Position Summary:

Provides skilled professional care to the patient as ordered by the physician and in compliance with the Nurse Practice Act for Vocational Nurses, regulations established by Federal/State laws, agency policies and procedures and JCAHO standards. Provides direct patient care for the age groups/acuity level for whom competency has been validated by TrinityCare.

Duties and Responsibilities:
1. Complies with established CHW/TrinityCare policies, procedures and objectives, performance improvement, legal, safety, environmental and infection control standards.
2. Documents and communicates all observed symptoms, reactions, treatments and changes in patient condition to the Case Manager, physician and other health care team members as appropriate. Records all communications and changes in the patient’s condition in the clinical record.
3. Establishes and maintains professional, cooperative interpersonal relationships with other staff members, physicians, patients, patient family members, and the public as appropriate, while assuring confidentiality of all patient information.
4. Observes, documents, and coordinates with the physician and Case Manager the need for changes in medications and/or treatments.
5. Promotes appropriate preventative and therapeutic nursing procedures and techniques as ordered by the physician and/or per TrinityCare’s clinical procedures.
6. Manages the patient’s pain control and obtains order for changes as appropriate.
7. Assist the patient with personal care, activities of daily living, nutritional and dietary needs.
8. Obtains and documents complete physician orders per regulatory and policy requirements, including but not limited to, verifying by read-back.
9. Complies in following policies and procedures for maintaining patients’ rights and responsibilities, advance directives, corporate integrity plan, ethics, confidentiality and National Patient Safety Goals.
10. Works collaboratively and cooperatively with the Case Manager, family/caregiver and other interdisciplinary team members to meet the physical, emotional, and spiritual needs of the patient/family/caregiver.
11. Recognizes and utilizes opportunities for health counseling with patient/families/caregivers. Documents all teaching provided in the medical record.
12. Records pertinent and concise information in the medical record that will reflect the patients' needs, problems, capabilities and limitations, as well as the patient’s response to prescribed treatments and nursing interventions. Entries will accurately record all care that has bearing on the patient.
13. Reads the current physician orders prior to each shift. Calls the office immendiatley if the current orders are not available.
14. Uses patient and PPE supplies and equipment effectively and efficiently. Coordinates with DME/HME as needed to ensure supplies/equipment are functional and safe.
15. Ensures and promotes organization and patient confidentiality per HIPAA regulations and agency policy.
16. Performs all activities incorporating and applying the principals of proper body mechanics and all employee safety guidelines.
17. Ensures compliance with all patient safety precautions, including but not limited to CDC guidelines for hand washing, blood-borne pathogen, etc. as appropriate for the patient.
18. Provides and maintains a safe environment for the patient. Complies with disaster preparedness plans and ensures compliance with all safety and environment of care regulations.
19. Identifies, reports and documents reportable safety/risk events. Assist with investigations of events and root cause analysis as requested. Educates patient/families regarding their roles in patient safety.
20. Participates in team conferences and mandatory education as requested.
21. Seeks consultation for, or an understanding of, principals of care for situations outside of employee’s area of expertise. Seeks and accepts direction from Case Manager or cinical office staff member.
22. Communicates and interacts with all personnel by TrinityCare’s core values and customer service standards, is open to others’ ideas and opinions, and is viewed by others as an example of professional, considerate behavior.
23. Promotes departmental and system compliance with legal, regulatory, accreditation-related programs and performance improvement efforts with other members of the team and the patients/families/caregivers.
24. Fulfills the obligation of assigned shift assignments. Coordinates all scheduling with the office prior to services being rendered.
25. Submits complete and accurate time cards and charting on Monday following the dates services were provided.

Qualifications:

To perform successfully in this position, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

One year of professional nursing experience or approval from the Department of Health Services of a Program Flex
Graduation from an approved school of Vocational Nursing

Certificates, Licenses, Registrations

Current California Vocational Nurse License
Current CPR
Current California Driver’s License preferred
Automobile and automobile insurance preferred