Job Description s.
6. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
7. Participate in the development, maintenance and implementation of the facility’s quality assurance program for the nursing service department.
8. Periodically review the resident’s written discharge plan.
9. Assist in planning the nursing services portion of the resident’s discharge plan as necessary.
10. Participate in surveys (inspections) made by authorized government agencies.
11. Make written and oral reports / recommendations concerning the activities of your shift as required.
12. Meet with your assigned nursing staff, as well as support personnel, in planning the shifts services, programs, and activities.
13. Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.
14. Admit, transfer, and discharge residents as required.
15. Complete all admission, Quarterly assessments as required for MDS process
16. Give copy of 24 hour report which contains daily census to the Business Office (11 7 shift).
17. Perform weekly wound rounds and provide written weekly reports to DON (11-7 N / A).
CHARTING AND DOCUMENTATION
1. Fill out and complete accident / incident reports. Submit to Director as required.
2. Chart all accidents / incidents involving the resident. Follow established procedures.
3. Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
4. Chart nurses’ notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident’s response to the care.
5. Complete and file required record keeping forms / charts upon the resident’s admission, transfer.
6. Receive telephone orders from physicians and record on the Physicians’ Order Form.
7. Record new / changed diet orders. Forward information to the Dietary Department using dietary change forms.
8. Transcribe physician’s orders to resident charts, cardex, medications book, treatment book, as required.
9. Assure that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.
10. Address / Resolve all discrepancies noted concerning physician’s orders, diet change, charting error, etc.
11. Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures (11-7 perform 24 hour chart checks).
12. Sign and date all entries made in the resident’s medical record.
13. Fill out and complete Transfer Forms in accordance with our established procedures.
DRUG ADMINISTRATION FUNCTIONS
1. Prepare / administer medications as ordered by the physician.
2. Verify the identity of the resident before administering the medication / treatment.
3. Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies.
4. Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hand to meet the nursing needs of the residents.
Report needs to the Director of Nursing.
5. Ensure that narcotic records are accurate for your shift. Dispose of drugs and narcotics as required, and in accordance with our established procedures.
6. Notify the Director of Nursing of all drug and narcotic discrepancies noted on your shift.
7. Notify the attending physician of automatic stop orders prior to the last dosage being administered.
8. Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.
PERSONNEL FUNCTIONS
1. Replace staffing when assigned personnel fail to report to work. Report absentee call-ins to the Director of Nursing.
2. Develop work assignments, and / or assist in completing and performing such tasks.
3. Make daily rounds of your unit to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards.
Report problem areas to the Director of Nursing.
4. Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the DON as required or as may be necessary.
5. Ensure that disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or martial status.
6. Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility to assure that nursing services and activities can be adequately maintained to meet the needs of the residents.
7. Assure that department personnel, residents, and visitors follow the departments established policies / procedures at all times.
8. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.
9. Meet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and / or the improvement of services.
10. Give / receive the nursing report upon reporting in and ending shift duty hours.
11. Provide leadership to nursing personnel assigned to your unit / shift.
12. Assist with Clinical Supervision for CNA’s in training.
NURSING CARE FUNCTIONS
1. Inform nursing personnel of admissions, their expected time of arrival, room assignment, etc.
2. Ensure that rooms are ready for new admissions
3. Greet newly admitted residents upon admission. Escort to room as necessary.
4. Make rounds with physicians as necessary.
5. Assess all new admissions and complete all admission required documentation
6. Follow emergency procedures for a sudden change in resident’s condition
7. Cooperate with and coordinate social and activity programs with nursing service schedules.
8. Make independent decisions concerning nursing care.
9. Notify the resident’s attending physician with the resident is involved in an accident or incident.
10. Make periodic checks to assure that prescribed treatments are being properly administered by nursing assistants and to evaluate the resident’s physical and emotional status.
11. Administer professional services such as; catheterization, tube feedings, suction, applying and changing dressings / bandages, packs, colostomy and drainage bags, taking blood, giving massages and range of motion exercises, care of the dead / dying, etc., as required.
12. Participate in the orientation of new residents / family members to the facility.
13. Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures, including transportation.
14. Meet with residents, and / or family members, as necessary. Report problem areas to the DON.
15. Admit, transfer and discharge residents as necessary.
16. Review the resident’s chart for specific treatments, med. orders, diets, etc., as necessary.
17. Carry out restorative and rehabilitative programs, to include self help and care.
18. Check foods brought into the facility by the resident’s family / visitors to assure that it is within the resident’s dietary allowances.
Report problem areas to the DON and Dietary Supervisor.
19. Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner. Keep med carts clean and neat.
20. Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.
21. Notify the resident’s attending physician and next-of-kin when there is a change in the resident’s condition.
22. Work with the facility’s consultants and implement those changes authorized by the DON.
23. Call funeral homes when requested by the family. Ensure that established post-mortem procedures are followed.
24. Use restraints when necessary and in accordance with our facilities policies and procedures And the Resident’s plan of care.
25. Obtain sputum, urine and other lab tests as ordered.
26. Take and record TPRs, blood pressures, etc., as necessary.
27. Monitor seriously ill residents as necessary.
28. Inform family members of Hospice Care and / or the death of resident as necessary.
STAFF DEVELOPMENT
1. Assist in standardizing the methods in which work will be accomplished.
2. Attend and participate in continuing education al programs designed to keep you abreast of changes in your profession.
SAFETY AND SANITATION
1. Monitor your assigned personnel to assure that they are following established safety regulations in the use of equipment and supplies.
