Position Overview:
The Charge Nurse is a working medical leader responsible for providing direct patient care while supporting nursing operations during assigned shifts in a residential behavioral health setting. This role serves as a liaison between nursing leadership and frontline staff to ensure safe, effective, and compliant patient care.
The Charge Nurse spends the majority of time performing hands-on nursing duties, while also assisting with staff coordination, clinical guidance, and regulatory compliance. This position supports adherence to Joint Commission standards, state regulations, and organizational policies.
Essential Duties:
Leadership & Shift Coordination (Non-Exempt Role)
- Assist with shift coordination and assignment delegation
- Provide real-time coaching and feedback
- Escalate performance concerns to management
- Ensure that nursing staff adheres to policies, procedures, and standards of practice
- Assist with shift coverage and assignments of duties
- Address staffing issues and escalate concerns as necessary to supervisor
- Audit nursing documentation for quality and compliance, support staff in correcting documentation deficiencies
- Ensure all nursing documentation is completed accurately and within timeframes in the EMR, including MARs, assessments, and incident reports
- Ensures all incidents are reported immediately per policy, including completion of incident reports before end of shift when applicable
Client Care:
- Provide direct and indirect nursing care to clients in a residential behavioral health setting
- Perform hands-on duties alongside nursing staff
- Collaborate with leadership to ensure appropriate treatment protocols
- Utilize trauma-informed care and de-escalation techniques (CPI)
- Participate in admissions/intake assessments as needed
- Administer medications as prescribed. Verify that all MAR documentation is completed and discrepancies are reported to leadership immediately
Collaboration & Communication:
- Communicate effectively with physicians, counselors, and other healthcare professionals to develop and update treatment plans
- Lead or participate in team meetings to discuss patient care, progress, and challenges
- Ensure that all patient documentation is accurate and up-to-date, including nursing assessments, progress notes, and treatment plans
Safety & Compliance:
- Ensure that safety protocols and infection control measures are strictly followed
- Monitor and report any adverse events, complications, or changes in patient condition
- Ensure that all legal, ethical, and regulatory standards of nursing care are met, including but not limited to Joint Commission standards, Environment of Care, Medication Management, and National Patient Safety Goals
- Maintains survey readiness at all times
- Assist with incident reporting, root cause analysis, and corrective actions as assigned by leadership
- Maintain confidentiality and comply with HIPAA regulations in all aspects of patient care
- Respond to emergencies and adverse reactions, providing timely interventions and ensuring client safety
Training & Education:
- Support and guide all newly hired nurses through their training period
- Promote ongoing professional development and education for nursing staff
Detox Protocol (if applicable to assigned facility)
- Assess and monitor patients undergoing detoxification from alcohol, drugs, or other substances
- Perform physical assessments and monitor vital signs, withdrawal symptoms, and overall health status
- Administer medications as prescribed to manage withdrawal symptoms and ensure patient comfort and safety
- Provide support and education to patients regarding their detoxification process and treatment options
- Stay updated on the latest evidence-based practices for detoxification and substance abuse treatment
- When assigned to detox services, responsibilities include monitoring withdrawal using approved assessment tools (e.g., CIWA, COWS), administering protocol-driven medications, and escalating to provider as clinically indicated
Other Duties:
- There may be times that other duties are assigned, these duties will be within the scope of practice for a licensed RN.
