Cornerstone Specialty Hospitals Round Rock is a long-term acute care (LTAC) hospital specializing in the treatment of patients recovering from post-intensive care and medically complex conditions. Our hospital provides 3 different levels of care to include LTACH, inpatient rehab, and outpatient wound care.  Our hospital provides both intensive care and telemetry-level services, offering advanced monitoring and support for patients requiring extended medical care. With a multidisciplinary team dedicated to personalized treatment plans, we focus on helping patients achieve significant recovery and transition to the next level of care.  Our 12-bed acute rehabilitation unit is designed for patients who are ready to progress to intensive therapy for 15 hours a week.  We also offer outpatient wound care, with 2 treatment rooms and a Hyperbaric oxygen suite with 2 individual chambers.

Job Summary

The Charge Nurse manages a designated group of nursing employees on a nursing unit and assures smooth operations of the unit for a designated staff. (Could encompass one or more units depending upon size and clinical programs.) Scope of work may be modified by State specific rules under the Nurse Practice Act.

Essential Functions

• Assesses, plans, coordinates and evaluates residents’ care along with members of the interdisciplinary team. Documents the resident’s condition and nursing needs accurately and in a timely manner. Reports pertinent observations and reactions regarding residents promptly to supervisor and physician as necessary. Receives and records physicians’ orders.
• Communicates staffing problems and needs to the DNCS or CCO. Provides input on staffing ratios and deployment. Provides oncoming shifts and supervisors with accurate and complete resident status reports. Maintains the 24-hour report book. Develops work assignments for RNs, LPN/LVNs, and nurse aides as directed. Supervises, directs and evaluates staff (i.e. RNs, LPN/LVNs, nurse aide, etc.) as directed. Participates in counseling, disciplinary action and termination of staff to the extent permitted by state practice act.
• Participates in hiring and selection of RNs, LPN/LVNs and nurse aides. Gives feedback and participates in performance appraisals as assigned. Supervises nursing assignment, which includes directing assigned nursing staff to the extent permitted by the state practice act.
• Coordinates and performs admission, transfer and discharge for residents. Completes all appropriate assessments relative to the resident’s status.
• Serves on and participates in committees as assigned.
• Assures that inventory and supplies are maintained in a clean and safe manner on the unit, are utilized economically and communicates need for housekeeping, maintenance or nutritional services assistance. Supports and participates in the center’s Performance Improvement initiatives. Participate in survey readiness. Completes records and reports as needed.
• Adheres to professional codes of ethics, Scion Health’s Code of Conduct and maintains PHI confidentiality in the center and in external locations, including electronic social networks.
• Provides direct care and/or assists with care as directed and consistent with their scope of practice and competency. Initiate the SBAR process and collaborate with the RN for assessment and recommendations. Make rounds with physicians and other team members as needed. Assist physicians and consultants with special tests or procedures within the scope of state specific nurse practice act and personal clinical competency.
• Coordinates patient assessments, recognizes the need to review and revise patients’ assessments as needed based upon resident condition. Coordinates patients’ care activities and communicates changes to other team members and resident family/significant other.
• Reviews, transcribes, communicates and implements physician orders, obtaining RN signature as required by state regulations. Communicates with resident’s physician. Initiates, recommends, communicates and implements changes in residents’ care plans. Assists with or institutes emergency measures for sudden adverse developments in residents. Directs and administers cardiopulmonary resuscitation.
• Documents care performed and observations of resident status in the clinical record promptly by utilizing standard clinical documentation guidelines as required by Scion Health, and local, state and federal rules and regulations. Monitors completeness and accuracy of own clinical medical record entries and those of assigned staff daily.
• Participates in medication management to promote optimal safety and effectiveness for residents by: Administering medications as ordered, including next scheduled dose following admission/readmission. Notify supervisor of medications not available. Preparing, administering and documenting medications as prescribed. Observing and reporting resident responses to medication. Identifying and promptly communicating adverse drug reactions. Initiate enteral or parenteral therapy as ordered. Maintaining narcotic records accurately.
• Responsible for completing medication interchange and insurance prior to authorization as assigned. Ordering or arranging for ordering of pharmaceuticals. Notifying physicians of automatic stop orders. Transcribe verbal orders obtained from other professionals. Completes recapitulated physician orders review as assigned. Notifying supervisors of discrepancies in drug inventories. Clean, organizes and replenishes supplies on medication/treatment carts after each use and prior to shift change.
• Completes clinical admission paperwork for new admissions. Initiates and assists consultants while providing services. Review documentation from consultant visit and follows up on recommendations. Assist with follow up on results of qualitative and quantitative medical record audits. Communicates and implements pharmacy review/DRR recommendation as assigned. Assists with clinical discharge process.
• Administers treatments. Collect specimens as ordered. Initiates, implements and monitors restorative and rehabilitative nursing programs.

Knowledge/Skills/Abilities/Expectations

• Approximate percent of time required to travel: 0%25
• Must read, write and speak fluent English.
• Must have good and regular attendance.
• Performs other related duties as assigned.

Education

• Graduate of accredited RN School of Nursing.

Licenses/Certification

• Current valid RN license in the state employed.
• Current BLS and ACLS required.

Experience

• At least (1) one year of nursing experience preferred.
• Evidence of continuing education or special preparation or experience in gerontological nursing and/or long-term acute care nursing desirable.