Follows the nursing care plan demonstrating consideration of the following criteria: Patient learning needs; Patient’s priority needs; Patient’s maximum health potential; Patient’s changing health status; Patient’s discharge planning needs; Safe, skillful, effective and efficient therapeutic action; and Collaboration and communication with other health care team members (i.e., R.N.’s, rehabilitation staff, physicians, social services, community agencies staff and home health aides). Follows the nursing care plan, established by the RN Case Manager, based on nursing diagnoses that includes measurable, realistic, and time directed goals and nursing interventions specific to the problem and individual patient; reports information about progress or changes to the RN Case Manager.