2. Ensure that your assigned work areas (i.e., nurses’ stations, medicine preparation rooms, etc.,) are maintained in a clean and sanitary manner.
3. Ensure that your unit’s resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner.
4. Ensure that your assigned nursing personnel follow established departmental policies and procedures, including dress codes.
5. Ensure that your assigned personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner.
6. Participate in the implementation, and maintenance of the infection control program for monitoring communicable and / or infectious diseases among the residents and personnel.
7. Ensure that your assigned personnel follow established infection control procedures when isolation precautions become necessary.
8. Participate in the implementation and maintenance of the procedures for reporting hazardous conditions or equipment.
9. Ensure that your assigned personnel follow established hand washing techniques in the administering of nursing care procedures.
10. Use only safety needles or needle systems for IV therapy to prevent needle sticks.
11. Assist in training department personnel in identifying tasks that involve potential exposure to blood / body fluids.
12. Assure that nursing personnel follow established procedures in the use and disposal of personal protective equipment.
EQUIPMENT AND SUPPLIES
1. Recommend to the DON the equipment and supply needs of your unit.
2. Participate in the implementation of the procedures for the safe operation of all nursing service equipment.
3. Ensure that only trained and authorized personnel operate your unit’s equipment.
4. Ensure that all personnel operate nursing service equipment in a safe manner.
5. Monitor nursing procedures to ensure that nursing service supplies are used in an efficient manner to avoid waste.
CARE PLAN AND ASSESSMENT FUNCTIONS
1. Complete care plans on admission to reflect care needs.
2. Inform all nursing staff of any changes that were made on the care plan via report
3. Ensure that your nurses’ notes reflect that the care plan is being followed.
4. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.
5. Ensure that your assigned nursing assistants are aware of the resident care plans and that they are used in administering daily care to the resident.
6. Update resident care plans with change of status. Document all falls, infections and skin tears o the appropriate tracking forms.
7. Review and update all care plans in accordance with the RNAC Care Plan schedule
RESIDENT RIGHTS
1. Maintain the confidentiality of all resident care information in accordance with current HIPAA regulations and all Federal, State and Local guidelines.
2. Monitor nursing care to assure that all residents are treated fairly, and with kindness, dignity, and respect.
3. Ensure that all nursing care is provided in privacy and that nursing service personnel knock before entering the resident’s room.
4. Ensure that all nursing service personnel are knowledgeable of the resident’s rights, and responsibilities.
5. Review complaints and grievances made by the resident and make a written / oral report to the Administrator or DON indicating what action(s) were taken to resolve the complaint or grievance.
Report any allegations of abuse to Administrator and / or the Director of Nursing.
MISCELLANEOUS
1. Adhere to 1 / 2 hour (30 min.) lunch and two (2) 15 minute breaks per day.
WORKING CONDITIONS
1. Works throughout the nursing service area (I.e., drug rooms, nurses’ stations, resident rooms, etc.).
2. Sits, stands, bends, lifts and moves intermittently during working hours.
3. Is subject to frequent interruptions.
4. Is involved with residents, personnel, visitors, government agencies / personnel, etc., under all conditions and circumstances.
5. Is subject to hostile and emotionally upset residents, family members, personnel, visitors, etc.
6. Communicates with the medical staff, nursing personnel, and other department supervisors.
7. Works beyond normal working hours, on weekends and holidays, and in other positions temporarily, and on other shifts when necessary.
8. Attends and participates in continuing educational programs.
9. Is subject to falls, burns from equipment, odors, etc., throughout the work day.
10. Is subject to exposure to infectious waste, diseases, conditions, etc., including the AIDS and Hepatitis B Viruses.
11. Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.
EDUCATIONAL REQUIREMENTS
Must be a graduate of an approved RN Program.
EXPERIENCE
1. Minimum of two years long term care experience mandatory.
2. One year supervisory experience preferred.
SPECIFIC REQUIREMENTS
1. Must possess a current, unencumbered license to practice as a RN or LPN / LVN in this state.
2. Must be able to read, write, speak, and understand the English language.
3. Must possess the ability to make independent decisions when circumstances warrant such action.
4. Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies / personnel and the general public.
5. Must be a minimum of twenty (20) years of age.
6. Must be knowledgeable of nursing and medical practices and procedures, as well as lows regulations, and guidelines that pertain to long-term care.
7. Must possess leadership and supervisory ability and the willingness to work harmoniously with professional and non-professional personnel.
8. Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc.
that are necessary for providing quality care.
9. Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
10. Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
11. Must be able to relate information concerning a resident’s condition.
PHYSICAL AND SENSORY REQUIREMENTS (With or Without the Aid of Mechanical Devices)
1. Must be able to move intermittently throughout the work day.
2. Must be able to speak and write the English language in an understandable manner.
3. Must be able to cope with the mental and emotional stress of the position.
4. Must be able to see and hear or use prosthetics that will enable these senses to function adequately to assure that the requirements of this position can be fully met.
5. Must function independently and have flexibility, personal integrity and the ability to work effectively with residents, personnel, and support agencies.
6. Must be in good general health and demonstrate emotional stability.
7. Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.
8. Must be able to lift, push, pull, and move a minimum of 50 pounds.
9. Must be able to assist in the evacuation of residents.
PAY RATE : $37.50 $39.50
$37.50 $39.50
Shift differential is $1.00 / hour for working evenings and $2.00 / hour for working nights.
PRN rate is $30.50 plus shift differential if working evenings or nights.