The Clinic Nurse has the responsibility and accountability for the nursing care of assigned participants and serves in the role of Primary Nurse on the Interdisciplinary Team. The Clinic Nurse is independent in his/her application of geriatric nursing knowledge and skills. He/she manages complex clinical situations for which he/she is responsible. This RN works with other Interdisciplinary Team members in the delivery of care and services according to each participant’s comprehensive interdisciplinary participant assessment and plan of care. As the Primary Nurse, he/she will assist in managing the care planning and service delivery processes in accordance with PACE philosophy and in compliance with standards of professional nursing practice and with all State and Federal laws and regulations. The Clinic Nurse utilizes resources in an efficient and economic manner to ensure that each participant achieves the highest attainable physical, mental and psychosocial well-being.
Essential Duties and Responsibilities:
1. Utilizes critical thinking skills and performs comprehensive nursing assessments to identify participant’s problems/needs and set priorities; follows up on identified problems through appropriate referral processes. Accurately interprets and records latest diagnostic results.
2. Performs pre-enrollment screenings as directed, completes enrollment assessments, and coordinates the development of the enrollment care plans. Routinely collects participant data and completes clinical entry fields with appropriate responses according to nursing practice standards.
3. In conjunction with other clinic staff, ensures that weekly wound assessments are completed and documented for all assigned participants with wounds.
1. Coordinates and facilitates the development of a plan of care based on nursing process, which incorporates the plans of other disciplines and assists the participant to attain or maintain the highest level of physical, mental, and psychosocial well-being. Plans of care are developed with the participation, to the extent practicable, and consent of the participant and/or the participant’s interested family members or legal representative.
2. Makes referrals or ensures that referrals are made to other clinicians, disciplines, and support services as indicated and authorized by the IDT.
3. Communicates participant changes to team members while also coordinating the periodic review of the participant care plan.
4. Continuously updates the care plan, as needed, to ensure it is always current regarding nursing and health-related care.
5. Coordinates with all IDT members regarding participant’s care plan ensuring communication, collaboration, and coordination of all services and interventions.
1. Provides treatments, procedures, teaching, and other care as prescribed and according to participant care standards.
2. Demonstrates understanding of the age-related characteristics and needs of participants served.
3. Identifies emergency situations and implements emergency nursing care as needed.
4. Understands and demonstrates respect for participant rights and utilizes established mechanisms for management of ethical issues in participant care.
5. Participates in formal quality improvement activities as directed by the Quality Improvement Committee.
6. Manages chronic conditions according to practice standards, promoting participant independence and empowerment whenever possible.
7. Promotes and coordinates with all disciplines and departments to ensure participant safety in all settings.
8. Effectively communicates with all IDT members regarding current issues. .
9. Meets participants in the Center and at home to assess, provide care, teach, coordinate and evaluate current status and interventions. Monitors and plans skilled nursing home care services.
10. Monitors the provision of medications to participants. Communicates with pharmacy, primary care, clinic and med-room staff regarding medications, while also coordinating plans for medication administration systems that meet the participant’s needs. Reconciles medication and ensures medication compliance with primary care orders.
11. Ensures appropriate infection control measures are implemented in all settings, and, when necessary, educates team members, caregivers, and participants as indicated to promote quality participant care.
12. Immediately informs the participant, consults with the participant’s physician, and notifies the designated family member and/or the participant’s legal representative when:
a. There is an accident involving an injury that has potential for requiring physician intervention;
b. There is a significant change in the participant’s physical, mental, or psychosocial status;
c. There is a need to alter treatment significantly; or
d. There is a decision to transfer the participant from the Center.
1. Monitors the status of participants to evaluate effectiveness of the care plan and provision of care by the IDT. Facilitates reviews and discussions regarding changes in the care plan to meet needs based on ongoing evaluation.
1. Maintains ongoing communication with other disciplines to evaluate participant responses to interventions, to suggest alternative approaches when indicated and to revise and update plans of care to reflect progress toward goals. Facilitates interdepartmental communication to meet participants’ needs.
2. Meets daily with the clinical team to discuss current acute, at-risk, and transitional issues with participants and associated interventions.
3. Assists with delegating to nursing support staff
4. Integrates cost-effective measures into nursing practice.
5. Demonstrates active participation in QI processes.
6. Complies with PACE Program expectations to meet staffing demands based on participant care needs.
7. Adheres to policies addressing safe working conditions and takes initiative when unsafe conditions appear.
8. Recognizes inappropriate and/or ineffective participant care management and intercedes as appropriate.
9. Resolves issues and/or problems and completes correlating written reports.
1. Assesses and closely follows participants after hospitalization and ER visits.
2. Identifies participants at high risk for institutionalization and implements measures to avoid institutionalization, whenever possible, in collaboration with the Interdisciplinary Team.
3. Actively participates in the analysis of rates of institutionalization and promotes measures to control or improve, as appropriate.
