LPN **New Higher Rates**

DUTIES & RESPONSIBILITIES • Complete a comprehensive nursing assessment upon admission/readmission and as changing health needs indicate • Complete a Quarterly Nursing Assessment every three (3) months that includes a review of systems, full body exam, skin checks, Braden Scale, and Fall Risk Assessment • Upon discharge, complete a Discharge Summary that includes all relevant medication, medical follow up, and pertinent health care information • Present clinical data obtained through direct observation, interview, physical assessment and other reports to the IDT; present information in a concise and organized manner • Set nursing priorities in accordance with professional judgment • Develop a health care plan for clients requiring 24/7 nursing care that includes specific nursing goals and directions for meeting the client's health care needs • Review and revise the health care plan at a minimum of every 90 days and incorporate data gathered through nursing assessments and communication with the IDT • Collaborate with Day and Work Services to ensure that the health care needs of the client are communicated and the necessary documentation forwarded • Refer clients to physicians when assessment indicates further medical evaluation is required; facilitate transfer to the hospital/Emergency Department as needed • Complete hospital and Emergency Department transfer sheets; copy and forward the annual physical exam, last set of 90 Day Physician Orders, current Medication Administration Records (MARS), and other pertinent information to the receiving facility • Monitor weight and blood pressure measurements at a minimum of monthly and more frequently as indicated by nursing judgement or physician orders • Prepare and administer medication as ordered by the physician in accordance with Elwyn's medication policies and procedures; obtain verbal orders when necessary and transcribe the information as per policy • Administer and document prescribed medications and treatments on hard copy MARs or in an electronic format (eMARs); use discretion during administration to provide as much client privacy as possible • Administer enteral tube feedings, blood glucose testing, nebulizer treatments, and skin care as ordered by the physician; use discretion during administration to provide as much client privacy as possible • Instruct direct care staff on the administration and documentation of specific treatments including but not limited to topical creams and other over the counter(OTCs) agents • Report any observed medication and treatment side effects and relevant laboratory values to the Health Care Coordinator/Charge Nurse timely; contact the physician as directed • If using hard copy MARs, review the monthly MAR and validate that all medication and treatment orders are correct and update as needed; remove old MARs from the medication binder and replace with new MARs at the start of every month • Assess client progress with the self-administration of medication and work to actively promote increased independence in client function. Assist with data collection related to medication goals • Complete monthly medication exchanges with the pharmacy provider; immediately reconcile identified issues • Administer and document immunizations as ordered by the physician; ensure that necessary consents have been completed prior to administration • Prepare clients for medical appointments through communication and maintenance of NPO (nothing by mouth) status, procedural preps, and the administration of pre-sedation medication • Validate that all lab work has been completed as scheduled and document in the nursing progress note; if not completed, schedule follow up and document • Document all behavioral and physical changes in the client's status and other pertinent information in the nursing progress notes; document all changes from baseline status