General Position Description

Under general supervision, provides professional psychiatric nursing care to acutely and chronically ill mental health, substance abuse and developmentally disabled consumers

within a 24/7/365 crisis unit. A crisis nurse performs the full range of psychiatric nursing duties. Work assignments require a thorough knowledge of behavioral health practices

and procedures, laws and regulations, and the ability to work independently. Will function as the Lead RN to accomplish scheduling, training in specific nursing duties and

requirements.

Essential Job duties and Performance Expectations

1. Will demonstrate the use of appropriate knowledge/skill/judgment to provide nursing care, examples of work performed include but not limited to:

a. Observes assigned consumers on a daily basis to identify, interpret, and document physical and emotional status and/or patterns, such as assaultive or suicidal behavior, and response to treatment or medication; as part of a multi-disciplinary team, assists in formulating a diagnosis and developing and implementing individualized consumer treatment plans based on observations; provides crisis intervention to those individuals experiencing acute episodes.

b. Participates in or leads individual or group counseling sessions, family conferences, and recreational and social therapy sessions to assist consumers in understanding the nature of emotional and physical problems, to accept the need for treatment, and to address issues such as communicable disease and family planning; participates in departmental and team meetings to discuss consumer care and progress, shift activity, and program policies and procedures.

c. Accurately take and administer physician/NP orders. Administers psychotropic medications to consumers, monitors use, calling in medication orders to pharmacies, and documents reactions; instructs consumers on the purpose, dosage, and side effects of medication, and explains the legal process related to the consumer's refusal to take prescribed medication.

d. Obtains medical, psychiatric, social, and family histories of new admissions; takes and records vital signs; obtains lab specimens; assists physicians with exams; schedules and arranges for special tests; develops discharge plans; maintains timely and accurate charts and logs; monitors supplies; and may draw blood.

e. Aids consumers in obtaining proper medical care, after release or during hospitalization, by identifying community agencies and resources to assist consumers with stabilization while living in the community; interacts with private medical facilities, courts, and county and State agencies to express concerns of the consumer and to discuss treatment; testifies in court as to the consumer's mental and physical condition

2. Shall attend assigned training and continuing education to maintain credentialing and privileging, to include, but not limited to:

§ Credentialing as a Registered Nurse or LPN

§ As required by NC Division of MH/DD/SA service definition and PCC Training Policy/Procedure.

§ CPR & First Aid Certification

§ Restrictive Interventions EBCI

§ Med Administration certified

3. Shall demonstrate the ability to work/be a part of organizational and therapeutic teams, and maintain positive working relationships with consumers, community stakeholders, referral organizations, and other employees/departments of Phoenix Counseling Center, Inc.

4. Shall develop a working knowledge of applicable organizational policy and procedure and demonstrate compliance. This shall include, but not be limited to:

• Clinical policies/procedures

• Training and professional development

• Personnel policies/procedures

• Employee Ethics/Corporate Compliance/Consumer Rights

• Service record documentation

• Confidentiality/HIPAA

5. Assure compliance with PCC’s Policy and Procedures regarding administrative and clinical record management (1-A-006)

a. 24/7 facilities shall maintain a rolling, locking file cabinet (LRFC) to house consumer records/information during the consumer’s treatment episode and/or needed chart correction after discharge.

b. HIM personnel shall place the record(s) in the LRFC assuring an out-guide is appropriately completed and placed in medical records. In addition, upon placement of the record in the LRFC, HIM personnel shall log the date/time, MR #, and sign the LRFC log. Upon completion, custody for the MR shall shift to the Registered Nurse on Duty (RNOD)

c. The RNOD and assigned facility HIM personnel shall retain keys for the locked, rolling file cabinet(s) (LRFC). Custody of the records shall be managed by the RNOD, who assures record security and that record(s) are checked in/out with a log-in sheet containing check in/out date/time, record number, and personnel signature for any records removed from the LRFC.

d. The off-going RNOD and on-coming RNOD shall verify that all records assigned to the LRFC are secure and accounted for as evidenced by signatures. Any discrepancy shall be documented during this process.

1. Any information that is determined to be missing will be accounted for. Should information not be accounted for the assigned 24/7 manager shall be verbally informed by the RNOD and an adverse event completed and submitted using PCC’s adverse event and critical incident reporting process.

e. Only designated personnel shall retain keys to MR offices at each location as designated by PCC HIM Coordinator.

f. HIM staff shall provide training to all personnel at each location on PCC’s Clinical Record Management Policies and Procedures. This training will be documented and verified with employee signatures. Evidence of this training will be placed in each employees personnel

6. Staff will assure appropriate scheduling of nursing coverage is maintained.

7. Staff will assure all nursing staff are trained and competent in nursing procedures.

8. Staff shall provide medication administration training to appropriate and designated staff.

9. Staff shall complete monthly medication administrative audits at Gaylain’s house and provide appropriate follow-up.

10. Ability to lift up to 25lbs.

11. Regular and reliable on site attendance.

12. Report for scheduled shifts during inclement weather and emergency conditions.

13. Shall complete other duties as assigned by supervisor.

General Knowledge and Skills Required for Position:

Knowledge of: the laws and regulations pertaining to psychiatric nursing; the various methods, techniques, and procedures used in psychiatric nursing; the uses and effects of psychotropic drugs and narcotics; consumer safety practices and facility security; symptoms and behavior patterns of emotionally disturbed and mentally ill consumers; theories, principles, and techniques of group and individual psychotherapy; mental health community resources and services; the principles, practices, and laws of professional nursing; health education; common illnesses, diseases, disabilities, injuries, and nutrition.

Ability to: explain mental health laws and regulations; observe emotional and physical behavior; evaluate and assess the need for mental health services; analyze a situation and adopt a course of action; prepare and maintain medical records and reports in an accurate and timely manner; recognize and respect limits of confidential information; direct and advise other nursing staff; communicate with people of diverse socioeconomic and ethnic origins; speak before groups; exercise independent judgment in medical emergencies; demonstrate tact, diplomacy, patience, and compassion; establish and maintain working relationships with co-workers, other agencies, and organizations; comply with nursing policies, protocols, and program regulations; understand and follow oral and written instructions; work independently.

Preferred and Minimum Position Qualifications:

• Minimum Associate Degree or Diploma in Nursing Required. Bachelor Degree in Nursing Preferred.
• One year of experience in an acute psychiatric care or consumer community mental health facility.

Additional Job Requirements (Licenses, Certifications, Personal Vehicle, etc.):

1. Possession of a valid Registered Nurse license issued by the North Carolina State Board of Registered Nursing.

2. May require working on a locked Involuntary Crisis Unit with consumers who can be a danger to themselves and others. Individuals must be able to restrain consumers in an emergent crisis.

3. 24/7/365 Shift-Work

Essential Equipment Routinely Used In This Position

1. Computer: A working knowledge of database

2. Vehicle:

3. Phone: Working knowledge

4. General Office Equipment: Copier, Shredder, Fax

5. Other (specify):

A. Glucometer, blood pressure machine, UDS, thermometer

Key Performance Indicators for this position:

1.Timeliness & Accuracy of Documentation

Complete 95% of required consumer documentation (service notes, MAR forms (med tech), admission/referral forms) within 24 hours,

2.Quality

Maintain a medication error rate below 5.0% on the inpatient floor.

3.Training & Professional Development

Successfully complete all required annual trainings/certifications (First Aid/CPR, Medication Management, Blood Borne Pathogens, Defensive Driving, etc.) within agency deadlines.