RN

Job Description

Job Description:\n\nPurpose of Your Job PositionThe primary purpose of this position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the Nursing Assistants and Licensed Practical Nurses in accordance with the Nurse Practice Act; current federal, state, and local standards; guidelines and regulations that govern the Facility; and as may be required by the Director of Nursing Services or Assistant Director of Nursing to ensure the highest degree of quality care is maintained at all times.Delegation of AuthorityAs Registered Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.Job FunctionEvery 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 ResponsibilitiesAdministrative Functions· Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, 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.· Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedure Manual.· May be expected to supervise nursing staff while abiding by scope of practice per position.· Make written and oral reports/recommendations concerning the activities of your shift as required.· Cooperate with other resident services when coordinating nursing services to ensure that the residents'· total regimens of care are maintained.· Participate in Facility surveys (inspections) made by authorized government agencies as may be requested· Assist in planning the nursing services portion of the residents' discharge plans as required.· Admit, transfer, and discharge residents as required.· Complete accident/incident reports, as necessary.· Complete all record keeping upon residents' admissions, transfers, and/or discharges into the electronic health record (EHR).· Receive telephone orders from physicians and transcribe as required by Facility policy.· Chart Progress notes in an informative and descriptive manner that reflects the care provided to residents as well as the residents' responses to the care.· Perform routine and required documentation/charting duties in accordance with established policies and procedures.· Sign and date all entries and electronically sign all entries in the EHR.· Prepare and administer medications as ordered by the physician in accordance with federal, state, and local regulations and as required by Facility policy.· Order prescribed medications, supplies, and equipment as necessary and in accordance with established policies.· Ensure that narcotics are handled in accordance with federal, state, and local regulations and as required by· Facility policy and that narcotic records are accurate for your shift.· Participate in associate performance evaluations and making recommendations to the Nurse Supervisor concerning associate dismissals, transfers, etc.· Develop work assignments.· Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards.· Meet with the nursing personnel on your shift on a regularly scheduled basis to assist in identifying and/or improving services.· Understand and implement the Disciplinary Policy and Procedures. Instigate and/or escalate disciplinary actions for resolution. Ensure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.· Make rounds with physicians, as necessary.· Consult with the residents' physicians in providing the residents' care, treatment, rehabilitation, etc. as necessary.· Implement and maintain established nursing objectives and standards.· Notify the residents' attending physicians and next-of-kin when there are changes in the residents' conditions or if the residents are involved in an incident or accident.· Administer professional services such as catheterizations, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, etc. as required.· Ensure that personnel providing direct care to residents are providing such care in accordance with the residents’ care plans and wishes.· Attend and participate in all Facility in-service programs as required.· Maintain professional competence through participation in continuing education programs, seminars, and training programs.· Monitor assigned personnel to ensure established safety regulations are followed in the use of equipment and supplies.· Ensure that established departmental policies and procedures are followed by self and assigned personnel.· Ensure work area, unit, resident care rooms, treatment areas, etc. are maintained in a confidential, safe, and sanitary manner.· Ensure self and assigned personnel follow established infection control procedures.· Review care plans to ensure that appropriate care is being rendered.· Ensure nursing documentation reflects that the care plan is being followed when administering nursing care or treatment.· Ensure assigned Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) are aware of and carry out resident care plans.· Assist the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising the MDS, including the implementation of CAAs and triggers. Charting and Documentation· Complete and file required recordkeeping forms or charts upon the 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, Kardex, medication and treatment orders, or care 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 the care.· Fill out and complete accident and incident reports. Submit to Director of Nursing, as required.· Chart all reports of accidents and incidents involving residents. Follow established procedures.· Record new and changed diet orders. Forward information to the Food Services Department.· Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Nurse Supervisor and/or Unit Manger.· Fill out and complete transfer forms in accordance with established procedures.