- Confer with the Medical Director and the attending physician regarding specific residents assigned to you.
- Consult with the physician concerning resident evaluation and assist the Director of Nursing Services in planning and developing the nursing services to be performed for the resident.
- Initiate requests for consultation or referral. Respond to requests from the resident, physician, or nursing staff.
- Examine the resident and his / her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional or mental problems.
- Determine when to refer the resident to a physician for evaluation, supervision, or directions.
- Perform administrative duties regarding assigned residents, such as completing medical forms, reports, evaluations, studies, charting, etc.
- Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control.
Interpret these to the physician, resident, family members, and public, as appropriate.
- Make written and oral reports / recommendations to the attending physician, Medical Director, or the Administrator concerning the status and care of the assigned resident.
- Participate in the planning and evaluation of the written policies and procedure that govern the day-to-day functions of the nursing service department.
- Participate in facility surveys (inspections) made by authorized government agencies.
- Resolves complaints and grievances made by nursing department personnel.
- Ensures that nursing department employment actions are administered fairly and in compliance with the facility's Policy Against Discrimination, Harassment and Retaliation.
- Supervises and assists in management of the infection control program including ensuring that personal protective equipment is used in the handling of infectious materials by nursing personnel.
- Assists in the development of preliminary and comprehensive assessments of the nursing needs of each resident are performed in furtherance of the resident care planning policy.
- Observes medication passes and treatments to ensure quality.
- Administer services within the applicable scope of nursing practice, which may include : catheterization, tube feedings, suction, applying and changing dressings / bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead / dying, etc.
as appropriate and in accordance with applicable standards.
- Prepare and administer medications as ordered by the physician.
- Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies.
- Chart nurses' notes in professional and appropriate manner that timely, accurately and thoroughly reflects the care provided to the resident, as well as the resident's response to the care.
- Chart all reports of accidents / incidents involving residents.
- Chart all changes in resident condition and the response to those changes.
- Chart all communications with the resident's attending physician regarding the resident, the resident's treatment, or the response to that treatment.
- Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations.
- Ensures that adequate stock levels of medications, medical supplies and equipment are maintained.
- Assist the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies.
- Performs other duties as may be assigned.
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21 days ago