Licensed Practical Nurse

Nurse Position

Summary Of Position Functions: The Nurse assumes responsibility and accountability for resident care of a designated shift and in accordance with federal and state regulations and company/community policies, procedures and Personal Service Plans.

Essential Position Functions:

• Coordinates patient care and non-patient care (cleaning, etc.) by developing and distributing written nursing assignments for each employee which outlines residents to be cared for and other duties to be executed during the shift. Assignments and rotations are provided with consideration that resident needs are matched with the skills of individual staff members, while maintaining consistency to the extent practicable.
• Describes personal service plan and approaches to direct care staff so that plan is consistently implemented on all shifts by all caregivers. Seeks input from personal care assistants about resident condition, functional abilities, preferences, and alternative approaches to care.
• Monitors delivery of care and services throughout shift to ensure needs are met, tasks are completed, including complete and accurate resident documentation, and that work of direct care staff is of acceptable quality and quantity. Insures compliance on unit with resident rights.
• Makes daily rounds on assignment at least at beginning and end of shift to observe, examine, or interview residents to verify information from ongoing shift, to monitor regulatory compliance, and to determine or rotate staff assignments and make adjustments according to qualified staff availability and resident needs.
• Provides orientation, trains, and develops staff by identifying learning needs while taking opportunities to teach on the unit. Updates employees regarding changes in resident needs. Instructs personnel on use of equipment.
• Coaches and monitors staff performance providing praise and redirection when applicable. Issues disciplinary actions to staff, when needed, in a fair and consistent manner in conjunction with federal and state laws and company policies and procedures.
• When necessary, schedules employees to work and replaces call-ins for the following shift. Ensures correct number of staff on duty, schedules lunch and rest breaks, approves or denies requests to leave early.
• Monitors and trains staff and corrects deficiencies for compliance with OSHA mandates on workplace safety including hazard communication, blood borne pathogens, and infection control procedures. In cases of work place exposure, coordinates immediate first aid, insures proper documentation and refers employee for post-exposure treatment.
• Monitors restorative measures provided by staff in daily care of residents (i.e. range of motion, self-help skills, positioning and body mechanics).
• Performs duties as assigned in Community Fire and Disaster Plan that may include taking charge of evacuation, drills, and transportation of residents.
• Receives, investigates and responds to employee problems and complaints.
• Complies with the community's privacy and confidentiality practices and procedures related to resident and employee records and all state/federal privacy laws.
• Completes required documentation of care and services delivered during shift including subjective findings, objective symptoms, interventions, and resident responses to interventions. Completes required documentation of special circumstances including accident/incident reports in compliance with state and federal laws and regulations.
• Writes comprehensive weekly/monthly summaries reflective of patient's status, abilities/disabilities, and specifically addressing problems identified on the patient Personal Service Plan. Initiates and updates patient Personal Service Plans as needed with appropriate problems, resident-oriented goals, and approaches based on resident needs.
• Completes written 24-hour community report. Gives and listens to verbal shift report making special note of significant changes in condition, admissions, transfers, discharges, unnecessary use of any drug, incidents, unexplained injuries, medication errors, loss of resident property, or evidence of resident or family dissatisfaction.
• Reports relevant information to Wellness Director including interdisciplinary team functioning and communication, regulatory compliance issues, resident risk factors, sudden changes in resident behavior, expressed dissatisfaction by resident or family, refusals of treatment, unexplained injuries, positive or negative staff behavior, staffing needs, equipment and supply needs, and opportunities to revise policies or procedures and improve quality.
• Ensures delivery of compassionate quality care evidenced by adequate services and staff coverage on unit, appropriateness of staff, absence of odors, cleanliness, absence of pressure wounds, and apparent maintenance of optimal physical, mental, and psychosocial function.
• Updates daily census, completes admission/discharge documentation, assures documentation of vital and neurological signs and weights, and notifies physician of significant weight loss/gain.
• Actively participates and positively supports the community quality improvement process which may include monthly meetings. Communicates action team recommendations, outcomes, and changes to subordinates and peers on other shifts not present at the meeting.
• Provides direct patient care, administers medications and specialized treatments and diet as prescribed to residents on unit according to physician orders and in compliance with community policies and procedures. Receives and gives a comprehensive report on all residents.
• Makes rounds with physicians, schedules lab, x-ray, and appointments as ordered, reviews lab test results, and notifies physician of the same.
• Performs physical assessment of new admissions and current residents as indicated by change in condition or as required by regulation. Completes assigned sections of resident assessment instruments used in the community.
• With participation members and resident, to the extent practicable, develops, implements, evaluates, and revises service plans with timetables to assist each resident to attain or maintain highest practical physical, mental, and psychosocial well-being. Modifies approaches in service plan to accommodate resident needs and preferences to manage risk factors for functional decline and to improve functional abilities. Coordinates care and delivery of services with all disciplines. Consults with and refers relevant resident care issues to the Wellness Director.
• Respects rights of residents regarding freedom of choice, consent for care and services, refusals of treatment and implementation of advance directives if any. Promptly consults with Wellness Director if unsure of proper course of action that respects resident's rights, complies with company/community policies and procedures and provides consistency with federal and state laws and regulations.
• Immediately informs the resident, consults with physician, and notifies the designated family member and/or legal representative when there is an accident involving an injury which has potential for physician intervention; a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly or a decision to transfer or discharge from the community or change room of the resident.
• Uses good judgment to prepare, administer and immediately document medications and treatments as ordered by physicians. Maintains awareness of prominent medication interactions and side effects, monitors resident for occurrence of such and notifies physician as needed. Orders timely medications to ensure continuity of administration.
• Keeps medication rooms and carts locked when unattended and is responsible for the security of the keys and correct reconciliation of controlled substances during shift. Counts all drugs on Individual Control Drug Records with on-coming charge person at change of shifts. Keeps medication room and cart clean and organized. Insures proper storage of drugs and biological items.
• Informs resident in advance about care and treatment and any changes to the Personal Service Plan.
• Attends in-service education programs and applies information to job tasks.

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