Southern Pines Health and Rehab - Purpose of Your Job Position The primary purpose of your job position is to provide direct nursing care to the patients, and to super- vise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in ac- cordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services to ensure that the highest degree of quality care is maintained at all times.
Delegation of Authority As a Charge Nurse / Shift Supervisor, you are delegated the authority, responsibility, and account- ability necessary for carrying out your assigned duties.
Job Functions Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work
is similar, related, or is an essential function of the position.
Duties and Responsibilities Administrative Functions
• Direct the day-to-day functions of the nursing assistants in accordance with current rules, regula- tions, and guidelines that govern the long-term care facility.
• Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility, it's corporate office, and governing
• Meet with your assigned nursing staff, as well as support personnel, in planning the shifts' services, programs, and activities.
• Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Ser- vice Procedures Manual.
• Make written and oral reports/recommendations concerning the activities of your shift as
• Cooperate with other patient services when coordinating nursing services to ensure that the pa- tient's total regimen of care is maintained.
• Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing service department.
• Participate in facility surveys (inspections) made by authorized government agencies as may be re-
• Periodically review the patient's written discharge plan. Participate in the updating of the patient's written discharge plan as required.
• Interpret the department's policies and procedures to personnel, patients, visitors, and government agencies as required.
• Admit, transfer, and discharge patients as
• Complete accident/incident reports as
• Write patient charge slips and forward to the Business
• Maintain the Daily Census Report and submit to the Business Office as
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as Charting and Documentation Functions
• Complete and file required recordkeeping forms/charts upon the patient's admission, transfer, and/ or
• Ensure that attending physicians review treatment plans, record and sign their orders, progress notes in accordance with established policies.
• Receive telephone orders from physicians and record on the Physicians' Order
• Transcribe physician's orders to patient charts, cardex, medication cards, treatment/care plans, as
• Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the patient, as well as the patient's response to the care.
• Fill out and complete accident/incident Submit to Director as required.
• Chart all reports of accidents/incidents involving Follow established procedures.
• Record new/changed diet Forward information to the Dietary Department.
• Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor.
• Fill out and complete transfer forms in accordance with established
• Ensure that appropriate documentation concerning unauthorized discharges is entered in the pa- tient's medical record in accordance with established
• Perform routine charting duties as required and in accordance with established charting and docu- mentation policies and procedures.
• Sign and date all entries made in the patient's medical Drug Administration Functions
• Prepare and administer medications as ordered by the
• Verify the identity of the patient before administering the medication/treatment.
• Ensure that prescribed medication for one patient is not administered to
• Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the Report needs to the Director of Nursing Services.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with estab- lished
• Ensure that narcotic records are accurate for your shift, and notify the Director of Nursing Services of all drug and narcotic
• Review medication cards for completeness of information, accuracy in the transcription of the physi- cian's order, and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage being
• Dispose of drugs and narcotics as required, and in accordance with established Personnel Functions
• Participate in employee performance evaluations as asked, determining your shift's staffing require- ments, and making recommendations concerning employee dismissals, transfers,
• Inform the Director of Nursing Services of staffing needs when assigned personnel fail to report to
• Report absentee call-ins to the Nurse
• Develop work assignments and/or assist in completing and performing such
• Provide leadership to nursing personnel assigned to your unit/shift.
• Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services.
• Ensure that department personnel, patients, and visitors follow the department's established poli- cies and procedures at all times.
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the patients.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and
• Review complaints and grievances made or filed by your assigned
• Make appropriate reports to the Director of Nursing Services as required or as may be
• Follow facility's established
• Ensure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital
• Receive/give the nursing report upon reporting in and ending shift duty
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures governing accidents and Nursing Care Functions
• Inform nursing personnel of new admissions, their expected time of arrival, room assignment,
• Ensure that rooms are ready for new
• Greet newly admitted patients upon Escort them to their rooms as necessary.
• Participate in the orientation of new patients/family members to the
• Make rounds with physicians as
• Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established
• Consult with the patient's physician in providing the patient's care, treatment, rehabilitation, etc., as
• Review the patient's chart for specific treatments, medication orders, diets as necessary.
• Make periodic checks to ensure that prescribed treatments are being properly administered by certi- fied nursing assistants and to evaluate the patient's physical and emotional
• Notify the patient's attending physician and next-of-kin when the patient is involved in an accident or incident, when there is a change in the patient's condition, and in the event of
• Carry out restorative and rehabilitative programs, to include self-help and
• Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.
• 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 for the dead/dying as required.
• Use doctor-prescribed restraints when necessary and in accordance with established policies and
• Obtain sputum, urine and other specimens for lab tests as
• Take and record TPRs, blood pressures as necessary.
• Monitor seriously ill patients as
• Check foods brought into the facility by the patient's family/visitors to ensure that it is within the pa- tient's dietary allowances. Report problem areas to the Director of Nursing Services and Dietary Su-
• Ensure that patients who are unable to call for help are checked
• Meet with patients, and/or family members, as necessary. Report problem areas to the Director of Nursing
• Assist in arranging transportation for discharged patients as . click apply for full job details
Date Posted: 31 March 2024
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