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Job Description
BETHESDA ADULT DAY REGISTERED NURSE JOB DESCRIPTION
Position Summary:
The Registered Nurse (RN) is responsible for coordinating and overseeing the health-related needs of participants enrolled in the Adult Day Services program. This position ensures accurate medical documentation, physician order management, participant assessments, care planning, health monitoring, regulatory compliance, and collaboration with healthcare providers, families, and interdisciplinary team members to support participant health, safety, and quality of life.
Scheduling:
Part-Time Position - No Weekends or Holidays.
Essential Duties and Responsibilities Clinical Documentation & Medical Records:
Coordinate and obtain physician orders for medications, treatments, diets, adaptive equipment, and other healthcare needs. Fax monthly physician order requests and follow up with healthcare providers to obtain signed orders. Request and maintain participant medical records, health histories, medication lists, and supporting healthcare documentation. Review, update, and maintain participant diagnoses and health information in the electronic health record system. Ensure all medical documentation is current, accurate, and compliant with organizational and regulatory requirements. Request hospital discharge summaries and update participant records following hospitalizations or significant health events. Document hospitalization admission and discharge dates and maintain supporting records.
Admissions & Assessments:
Complete nursing-related admission requirements for new participants, including medication orders, treatment orders, code status documentation, and health history information. Obtain and maintain physician orders for services provided during program participation. Complete comprehensive needs assessments within required timelines following admission. Conduct annual reviews and updates of participant diagnoses, health records, and assessments. Complete annual social history reviews and maintain supporting documentation.
Care Planning & Participant Support:
Develop, review, and update individualized care plans in collaboration with participants, families, and interdisciplinary team members. Complete and update Participant Activity Care Plans at least quarterly, including short-term and long-term goals. Review participant activity preferences and goals with participants on a regular basis. Monitor participant health status and recommend care plan revisions when appropriate. Maintain and update Master Care Plans and Resident Profiles annually and whenever significant changes occur.
Health Monitoring:
Conduct and document monthly blood pressure, pulse, weight, and other health monitoring activities. Complete monthly Health and Activity Assessments and ensure all information is accurately documented. Monitor participant health conditions and communicate significant changes to families, healthcare providers, and program leadership. Update diagnoses and participant health information whenever changes occur.
Regulatory Compliance & Safety:
Maintain accurate code status documentation, including Do Not Resuscitate (DNR) orders and related records. Ensure DNR documentation is properly obtained, signed by physicians, distributed, maintained, and updated according to organizational policies and state regulations. Maintain current DNR lists and communicate updates to appropriate staff. Ensure participant emergency and medical information is available for transportation, community outings, and program activities. Ensure nursing practices comply with all applicable regulations, licensing requirements, organizational policies, and professional standards.
Participant Support Plans:
Review and update Individual Abuse Prevention Plans (IAPPs) at least quarterly. Review and update Positive Support Strategies at least every six months or as participant needs change. Ensure support plans accurately reflect participant needs, risks, and intervention strategies.
Communication & Collaboration:
Serve as a liaison between participants, families, physicians, pharmacies, hospitals, and other healthcare providers. Collaborate with program staff to ensure participant health needs are understood and supported within daily programming. Provide education and guidance to staff regarding participant health concerns, safety precautions, medical conditions, and care strategies. Participate in interdisciplinary meetings and contribute to participant-centered care planning.
Record Management:
Maintain and update participant profiles, emergency information, travel notebooks, and health records. Ensure participant information is updated following admissions, discharges, hospitalizations, diagnosis changes, and physician recommendations. Maintain participant travel and emergency notebooks, including current profiles and DNR information. Ensure all required nursing documentation is completed, filed, scanned, retained, and archived according to agency policies.
Qualifications:
Current Registered Nurse (RN) license in the State of Minnesota. Experience working with older adults, individuals with disabilities, dementia, or chronic health conditions preferred. Knowledge of care planning, assessments, healthcare documentation, and regulatory compliance. Strong organizational, communication, and interpersonal skills. Ability to work collaboratively within an interdisciplinary team while maintaining participant confidentiality.
Preferred Skills:
Experience in adult day services, long-term care, assisted living, home care, or community-based services. Proficiency with electronic health record systems, including documentation and care planning software. Strong attention to detail and ability to manage multiple priorities while maintaining accurate documentation. The Registered Nurse plays a vital role in supporting participant health, independence, safety, and quality of life while helping create a welcoming and person-centered environment for all participants.