1. Participates in the on-call schedule; triages phone calls to appropriate staff.
2. Interacts with participants, family members, legal representatives, and surrogates to answer questions and resolve concerns. Makes prompt attempts to resolve all participant grievances, seeking consultation or assistance from other departments or administration, as appropriate.
3. Reports relevant information to the Medical Director, Center Manager, Quality Improvement Coordinator and Interdisciplinary Team regarding:
a. Functioning and communication
b. Regulatory compliance issues
c. Participant risk factors
d. Sudden changes in participant behavior
e. Expressed dissatisfaction by participant or family
f. Reviews of treatment, unexplained injuries, staff behavior (positive or negative)
g. Staffing needs
h. Equipment and supply needs
i. Opportunities to revise policies, procedures and improve quality
4. Reports all injuries to self or others to the supervisor immediately.
5. Participates in fire and disaster drills. In the event of an emergency, carries out assigned duties to assure participant safety.
a. Graduate of an accredited school of professional nursing; BSN preferred
b. Current active license as a Registered Nurse in Delaware
a. Two years professional nursing experience required. Long-term care and/or home health care experience preferred
b. One year experience working with elderly individuals required
c. Familiarity with State and Federal regulatory requirements preferred
d. Proficient use of Electronic Health Records, Outlook, Word, and Excel preferred
Age of Patients Rendered Care:
e. Adult and geriatric patients
***Freedom from illegal use of drugs, and freedom from use and effects of use of drugs and alcohol in the workplace.
***Persons who have been found guilty by a court of law of abusing, neglecting or mistreating individuals in a healthcare-related setting are ineligible for employment in this position.
Knowledge and Skills:
1. Knowledge of geriatric and general chronic-care nursing principles and professional standards of nursing practice, and the ability to apply to participant-specific circumstances. Able to identify, implement and evaluate appropriate objectives and interventions for participants.
2. Demonstrates competency in clinical skills needed for participant population.
3. Demonstrates competency in physical, behavioral and functional capacity assessment of long-term care geriatric participants.
4. Current knowledge of laws and regulations that influence provision of care and services in PACE, in the home, and other settings.
5. Working knowledge of and ability to interpret and demonstrate policies and procedures to direct care staff.
6. Sufficient organizational and interpersonal skills to interact effectively with participants, families, Interdisciplinary Team members, administration, government officials, consultants and others, in addition to staff.
7. Carries out all duties in accordance with the PACE Your LIFE mission.
8. Demonstrates knowledge of and respect for the rights, dignity and individuality of each participant in all interactions. Able to act as role model for program staff by protecting and promoting participants’ rights in all interactions with participants and families.
9. Maintains the confidentiality of participant and program information.
10. Demonstrates honesty and integrity at all times in the care and use of participant and program property.
11. Able to understand and to follow written and verbal directions. Able to communicate effectively with staff members and participants through verbal and written means.
12. Knowledge of emergency and disaster procedures of the facility. Able to locate nearest exit, and to understand and respond to written or oral instruction in case of an emergency.
13. Sufficient mobility and strength to move freely through the building, to ensure participant safety at all times, and to assist, transfer, or otherwise move participants of the Center out of danger in case of an emergency.
14. Demonstrates respect for co-workers and responds to needs of participants by complying with policies on attendance, punctuality and dress code. Able to arrive and to begin work on time and to report for duty on all shifts, weekends and holidays.
15. Working knowledge and ability to comply with policies and procedures for workplace safety, including infection control procedures, application of universal precautions for blood-borne pathogens, use of personal protective equipment and handling of hazardous materials.
16. Demonstrates ability to prioritize responsibilities and complete projects within allotted time.
17. Able to respond to change productively and to handle additional tasks/projects as assigned.
18. Able to respond to program needs on an on-call basis.
19. Knowledge of and ability to apply facility personnel policies to job actions without regard to race, religion, age, sex, national origin or disability.
20. Able to carry out the essential functions of this job (with or without reasonable accommodation) without posing specific, current risk of substantial harm to the health and safety of self and others.
1. Is knowledgeable of facility participant care policies as defined by the Medical Director. Makes recommendations for revision, as necessary.
2. Is knowledgeable of Personnel Policies and Procedures as defined by the Program Director. Makes recommendations for revision, as necessary.
3. Implements nursing care and nursing personnel policies.
4. Participates in pre-admission screening of participants who may be potential enrollees.
5. Participates in development and revision of job descriptions for the nursing department.
6. Communicates directions in a clear and concise manner.
7. Audits participant care clinical records for appropriate action and follow-up as well.
8. Personally evaluates care of new participants with acute care issues, (i.e., participants with infections, decubiti, depression, behavior problems, recent/ frequent falls, and recent change in condition, etc.).
9. Supports education policies and procedures with staff. Communicates issues to the Center Manager.
10. Supports facility Infection Control Program with staff. Performs one-to-one education, as requested.
11. Is a role model for others – projects a professional, confident and caring attitude.
12. Sets an example for other staff: