The Inpatient and Skilled Nursing Facility Nurse (RN) are responsible for assessing, planning, providing and documenting direct and indirect nursing care for a designated group of hospital patients or skilled nursing facility residents in accordance with the physician's plan of care. All nursing practice is based on the legal scope of practice, national and specialty nursing standards, HSC Policies and Procedures, and in accordance with all applicable laws and regulations. The RN also provides nursing care interventions, preventing complications and promoting improvement in the patients'/residents' comfort and wellness, informing the interdisciplinary team of their condition as appropriate. All efforts are directed towards continuous quality improvement and family-centered care.
Nursing Care Functions
- Provide direct care to assigned patients/residents.
- Perform admission, discharge, and transfer procedures, and assist others with patient's/resident’s activities and care.
- Execute physician's orders for all assigned patients/residents; safely and properly administers medications and treatments.
- Assesses patients/residents; determines nursing diagnosis; plans, implements, and evaluates patient/resident care upon admission and throughout hospitalization. The assessment must include biophysical, psychosocial, environmental, self-care, education, and discharge planning factors incorporating data from the patient/resident and or family when appropriate, in collaboration with the interdisciplinary team.
- Demonstrate critical thinking skills by problem-solving appropriately when providing patient/resident care.
- Anticipate and proactively plan for educational needs verified with patient/resident and family throughout the hospital stay.
- Assesses teaching/learning needs of patient/resident/caregiver(s) while preparing for independence/discharge. Documents patient/resident and caregiver’s education and understanding of information.
- Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and hospital or regulatory standards.
- Integrate nursing interventions into the multidisciplinary plan of care, incorporating appropriate standards of care and practice and patient/resident outcomes.
- Anticipate patient/resident needs and secure proper equipment and personnel for transport to outside clinic appointments. Accompany patient/resident to outside clinic appointments and community integration when necessary.
- Participates in interdisciplinary patient/resident rounds and related activities.
- Administers medications according to policy and monitors patient/resident’s response and documents in the electronic medical record according to policy.
- Verifies physician orders accurately and acknowledges new orders in the electronic medical record.
- Maintains documentation that exemplifies adherence to the highest standards of practice.
- Perform hospital-wide and unit specific technical skills competently and independently in accordance with policy and procedure guidelines, and as instructed by the Nurse Manager and/or House Supervisor.
- Demonstrate proper use of the identified hand-off processes.
- Adhere to standard precautions and infection control policies.
- Acts as a member of the Code Blue Team as assigned.
- Independently maintain regulatory requirements e.g. RN license, BLS, etc.
- Independently initiate escalation of concerns/issues utilizing chain of command.
- Plan for attendance at mandatory education and professional activities to enhance nursing practice.
- Demonstrate professional review of peers through timely participation in evaluations.
- Seek out opportunities to participate in enhancing departmental goals by ensuring adherence to national safety standards and service excellence standards; support the advancement of education and certification as well.
- Collaborate with members of the healthcare team and role model professional behavior and teamwork with coworkers.
- Communicate in a courteous, professional, and empathetic manner with patients/residents, and families.
- Participate in implementing change and support management decisions.
- Role model organizational skills, adjust for changes and can complete assignments on time.
Other Job Duties
- The SNF RN delegates and supervises the care provided by certified nursing assistants (CNAs) and licensed practical nurses (LPNs).
- The Inpatient RN provides supervision to the Pediatric Care Aides (PCAs).
- Serves as an active member of departmental or hospital committee as requested.
- Participates in interdisciplinary, interdepartmental performance improvement activities.
- Serves as a resource for other nursing staff members.
- Refer to Inpatient RN and SNF Roles and Responsibilities document for additional duties within each area.
- Other duties, as assigned.
Organizational Accountabilities (Staff)
- Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence standard is achieved
- Innovates through improvement of care and/or efficiency of operational processes.
- Dedicated to a standard of performance excellence and high quality
- Embraces changes/improvements and actively participates in the implementation of new/improved programs, technology, new equipment, systems and resources that promote quality of care, safety and efficiency
- Identifies, prioritizes and selects alternative solutions to determine best outcome
- Maintains a high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands
- Anticipates problems and attempts to solve before they develop
Blood Borne Pathogen Exposure
- Category I: Job usually involves contact with patients or patient specimens. Exposure to blood, body fluids, non-intact skin or tissue specimens, is possible.
Protected Health Information Access Level
- Level IV - Full Access Incumbents in this job may access any protected health information associated to a customer's needs, the service(s) rendered and the position's functions.
- This job operates in a hospital or office environment.