Job Description
Job Description
Description :
PRINCIPAL RESPONSIBILITIES :
A. CLINICAL :
- Performs patient assessments by developing, implementing, and evaluating Patient Care Plans.
- Performs treatments, administers medications, and / or implements other nursing interventions as indicated by the Patient Care Plan and / or Physician Order.
- Provides nursing care in accordance with infection control standards.
- Follows safety policies when performing nursing care.
- Initiates emergency measures according to Center policy and within standards of nursing practice.
B. ADMINISTRATIVE
- Ensures the exchange of essential information necessary for quality patient care.
- Maintains all documentation as required by Federal, State, and Company and policies.
- Maintains inventory of supplies and / or medications to meet patient needs.
- Participates in all assigned meetings and in-services.
C. SUPERVISORY
- Meets unit work goals through assignment of staff to patient care needs.
- Monitors performance through coaching and praising.
- Recognizes effective performance (or) takes direct corrective action after coaching / counseling as needed
- Evaluates quality and quantity of patient care service accomplished by staff.
D. CONSUMER SERVICE :
- Presents professional image to consumers through dress, behavior, and speech.
- Adheres to Company standards for resolving consumer concerns.
- Ensures that all patient rights are protected.
E. QUALIFICATIONS :
- Current nursing licensure in the state of California required.
- Written and verbal communication skills in English as business necessity.
- Administrative and organizational abilities necessary.
- Current CPR certification required.
- One year of nursing experience preferred.
- Supervisory experience preferred.
Requirements :
STANDARD OF PERFORMANCE
A. CLINICAL : Activity :
Activity :
- Participates in Shift Report.
- Performs patient assessments :
- Admission;
- Daily;
- Change of condition; and
- Discharge.
- Conducts comprehensive assessment (MDS) and initiates / updates patient plan of care.
- Performs treatments as prescribed.
- Passes medications as prescribed.
- Follows infection control policies in performing nursing care :
- Hand washing;
- Universal precautions; and
- Linen handling procedures.
- Follows all safety policies in performing nursing care.
- Initiates and conducts emergency measures required to stabilize patient condition.
- Follows Company nursing policies and procedures at all times when delivering resident care.
Measured by :
- Time and Attendance Records and direct observation by Director of Nursing.
- Admission Checklist, rounds by Patient Care Coordinator, and review of Clinical Record Summary discharge notes.
- Results of Quality Assurance Standard review by DON and completion of MDS audits and Plan of Care audits.
- Quality Assurance standards outcome properly documented to Treatment Sheet and direct observation by Patient Care Coordinator.
- Quality Assurance standards documented to Medication Record and direct observation by Patient Care Coordinator.
- Quality Assurance Standards, direct observation by Patient Care Coordinator, and review of Infection Control Report by Patient Care Coordinator.
- Review of Safety Committee Reports.
- Required documentation (i.e., daily nurse's notes).
- Direct observation by the Patient Care Coordinator.
B. ADMINISTRATIVE : Activity :
Activity :
- Communicates patient needs and change of condition to appropriate persons, i.e. :
- Other shifts and patient care;
- Coordinator;
- Dietary;
- Activities and social services;
- Physicians;
- Responsible parties (i.e., families, conservator);
- Outside therapies; and
- Maintenance Department.
2. Maintain all documentation (current and complete) including, but not limited to :
- Patient Care Plans;
- Nursing Progress Notes;
- Medication Administration Record;
- Treatment Records;
- Physician Order Sheets;
- Quality Assurance audits;
- Acuity Reports;
- Incident Reports; and
- Restorative Progress Summary.
3. Utilizes nursing supplies as needed.
4. Orders medications as needed and as ordered by physicians :
- Logs ordered and received;
- Removes discounted medications; and
- Reorder emergency medication kit.
5. Participates in all meetings as required.
6. Participates in all in-service as required.
Measured by :
- Direct observation and review by Patient Care Coordinator.
- Review of appropriate documentation by Patient Care Coordinator and Medical Records audit.
- Review of supply inventory and observation of patient bedside units by Patient Care Coordinator.
- Review of medication storage and preparation areas, review of appropriate documentation by Patient Care Coordinator, and review of pharmacy audit.
- Review of minutes, review of attendance records, and direct observation by Patient Care Coordinator.
- Review of in-service records by Director of Staff Development and Patient Care Coordinator.
C. SUPERVISORY : Activity :
Activity :
- Assigns staff to meet patient care needs by verbal and / or written Condition Report.
- Assists in providing adequate staffing by seeking replacements for current and oncoming shifts.
- Uses Absentee Report forms appropriately.
- Observes staff performance during patient rounds.
- Coaches staff during rounds for both quality and quantity of work performance and work habits.
- Demonstrates effective work habits to staff during rounds and as needed.
- Praises and recognizes staff for effective performance.
- Participates with Patient Care Coordinator in Progressive coaching and follow-up.
- Monitors patient appearance and comfort.
- Audits documentation by nursing staff.
Measured by :
- Review of completed Daily Assignment Sheet and direct observation by Patient Care Coordinator.
- Review of documentation in Shift Log Book and verbal report.
- Completed Absentee Report on file.
- Resident outcome Quality Assurance tool and direct observation by Patient Care Coordinator.
- Direct observation by Patient Care Coordinator.
- Direct observation by Patient Care Coordinator.
- Positive feedback from staff and direct observation by Patient Care Coordinator.
- Review of documented Progressive Coaching Form.
- Direct observation by Patient Care Coordinator and absence of complaints.
- Medical Records audit.
D. CONSUMER SERVICE :
- Reports for duty in approved uniform and maintains high standards of personal hygiene.
- Refrains from rude and discourteous behavior toward consumers and co-workers. Avoids the use of profanity.
- Limits eating and / or smoking to designated areas.
- Reports to duty promptly as scheduled (and) takes breaks only during assigned times and in designated places.
- Speaks, writes, and understands English for business necessity.
- Follows consumer service standards for :
- Making daily contact with patients;
- Greeting visitors;
- Making initial contact with newly admitted residents;
- Giving information to patients and visitors;
- Getting information from patients and visitors;
- Referring patients and visitors; and
- Handling complaints.
7. Utilizes the telephone in accordance with consumer service standards when :
- Answering phones;
- Placing a caller on hold;
- Transferring a call; and
- Taking a message.
8. Utilizes the paging system effectively.
9. Monitors general patient care to identify and correct any infringement of patient rights.
Measured by :
- Visual inspections by Patient Care Coordinator.
- Absence of complaints.
- Direct observation by Patient Care Coordinator.
- Direct observation by Patient Care Coordinator.
- Direct observation by Patient Care Coordinator.
- A combination of absence of complaints (and) periodic audit of skills by Patient Care Coordinator or other management staff.
- A combination of absence of complaints (and) periodic audit of skills by Patient Care Coordinator or other management staff.
- A combination of absence of complaints and periodic audit of skills by Patient Care Coordinator and other management staff.
- A combination of absence of complaints and periodic audit of skills by Patient Care Coordinator and other management staff.