Fahrney Keedy
Nurse / LPN - Assisted Living / Memory Care
$5,000 Sign on Bonus for FULL TIME DAY SHIFT - Full Time
Boonsboro Maryland ( near Hagerstown )$25.00 - $32.00
plus any applicable shift differentials
SUMMARYThe purpose of this position is to deliver daily quality nursing care to ALU residents. The Staff Nurse has the responsibility of monitoring the MT's and CNA's assigned to his/her floor to ensure the residents are receiving quality care and that they are following the policies and procedures of the FKHV and those mandated by the Federal, State, and Local Agencies.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
- Conduct rounds at the beginning and end of each duty shift with on-coming/off-going shift.
- Perform Admission Assessment on new resident admissions or re-admissions.
- Make rounds with physicians when applicable.
- Consult with the resident's physician in providing the resident's care, treatment, lab report results review and rehabilitation as necessary. Ensure necessary follow-up to consults is completed as directed.
- Arrange for diagnostic and therapeutic services as ordered by the physician.
- Assist the DRN/ALM in assessing residents, gathering data and establishing an accurate and appropriate care plan.
- Make referrals to the Dietitian when the resident experiences a weight loss or there is an observed change in the resident's oral intake or when other nutritional concerns are noted.
- Prepare referrals to the Rehabilitation Department when there is a change noted in the resident's physical functional status.
- Review the resident's chart for specific treatments, medication orders, diets, etc. as necessary.
10. Notify the attending physician when the resident has been in an accident or incident or when there is a change in the resident's condition. Provide the physician with an accurate assessment of the resident's condition.
11. Notify the resident's family and/or responsible party when the resident has been in an accident or incident or when there is a change in the resident's condition.
12. Administer professional services such as medication administration, catheterization, tube feeding, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, taking vital signs, transferring residents, feeding, toileting, etc. as required; document the provision of services accurately and on a timely basis.
13. Obtain sputum, urine, stool and other specimens for lab tests as ordered.
14. Monitor seriously ill residents as necessary.
15. Ensure that the use of restraints (personal protective devices) is per established policies and guidelines.
16. Institute and maintain preventative measures for skin breakdown.
17. Complete resident skin assessments for signs of breakdown and take immediate action for treatment when indicated.
18. Ensure that residents with decubitus ulcers receive appropriate treatment such as daily inspection of wounds, turning and positioning, nutritional support and maintaining a clean, dry bed.
19. Participate in wound rounds when indicated.
20. Review weights obtained by CNAs and verify accuracy; obtain reweigh and monitor when indicated.
21. Cooperate with and coordinate social and activity programming in conjunction with Activities Department.
22. Ensure that the CNA/MT's are providing direct care to the residents and are providing such care in accordance with the resident's care plan and wishes.
23. Meet with residents, and/or family members as necessary. Report problems to DRN/ALM.
24. Inform the family member of the death of a resident; contact the funeral home when requested by the family; follows facility policy for postmortem care.
25. Perform ADLs as required.
MEDICATION ADMINISTRATION FUNCTIONS- Prepare and administer medications as ordered by the physician within the specified time frames and according to established FKHV policy.
- Document acceptance and/or refusal of medications per FKHV policy.
- Administer medications orally, topically, by feeding tube, intramuscularly, subcutaneously, or rectally as specified per physician's order.
- Administer all physician ordered nourishments.
- Assess and observe resident for drug interactions and adverse reactions.
- Assess need for PRN medications; assess and record effectiveness of administered dose.
- Verify the identity of the residents before administering the medication.
- Ensure that prescribed medication for one resident is not administered to another.
- Ensure that an adequate supply of medications for assigned residents, floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the DRN/ALM.
10. Maintain medicine cart in a neat, clean and orderly manner.
11. Order prescribed medications, supplies and equipment as necessary and in accordance with FKHV and pharmacy policies.
12. Count narcotics accurately for the shift and document. Notify the DRN/ALM of any discrepancies.
13. Dispose of drugs and narcotics as required and in accordance with established procedures.
TREATMENT ADMINISTRATION FUNCTIONS1. Perform sterile and clean dressing changes as ordered and per FKHV policy; label, date and initial dressings.
2. Assess wound appearance, stage, drainage, size, and document on skin grid per FKHV policy.
3. Administer tube feedings per physicians order (continuous or bolus) and flushes per physicians order and FKHV policy.
- Insert/change urinary catheters (Foley and suprapubic) per physician's orders and FKHV policy.
- Irrigate Foley catheters per physician's orders and FKHV policy.
- Insert/change gastric tubes per physician's orders and FKHV policy.
- Administer oxygen and respiratory treatments.
- Change oxygen tubing and other respiratory equipment per FKHV policy.
- Perform Colostomy Care as ordered.
10. Administer douches and enemas as ordered.
11. Assess and document resident's response to treatments and procedures.
CHARTING AND DOCUMENTATION1. Complete and file required forms upon resident's admission, transfer and discharge.
2. Ensure that attending physician's review, record and sign their progress notes and orders in accordance with FKHV policies.
3. Receive telephone orders from physicians and record accurately.
4. Transcribe physician's orders to resident's charts, MAR, TAR, ADL and Lab books accurately.
5. 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 care. Review previous nurse's notes to assure continuity and follow up.
6. Date, time and sign all entries in the clinical record.
7. Write legibly in black ink.
8. Use only authorized abbreviations established by FKHV when recording information.
9. Chart all reports of accidents, incidents and change of condition.
10. Complete incident report for all accidents and injuries - witnessed or non-witnessed; initiate non-witnessed injury investigation when indicated.
11. Record new or changed diet orders and forward information to Dining Department.
12. Report all discrepancies noted concerning physician's orders, diet changes, charting errors to DRN/ALM. Complete Medication error reports as indicated.
13. Document medication and treatment administration and refusal and response to drugs per FKHV policy. Report refusal of medications to physician.
SAFETY AND SANITATION1. Observe and follow established infection control policies and procedures; ensure that staff follows procedures and that par levels of personal protective devices is available.
2. Ensure that ALU areas are maintained in a clean and sanitary manner.
3. Ensure that resident's rooms and common areas are maintained in a clean, safe, sanitary manner.
4. Participate in all fire safety and disaster preparedness drills in a safe and professional manner.
5. Follow established safety regulations for the use of equipment and supplies and ensure that staff follow established polices for their use.
6. Report broken or damaged equipment and supplies and complete work order slips as indicated.
7. Participate in Fall Risk Management program and ensure that CNAs and MTs are aware of residents at risk.
8. Institute appropriate infection control procedures when residents require specific precautions and/or isolation.
RESIDENT'S RIGHTS1. Honor and maintain all Resident's Rights.
2. Maintain the confidentiality of all resident care information.
3. Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity and respect.
4. Ensure that all nursing care is provided in privacy and knock before entering the resident's room.
5. Understand and honor the resident's rights to refuse treatment.
6. Report and assist in the investigation of all allegations of resident abuse and/or misappropriation of resident property. Notify DRN/ALM immediately when abuse is suspected.
PERSONAL AND PROFESSIONAL1. Follow all rules and policies as outlined in the Associate Handbook.
2. Attend and participate in assigned committee FKHV meetings.
3. Attends and participate in all mandatory and scheduled in-services.
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