursing.

? At least one year experience as a staff nurse preferably in the field of chemical dependency and/or behavioral health.

? Current Basic Life Support certification

? Current Handle with Care Physical Holding Certification

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

? Knowledge of industry standards: organization, theory, principles, and research processes, accreditation and regulatory standards, ability to assess clinical care requirements based on nursing principles, scope of practice.

? Texas Nurse Practice Act 

? AND Cod of Ethics for Nurses

? Texas Administrative Code 448

? Understanding of Addiction: Basic knowledge about substance use disorders

? Treatment knowledge: familiarity with behavior change and recovery models

? Application to practice: Methods for applying intervention and recovery knowledge to practice

? Professional readiness: Issues related to self-awareness, diversity, ethics, ad continuing education

? Knowledge of medications, indications, dosage ranges, side effects, and potential toxicity.

? Knowledge of PC software programs, particularly Microsoft Word and Excel is required.

? Written and oral communication skills; must be able to concentrate on work amid distractions such as noise, conversations, and foot traffic

? Must be able to correctly utilize breathalyzer, vital signs machine, EKG, urinalysis collection cups, and process urine drug screens.

? Must be able to collect blood samples by performing venipuncture and fingersticks. 

? Must maintain self-control in volatile or hostile situations such as when verbally or physically confronted in an aggressive manner.

? Must be able to work independently with little supervision in an unstructured environment with multiple demands

? Reading and writing level that can clearly express or understand complex concepts, assessments, directions and processes or sequences of events - level equivalent to at least two years of college.

? Ability to represent the program well in interactions both inside and outside the facility

? Working knowledge of (American Society of Addiction Medicine) ASAM criteria

PHYSICAL DEMANDS/WORKING CONDITIONS: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand or sit for extended periods of time. The employee must occasionally lift and/or move up to 25 pounds.

The job requires frequent contact with water (hand washing and cleaning) and working with body fluid and hazardous chemicals. When under these working conditions, OSHA standards and universal precautions must be followed at all times.

While performing the duties of this job, the employee must be able to work in a fast-paced environment with minimal to high volumes of stress.

EEOC STATEMENT:

It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.