Description
The Licensed Practical Nurse (LPN) is responsible for ensuring that all Agency clinical records and databases (including EMR / MAR / PNOs) are accurate and compliant with all NYS and Agency procedures and regulations. Additionally, the position will be responsible for assisting the Site Manager and Registered Nurse (RN) with the monitoring of health care needs and as needed, the provision of direct personal care and / or medication administration primarily at medically complex IRAs. This includes, monitoring that routine and as needed medical appointments are being scheduled and attended, monitoring that health care instructions are being followed, providing training to residential employees on how to provide appropriate hands-on care, checking medication administration records for errors, and notifying the RN and Site Manager of any identified areas of concern.
POSITION RESPONSIBILITIES
- Conducts regular audits of medical and clinical documentation at all residential sites, focusing on medically complex sites.
- Mentors site staff regard proper preparation, review and follow up to all medical appointments and medication changes for people supported.
- Regularly communicates with the Registered Nurse on the status of their sites and ensures that the assigned RNs and Site Managers are aware of any concerns.
- Directly assists the Site Manager and Registered Nurse in the monitoring of each individual's healthcare status and treatments at medically complex sites. This includes monitoring for the completion of health-related exams, appointments, laboratory / diagnostic testing as ordered or required.
- Assists with maintaining clinical databases to ensure files are updated and current.
- Provides training and instructions to site staff on the provision of appropriate hands-on care, including bathing, transferring, feeding, etc. This also includes the use of adaptive equipment and devices. While onsite, immediately addresses any identified retraining needs.
- When necessary, directly provides any needed personal care and / or medication administration.
- Assists with the training of all staff regarding the review, completion, communication, and the overall preparation of escorting individuals to medical appointments, as well as the necessary follow-up afterwards.
- Ensures attendance at any Day Medical DSP and Nursing meetings as well as all Agency medical meetings.
- Conducts individual-specific medication reviews weekly to ensure the proper administration of medications. Assists with medication error completion for Site Manager and RN review, if not completed timely.
- Completes required nursing care documentation promptly such as data entry into Therap and EMAR. Assists with maintaining the database to ensure individual files are updated and current.
- Participates in monthly meetings that are needed to address the health needs of the individuals.
- Participates in Agency Self Survey and DQI survey as necessary.
- Develops rapport and communicates with medical providers, pharmacies, people served, staff, and family members as needed.
- Ensures individual medical files are organized with accurate relevant information. Maintains required records including daily weekly case summaries, case notes etc.
Requirements
Education and Experience
Licensed Practical Nurse registered by the New York State Education Department (NYSED)One year experience in OPWDD certified residential / day habilitation setting; or comparable.Skills, Knowledge and Abilities
Knowledge of developmental disabilities.Good oral and written communication skills and basic computer skills.Must be able to read and write case notes as well as understand written directions.Certifications, must have or obtain
Medication Administration Certification through OPWDD.CPR / First Aid certificationPhysical and Mental Requirements
Seeing, hearing, walking, sitting, standing, driving, stooping, bending, carrying, stretching, and climbing stairs.