This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents. Therefore, the following list of duties is not all-inclusive:
Administrative Functions:- Direct the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the long-term care industry.
- Confirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
- Meet with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs and activities.
- Verify that all nursing personnel comply with the procedures set forth the in the Nursing Policies and Procedures Manual.
- Make written and oral reports/recommendations concerning the activities of your shift, as required.
- Cooperate with other resident services when coordinating nursing services be certain that the resident's total regimen of care is maintained.
- Verify that all nursing service personnel are in compliance with their respective job descriptions.
- Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing department.
- Participate in surveys (inspections) made by authorized government agencies.
- Periodically review the resident's written discharge plan. Participate in the updating of the resident's written discharge plan, as required.
- Assist in planning the nursing portion of the resident's discharge plan, as necessary.
- Admit, transfer, and discharge residents, as required.
- Complete accidenUincident reports, as necessary.
Charting and Documentation:- Complete and file required forms/charts upon resident's admission, transfer, and/or discharge.
- Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
- Receive telephone orders from physicians and record on the Physicians' Order Form.
- Transcribe physician's orders to resident charts, cardex, medication cards, and treatmenUcare plans, as required.
- 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.
- Record new/changed diet orders. Forward information to the Dietary Department.
- Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse
- Fill out and complete transfer forms in accordance with established procedures.
- Enter appropriate documentation concerning unauthorized discharges in the resident's medical record in accordance with established procedures.
- Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
- Sign and date all entries made in the resident's medical record.
- Write nurses' notes to reflect that the care plan is being followed when administering nursing care or treatment.
Medication Administrative Functions:- Prepare and administer medication as ordered by the physician.
- Responsible for IV medication/fluid administration.
- Verify the identity of the resident before administering the medication/treatment.
- Verify that prescribed medication for one resident is not administered to another.
- Verify that adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the Nurse Supervisor.
- Order prescribed medications, supplies, and equipment as necessary, and in accordance with established procedures.
- Verify that narcotic records are accurate for your shift.
- Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
- Review medication cards for completeness of information, accuracy in the transcription of the physician's order and adherence to stop order policies.
- Notify the attending physician of automatic stop orders prior to the last dosage being administered.
- Immediately notify the Nurse Supervisor and attending physician of any medication administration errors.
Nursing Care Functions:- Perform physical assessment through observation, inspection, palpitation, percussion and auscultation.
- Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.
- Promptly respond to call lights and other resident needs.
- Make rounds with physicians, as necessary.
- Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary.
- Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary.
- Make periodic checks to confirm that prescribed treatments are being properly administered by CNAs and to evaluate the resident's physical and emotional status.
- Notify the resident's attending physician when the resident is involved in an accident or incident.
- Notify the resident's attending physician and responsible party when there is a change in the resident's condition.
- 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, etc., as required.
- Monitor seriously ill residents, as necessary.
- Review care plans daily to confirm that appropriate care is being rendered.
- Confirm that CNAs are aware of the resident care plans. Verify that the CNAs refer to the resident's care plan prior to administering daily care to the resident.
Minimum Qualifications- Registered Nurse with current state license.
- Excellent technical, assessment and documentation skills.
- Good Leadership qualities.
- Organized and detailed in work performance.
- Good communication skills with excellent self-discipline and patience.
- Genuine caring for and interest in elderly and disabled people in a nursing facility.
- Comply with the Residents Rights and Facility Policies and Procedures.
- Perform work tasks within the physical demand requirements as outlined below.
- Perform Essential Duties as outlined above.