Qualifications The Assistant Registered Nurse or covering Registered Nurse shall be a registered professional nurse who possesses a current New Jersey State Board of Nursing issued license. (2 Step PPD and H&P, References, and License Confirmation)
(a) The facility shall provide nursing services to participants, directly in the facility.
(b) The registered professional nurse shall be responsible for, but not limited to, the following:
1. Interviewing the participant and caregivers in order to evaluate the client’s health and health care status.
2. Maintaining standards of nursing practice, including, but not limited to:
i Monitoring of identified medical conditions
ii Administration and supervision of prescribed medications and treatments
iii Coordination of rehabilitative services.
iv Development of a restorative nursing plan
v Monitoring of clinical behavior and nutritional status
vi Assisting with the maintenance or re-development of ADL skills
vii Monitoring growth & development
viii Implementing infection control procedures
ix Communicating finding to the attending physician.
3. Managing medical emergencies
4. Documenting the nursing services provided, including the initial assessment and evaluation of the participant’s health care needs, development of the nursing component of the individualized plan of care, evaluation of the participant’s progress in reaching established goals and defining the effectiveness of the nursing component of the individualized plan of care.
5. Overseeing the development of the initial individualized interdisciplinary plan of care.
6. Alerting others involved with the participant’s care about changes in status and the need to change the individualized plan of care.
7. Developing community medical referral resources and maintaining ongoing communication with those providers.
8. Linking the participant to necessary health care services outside of the program.
9. Coordinating the services provided by other staff to meet the mutually identified health care and psycho social needs of each recipient.
10. Provides in-service to training to facility staff about the participant’s health care needs.
11. Providing health education for a participant’s family or primary care giver.
12. Serving as an advocate to assist the participant / caregiver to resolve problems.
The facility’s nursing staff shall assure that nursing services provided to participants are coordinated with health services currently received at home, as well as with existing community health agencies and services available to participants in times of need.
RESPONSIBILITIES OF LICENSED NURSING PERSONNEL
The registered professional nurse may delegate selected nursing tasks in the implementation of the nursing regimen to licensed practical nurses and unlicensed assistive personnel in accordance with N.J.A.C. 13:37-6.2
Policy Statement
Policy Interpretation and Implementation
In accordance with the New Jersey Nursing Practice Act, N.J.S.A. 45:11-23 et seq., as interpreted by the New Jersey State Board of Nursing, and written job descriptions, licensed nursing personnel are responsible for:
A. Nursing Services, including but not limited to:
1. Care of participants through health promotion, maintenance and restoration emphasizing capabilities;
2. The prevention of infection, accident and injury;
3. Registered nurse assessment of the nursing needs of the participant;
4. Registered nurse preparation of the nursing portion of the care plan based upon the assessment, including, but not limited to nursing actions which reflect:
a. recognition of the rights of the participant, caregiver, family;
b. involvement of the participant, caregiver and family;
c. continuous and systematic collection of data regarding the health status of the participant;
d. integration with other therapeutic regimes;
e. knowledge of relevant theory and scientific principles;
f. a safe and therapeutic environment;
g. prioritization of health care needs;
h. individualized, realistic and measurable goals and approaches congruent with other problems identified by other professionals caring for the participant;
i. accessibility to care staff;
j. communication to all care staff; and
k. Documentation in the participant’s medical record
5. Provision of nursing care services as specified in the nursing portion of the care plan;
6. Registered nurse reassessment and revision of the care plan at specified intervals or his/her discretion in relation to goal achievement or lack of goal achievement;
7. Registered nurse initiation of teaching, supervising and counseling of the participant, caregiver, family and staff regarding nursing care and the participants needs;
8. Reinforcement of the teaching, supervising and counseling regarding nursing care and participant needs may be done by other licensed nursing personnel;
9. Timely, legible and signed documentation of all clinical notes and progress notes in the participant’s medical record.
