Nurse, RN (62100)

FLSA Status: Non-Exempt – eligible for overtime pay under the Fair Labor Standards Act.

About the role

Essential member of an interdisciplinary treatment team. Provides quality medical and mental health nursing care to individuals in an inpatient setting, including initial and shift nursing assessments, medication administration and management, medical triage, treatment planning, group support, phlebotomy, waived laboratory testing, and patient/family education. Collaborates with crisis services, emergency rooms, outpatient clinics, walk-in centers, and other external entities to support both medical and mental health decision-making. Provides care coordination through rounding, external provider communications, and discharge planning. Ensures all documentation for care is accurate and completed before the end of the shift. Operates strictly within the scope of the Nurses’ Practice Act and in accordance with professional nursing ethics and state and city regulatory guidelines.

Responsibilities

• Conducts initial admission assessments and documents within the Electronic Medical Record (EMR).
• Performs nursing assessments and/or mental and substance use assessments with consideration to the standard of care for the client’s age and clinical condition, every shift, and documents within the shift note.
• Communicates critical information and differentiating conditions/symptoms to the treatment team and provides appropriate follow-up clinical interventions to stabilize and treat the client.
• Reviews client information medically prior to acceptance to the unit to ensure no medical concerns are present that would make the client inappropriate for the ATU level of care.
• Collaborates with nurses at requesting facilities, crisis services, and providers, and receives admission orders when appropriate.
• Ensures laboratory orders are completed and reviewed by the provider.
• Provides direct client care, including but not limited to: vital signs (pain evaluation), oral and IM medication administration and evaluation of effectiveness, basic nursing and hygiene care support, EKGs, lab specimen collection and processing, nebulizer treatments, oxygen monitoring, positive fetal heart tone assessments, withdrawal evaluations, and First Aid as clinically indicated and/or ordered by the prescriber.
• Ensures documentation for all client care is accurate and complete before the end of the shift.
• Monitors and documents medication compliance as prescribed by the medical provider.
• Evaluates and monitors the dietary needs of clients and communicates specialized needs directly to the café.
• Conducts nursing groups on topics such as self-care, medication pharmacokinetics and pharmacodynamics, medication adherence, exercise, healthy living, and additional topics based on client need.
• Collaborates with interdisciplinary team members to develop appropriate treatment plans.
• Provides education to clients, caregivers, and families tailored to the client’s learning style, education, and/or reading level, while displaying sensitivity to their health needs around the plan of care, including psychotropic medication benefits and side effects.
• Assists with medical and psychiatric emergencies throughout the building, including seclusions and restraints, and ensures clients receive emergency services as needed.
• Ensures appropriate documentation is completed before the end of the shift.
• Supports client care by optimizing client safety and risk reduction, developing safety plans, following safety check protocols as ordered, and collaborating with the team to ensure client and community safety.
• Assists in maintaining a safe and secure environment for staff and clients.
• Uses accurate knowledge of Crisis Prevention Intervention (CPI) in safely managing crisis situations with escalated clients and responds according to approved protocols for crisis situations and restraint/seclusion events.
• Actively engages in team meetings, in-service trainings, and supervisory sessions as required.
• Adheres to Universal Precautions per CDC guidelines and OSHA regulations, and HIPAA regulations per standards developed by the Department of Health and Human Services.
• Performs other various shift duties as assigned by management.

Requirements

• Registered Nurse (RN) licensure in good standing and with no restrictions in the state of Colorado, or Licensed Practical Nurse (LPN) with 5+ years of mental health experience (inpatient preferred).
• Current CPR certification.
• Proficient written and oral communication skills with the ability to accurately and professionally implement and document services provided to clients.
• Basic computer skills and the ability to type 25+ words per minute for input and output of client information using electronic medical records.
• Working knowledge of Electronic Medical Records (EMR).
• Experience working therapeutically with specified populations, including using various treatment modalities appropriate for the population and utilizing strength-based therapeutic approaches.
• Experience working in a team environment.