· Ensure that appropriate documentation concerning unauthorized discharges is entered 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. Drug Administration Function· Prepare and administer medications as ordered by the physician.· Verify the identity of the resident before administering the medication and treatment.· Ensure that prescribed medication for one resident is not administered to another resident.· Ensure that an 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 and/or Unit Manager.· Order prescribed medications, supplies, and equipment, as necessary, in accordance with established policies.· Ensure that narcotic counts are accurate before and after every shift.· Notify the Nurse Supervisor and/or Unit Manager 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.· Dispose of drugs and narcotics as required, and in accordance with established procedures. Personnel Functions· Inform the Nurse Supervisor and/or Unit Manager of staffing needs when assigned personnel fail to report to work. Recommend overtime for assigned CNAs and other nursing personnel to the Nurse Supervisor or Unit Manager to insure residents’ needs are met.· Report absentee call-ins to the Nurse Supervisor and/or Unit Manager.· Provide feedback and recommendations for probationary and annual employee performance evaluations for CNAs and other nursing personnel. Prepare probationary and annual employee performance evaluations for CNAs and other nursing personnel. Meet with CNAs and other nursing personnel to review performance.· Develop work assignments and/or assist in completing and performing such assignments. Reassign assigned CNAs and other nursing personnel based upon skills and qualifications.· Provide leadership, education, counseling, and discipline, when appropriate, to assigned CNAs and other nursing personnel.· Make daily rounds of your unit/shift to ensure that assigned CNAs and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards. Make changes to assignments based upon resident needs and availability of skilled staff.· Evaluate daily performance of assigned CNAs and other nursing personnel. Document any disciplinary issues and report problem areas or disciplinary actions to the Nurse Supervisor and/or Unit Manager.· Meet with your assigned CNAs and other nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services. Assign personnel accordingly to insure quality resident care while allowing personnel to improve in areas where they may be deficient, with appropriate supervision. · Ensure that CNAs, department personnel, residents, and visitors follow the department’s established policies and procedures at all times.· Resolve personnel disputes and issues within the unit and reassign or remove personnel, if necessary, to insure patient safety. · 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 residents.· Review complaints and grievances made or filed by your assigned CNAs or other nursing personnel. Make appropriate reports to the Nurse Supervisor and/or Unit Manager as required or as may be necessary. Follow Facility’s established procedures.· Receive/provide the nursing report upon reporting in and ending shift duty hours.· Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the Facility’s policies and procedures governing accidents and incidents. Nursing Care Functions· Inform nursing personnel including assigned CNAs of new admissions, their expected time of arrival, room assignment, etc.· Ensure that rooms are ready for new admissions.· Greet newly admitted residents upon admission. Escort them to their rooms, as necessary.· Participate in the orientation of new residents and family members to the Facility.· Make rounds with physicians, as necessary.· Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.· 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.· Maintain established nursing objectives and standards.· Make periodic checks to ensure that certified nursing assistants, CNAs, and/or other nursing personnel are properly administering prescribed treatments and to evaluate the resident’s physical and emotional status.· Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, CNA, and/or a nurse aide trainee qualified to perform the procedure.· Cooperate with and coordinate social and activity programs with nursing service schedules.· Notify the resident’s attending physician when the resident is involved in an accident or incident.· Notify the resident’s attending physician and next-of-kin when there is a change in the resident’s condition.· Carry out restorative and rehabilitative programs to include self-help and care.· 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 and bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead and dying, etc., as required.· Use restraints when necessary and in accordance with established policies and procedures and applicable state laws and guidelines.· Use an Automated External Defibrillator, as required.· Obtain sputum, urine, blood, and other specimens for lab tests, as ordered· Take and record TPRs, blood pressures, etc., as necessary.· Perform Cardiopulmonary resuscitation (CPR), as necessary.· Monitor seriously ill residents as necessary.· Check foods brought into the Facility by the resident’s family or visitors to ensure that it is within the resident’s dietary allowances. Report problem areas to the Nurse Supervisor and/or Unit Manager and Dietary Supervisor.· Ensure that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.· Ensure that residents who are unable to call for help are ch