Registered Nurse; RN - PACE

Job Details:

Location:

HSRC Fortuna, Fortuna, CA 95540. Position Type:
Full Time. Salary Range: $47.60 - $52.50 hourly.

Shift: Day.

Schedule:

Monday through Friday, 8:30 a.m. to 5 p.m.

The Registered Nurse (RN) provides comprehensive nursing care and care coordination for participants in a PACE setting, supporting the health, safety, and independence of frail and elderly adults. The RN conducts assessments, develops and implements individualized Plans of Care in collaboration with the Interdisciplinary Team, and delivers skilled nursing services in both clinic and home settings. This role monitors participant health status, manages medications and treatments, and ensures timely communication with Primary Care Providers, caregivers, and team members.

The RN also provides education to participants and families, supports quality improvement initiatives, and promotes a safe, compliant, and participant‑centered care environment.

• Conduct initial participant assessments and reassessments to identify overt problems/needs and set nursing priorities; record assessments, reassessments, and care delivered in the medical record.
• Provide treatment or interventions that address problems requiring immediate referral and/or follow‑up; interpret and record latest diagnostic results.
• Develop a Plan of Care in coordination with the Interdisciplinary Team, incorporating immediate and continuing care needs and participant/family perspectives.
• Provide direct care such as wound care, IV therapy, blood sugar checks, IM injections, vital sign checks, and follow‑up on episodic problems identified by Primary Care Providers.
• Perform scheduled and as‑needed home visits to assess participant health status, provide skilled nursing care, and reinforce care plans.
• Participate in daily morning and Interdisciplinary Team meetings, providing updates on changes in participant condition and movement between settings.
• Communicate participant health problems, daily schedules, planned tests, and appointments to the IDT to ensure coordination.
• Consult with and educate participants, family members, and/or caregivers regarding disease processes, self‑care techniques, prevention strategies, and medical interventions.
• Provide the Primary Care Provider with a summary of health findings and any changes in a participant’s health condition.
• Ensure that all tests, lab work, and diagnostic studies ordered by the Primary Care Provider are executed.
• Coordinate medication management for Redwood Coast PACE participants, including stocking, ordering, administering, and monitoring compliance; arrange delivery of needed medications and supplies to participants’ homes.
• Monitor participants in the Day Center during mealtime to assess adequate food intake; coordinate with the Registered Dietitian to address problems and provide nutritional counseling.
• Collaborate with Primary Care Providers to ensure protocols are in place and standing orders are carried out (e.g., bowel care, foot care, skin care, urinary tract infection, vital signs, weight, and wound care); provide self‑care education and training to participants, family members, and caregivers.
• Delegate tasks for personal care needs to Day Center team members; provide leadership and oversight to Care Partners in executing Plans of Care; provide education, training, and competency validation for tasks and interventions assigned to Care Partners; communicate priorities for care delivery.
• Support the Infection Control function in coordination with the Quality Assurance Coordinator, Medical Director, and Nurse Practitioner.
• Actively participate in Quality Assessment and Performance Improvement (QAPI) for processes, structures, policies, workflow, and procedures directly affecting participant care; take immediate action to correct, report, and follow up on participant health and safety issues and concerns.
• Work collaboratively with the IDT and co‑workers to meet or exceed Redwood Coast PACE quality assessment and performance improvement targets.
• Participate in on‑call coverage in conjunction with Primary Care Providers.
• Pursue continual improvement in service delivery and communication with…