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 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.

• 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…