Position Description

Registered Nurse

Position

Provides medication management, staff training as well as nursing oversight over all Trivium New England programs.

Essential Duties

This position includes, but is not limited to, the following essential functions: 

• Provide nursing oversight and supervision across the Trivium New England programs.  
• Complete nursing assessment upon admission to Trivium New England and as needed thereafter. Assess and chart observations of the client's condition, review medication with the client, establish baseline vital signs, review any medical conditions present upon arrival. The information gathered will be charted in the client's EMR and reviewed with the Program Manager.
• Assess each client's ability to self-administer medication upon admission and at least annually thereafter.
• Partner with Program Managers to complete State Assessment upon admission and on an annual basis.
• Write a Care Plan when required by licensing, and train staff on implementation.
• Administer prescribed injections to clients.
• Triage resident medical complaints as necessary, make recommendations for follow-up care.
• Dress and or redress wounds and assess the healing progress. Give staff and clients proper guidance on how to redress wounds if needed. Refer for external care when necessary
• Recommend tools or devices that may improve the quality of life for the client.
• Coordinate with Physicians, Pharmacy, Program Managers as well as other individuals on the clients' internal and external care team to ensure continuation of care.
• Provide staff education regarding client medications and diagnosis.  Provide education to clients and staff on proper home health care procedures and strategies. 
• Lead time-limited and topic-specific educational groups for residents when indicated by needs of milieu.
• Must comply with all company and financial policies and regulations.  Attend staff meetings as necessary.
• Medication Management Oversight
• Recommend and initiate best practices for charting clients medications and conditions in accordance with licensing regulations and Trivium New England's policy.
• Ensure unused medication is disposed of in accordance with licensing regulations and Trivium New England's policy.
• Ensure procedures are followed to document trip and holiday medication requests and medication check-ins upon client's return.
• Communicate with prescribers regarding medication refusal, errors, or in the event an order is unclear.
• Maintain a list of staff who are authorized to monitor self-administration.
• Ensure that all employees who supervise self-administration are properly trained and following through on their duties. Duties include effectively monitoring self-administration, properly completing documentation, communicating in the event of confusion, and taking appropriate action in the event of missed medication and other incidents or errors.
• When indicated, train and delegate medication administration to specific staff. Notify the Program Manager in advance to ensure compliance with regulations.
• Review and modify Trivium New England's medication policies as appropriate, in collaboration with the Market Director.
• Auditing
• Monitor MARs. Review weekly. Note errors and follow-up with pertinent staff. Add medications as necessary.
• Complete monthly MAR changeover. Ensure new MARs are accurate, making note of discontinued medication, trip medication, PRN sheets, etc. Check that the MAR and the medication form in BN are identical.  
• Oversee record-keeping for all controlled medication. Ensure weekly audit and double count.
• Collaborate with Program Managers as medications are changed to add new controlled medication sheets. When a sheet is retired (because it is full or the medication/dose has been changed), add to BN file and shred.
• Review medication errors monthly with Program Managers and Market Director. Collaborate on plans to address noted trends and prevent future med errors.
• Review all medication changes and ensure physicians orders are rejected in the Med form on BN and in the MAR.
• Review, approve, and train staff on individual resident psychoactive PRN plans.

To perform the job successfully, the individual must be able to perform each essential responsibility satisfactorily.

Physical Demands

These physical demands are representative of the physical requirements necessary for an employee to successfully perform the essential functions of this position.  Reasonable accommodations may be made to enable individuals to perform the essential functions of the position. 

While performing the responsibilities of this position, the employee is required to talk and hear. The employee is often required to sit and use their hands and fingers, to handle or feel and to manipulate keys on a keyboard. The employee is frequently required to stand, walk, reach with arms and hands, climb or balance, and to stoop, kneel, crouch or crawl. Vision abilities required by this job include close vision.

The employee must be able to travel between locations, and occasionally attend seminars which may require an overnight stay.

Working Conditions

Working conditions are normal for an office or residential home environment. The noise level in the work environment is usually quiet to moderate. Work requires occasional weekend and/or evening work based upon the needs of the business.

Requirements/Qualifications

To perform this position successfully, the individual must be able to perform each essential responsibility satisfactorily.  The person in this position will have the following experience and attributes:

• Associate's degree in Nursing; Bachelor's degree preferred 
• Eligible to practice as an RN in Vermont and New Hampshire, either through holding an active Vermont or New Hampshire license or by possessing a valid multistate compact license OR eligibility to obtain licensure prior to start date.
• Prior psychiatric nursing experience required
• Patience and compassion with difficult clients
• Excellent verbal and written communication skills.
• Proficient in Microsoft Office (Outlook, Word)
• Must have strong attention to detail and good analytical skills.
• Be flexible as to scheduled hours.
• Possess above average problem solving, decision making and organizational skills.
• Ability to push, pull, lift and/or transfer up to 50 pounds.
• Committed to self-improvement.

Confidentiality Statement

I acknowledge and understand that I may have access to confidential information, including Protected Health Information (PHI), regarding employees, clients, or the public.  In addition, I acknowledge and understand that I may have access to proprietary or other confidential information or business information belonging to Trivium.  Therefore, except as required or permitted by law, I agree that I will not:

• Access or attempt to access data that is unrelated to my job duties at Trivium.
• Access or attempt to access Protected Health Information (PHI) beyond my stated authorized HIPAA access level.
• Use or disclose to any other person, or allow any other person access to, any information related to facility that is proprietary or confidential and/or pertains to employees, students, clients, or the public.  Use or disclosure of information includes, but is not limited to, verbal discussions, FAX transmissions, electronic mail messages, voice mail communication, written documentation, loaning computer access codes, and/or another transmission or sharing of data.
• Use or disclose Protected Health Information (PHI) for use in violation of HIPAA regulations.

I understand that Trivium Life Services and its employees, clients, or others may suffer irreparable harm by use or disclosure of proprietary or confidential information and that facility may seek legal remedies available to it should such use, or disclosure occur.  Further, I understand that violations of this agreement may result in disciplinary action, up to and including, termination of my employment.

Statement of Understanding

I have read and understand the above position description. I assert that I can perform all essential job functions, meet the physical requirements of this position, perform satisfactorily in the stated working conditions, and satisfy the expectation for regular attendance.