Position Summary:

The LVN/LPN will provide patient care and assist in the collection of data during the assessment process, within their scope of practice, under the direction of an RN, mid-level practitioner, licensed physician, or supervisor at all times.

Essential Job Functions:

• Informing personnel (i.e. UR, psychiatry, dietician) of new admissions when appropriate.
• Administering and documenting vital signs, CIWAs, COWS (SUD only), collects data for fall assessments/precautions, seizure precautions, suicidal/homicidal assessments, pain scales, anxiety scales, craving scales, standard and infection control precautions adding co-signers as necessary.
• Observation, documentation, audit functions, education, and record keeping of all observed/inventoried/destroyed/prescribed medications.
• Assessment of patients with addiction and mental health conditions and assisting in ascertaining clinical medication management with Registered Nurses, Nurse Practitioner, Physician Assistant, Psychiatrist, and Medical Doctor.
• Administering medications via oral, sublingual, inhalation, auricular, topical, intramuscular, subcutaneous, vaginal, and rectal routes as ordered.
• Entering medication orders into the electronic medical record.
• Manages the Medication Administration Record, documenting administration, efficacy, and first response.
• Collaborate with staff in assessing patient, family age-specific nursing needs and develops plan of care for complex high-risk patients.
• Help Utilization Review in communicating pertinent nursing information.
• Designs teaching programs for patients/families and helps staff in program implementation.
• Work closely with physicians to provide education and counseling for clients and other organizational health care providers on optimal use of medicines (e.g., proper use, avoidance of over medication).
• Provide nursing care adapted to the individual patient needs based on the nursing process, which includes data collection, planning, implementation and evaluation.
• Direct patient care, including the reporting of observed changes in mental status and/or physical condition, response to emergencies, safety risks.
• Documents nursing incidents and medication errors.
• Oversee the medication management system that includes but not limited to, medication planning, storage, ordering and transcribing, administration, monitoring and evaluation.
• Verifies the integrity of and controls medications brought into the organization by the client, their families, and licensed independent practitioners.
• Systemically collect, record and analyze data and other relevant interactive social systems, including mental status, special precautions (suicidality, homicidally, elopement); physical problems/medical acuity (withdrawal and nutritional needs); and ethnic concerns (social, religious, or cultural needs).
• Uses assessment data to identify.

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