The LVN/LPN will provide patient care and assist in the collection of data during the assessment process, within their scope of practice, under the direction of an RN, mid-level practitioner, licensed physician, or supervisor at all times.ResponsibilitiesAdheres to all DBH Policy and Procedures.Conducts self in a manner that represents DBH mission, vision and values.Meets productivity standards and performs duties as workload necessitates.Collects relevant medical data within state specific scope of practice utilizing proper grammar, spelling, and complete sentences without using unapproved abbreviations.Informing personnel (i.e. UR, psychiatry, dietician) of new admissions when appropriate.Administering and documenting vital signs, CIWAs, COWS (SUD only), collects data for fall assessments/precautions, seizure precautions, suicidal/homicidal assessments, pain scales, anxiety scales, craving scales, standard and infection control precautions adding co-signers as necessary.Observation, documentation, audit functions, education, and record keeping of all observed/inventoried/destroyed/prescribed medications.Assessment of patients with addiction and mental health conditions and assisting in ascertaining clinical medication management with Registered Nurses, Nurse Practitioner, Physician Assistant, Psychiatrist, and Medical Doctor.Administering medications via oral, sublingual, inhalation, auricular, topical, intramuscular, subcutaneous, vaginal, and rectal routes as ordered.Entering medication orders into the electronic medical record.Manages the Medication Administration Record, documenting administration, efficacy, and first response.Provides direct patient care to a diversified patient population, across continuum of care.Collaborates with staff in assessing patient, family age-specific nursing needs and develops plan of care for complex high-risk patients.Provide assistance to Utilization Review in communicating pertinent nursing information.Designs teaching programs for patients/families and provides assistance to staff in program implementation.Work closely with physicians to provide education and counseling for clients and other organizational health care providers on optimal use of medicines (e.g., proper use, avoidance of over medication).Provide nursing care adapted to the individual patient needs based on the nursing process, which includes data collection, planning, implementation and evaluation.Direct patient care, including the reporting of observed changes in mental status and/or physical condition, response to emergencies, safety risks.Documents nursing incidents and medication errors.Oversees the medication management system that includes but not limited to, medication planning, storage, ordering and transcribing, administration, monitoring and evaluation.Verifies the integrity of and controls medications brought into the organization by the client, their families, and licensed independent practitioners.Ensures to use the utmost of care in protecting the confidentiality of client records in accordance with state and federal laws.Understands and adheres to DBH compliance standards as they appear in DBH’s Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy.Keeps abreast of all pertinent federal, state and DBH regulations, laws, and policies as they presently exist and as they change or are modified.Systemically collect, record and analyze data and other relevant interactive social systems, including mental status, special precautions (suicidality, homicidally, elopement); physical problems/medical acuity (withdrawal and nutritional needs); and ethnic concerns (social, religious, or cultural needs).Uses assessment data to identify problem list and other interactive social systems.Working knowledge of (American Society of Addiction Medicine) ASAM criteria (SUD)Maintains NG Tube and administration of bolus feeds, where applicable.Intervenes as guided by the treatment plan to implement appropriate interventions that promote, maintain, or restore physical and mental health, prevent illness effect rehabilitation, and restore developmental progression.Provides health education for patients through individual and group interactions.Recommends special precautions, as needed.Evaluates the response of the patients to interventions in order to revise the plan, including discharge criteria.Consistently reports to work on time, prepared to perform the duties of the position.Performs other duties and tasks as assigned.This is a full-time position located in Manor, TX. We have the following shifts available:Day Shift: Thursday-Saturday 6am-6pmFor a virtual tour of the facility, please visit our website at newhoperanch.com
