Registered Nurse (RN)

Licensed Personnel Job Description

Registered Nurse-R.N.

Job Description -Licensed personal have graduated from either a NYSED Registered RN education Program or an LPN education program registered by NYSED.Nursing license is valid for life, unless it is surrendered or revoked, annulled or suspended by the New York State Board of Regents. Registration certificate will authorize licensed personal to practice nursing and renewed as per state mandate to continue practicing in nursing.Licensed personnel are not legally allowed to practice nursing while registration is expired.Licensed personnel job tasks include but are not limited to providing and coordinating resident care, educating residents, family members, and the pubic about health conditions, providing emotional support to residents and family members, overseeing non‑licensed personnel direct care giver staff, providing person centered care, directing goals and interventions. Provide person centered focused care with attention to residents with diagnosis of Alzheimer’s Dementia requiring individualized interventions.Licensed personnel consult and coordinate with the interdisciplinary team members to plan, implement, or evaluate resident’s plan of care.

Administrative Functions

Registered Nurse (RN) administrative functions include but are not limited to directing day to day functions and monitoring compliance with facility policies of non‑licensed personnel, participation in QAPI performance improvement projects, attendance to all mandatory and assigned in services, adherence to corporate compliance code of conduct, interpreting facility policy and procedures to residents and visitors, maintain confidentiality of all residents health care information, monitor that resident’s rights, dignity, and privacy are maintained, monitor for fair treatment of all residents,ensure all personnel are knowledgeable of the residents right to guide the plan of care and refuse recommended treatment, review of complaints/grievances made by residents and participate in completing/collecting statements or incident reports, and report all allegations/witnessed abuse in a timely manner to superiors or anonymous abuse hotline.

Charting and Documentation

Registered Nurse (RN) are required to perform the following charting and documentation including but not limited to transcribe orders from Physician Assistants/Nurse Practitioners/Medical Doctors in timely manner, document in clear professional manner relaying facts and care provided to residents as well as response to care, sign and date all documentation, oversee non‑licensed personnel documentation, educated non‑licensed personnel on documentation practices.

Daily Functions

• Monitor, record, and report symptoms or changes in residents' conditions.
• Maintain accurate, detailed reports and records.
• Record patients' medical information and vital signs.
• Order, interpret, and evaluate diagnostic tests to identify and assess patient's condition.
• Modify patient treatment plans as indicated by patients' responses and conditions.
• Direct or supervise non‑licensed personnel direct care staff.
• Inspect treatment areas are clean and safe.
• Consult and coordinate with interdisciplinary team to plan, implement, or evaluate resident care plans.
• Monitor all aspects of resident care, including diet, cognitive and physical functioning.
• Instruct residents, families, or visitors on health education, disease prevention, and/or facility protocols/policies and procedures.
• Prepare residents for and assist with examinations, treatments, or testing.
• Prepare and administer medications as ordered by practitioner.
• Ensure adequate supply of medication and supply in order to deliver care.
• Ensure accurate narcotic records.
• Notify supervisor of any drug discrepancy, change in resident condition, and emergency situations.
• Dispose of drugs in accordance with established protocols.
• Develop work assignments for non‑licensed personnel.
• Make round of unit to ensure personnel are performing their assignments.
• Receive/Give 24-hour report.
• Report exposures to blood, body fluids, infectious material according to facilities policies.
• Participate in performance evaluations, making recommendations to supervisor.
• Administer Clinical Care including but not limited to invasive device care, prosthetic/splint device assist, wound care, tube drainage, IV-line site monitoring, post mortem care, and/or CPR.
• Ensure all food provided to resident is within dietary restrictions.
• Perform monitoring of any resident activity, or vital signs.
• Initiate/Discontinue Intravenous lines.
• Provide/or Discontinue PICC/or central line, provide PICC/or central line care.
• (Central Lines only to be inserted by Outside facility provider “ACCESS RN”)
• Perform any kind of “ASSESSMENT” for residents.
• Read/assess PPD Results.

Admission, Discharge, Transfers (A.D.T.)

Registered Nurse's (RN) duties inclide admission/discharge/ transfer responsibilities include but are not limited to inform Medical Doctor, supervisor, and direct care non‑licensed personnel of A.D.T. changes, ensure room is ready to receive admission, greet newly admitted residents, escorting them to the appropriate room, coordinate with the concierge,review resident’s medical record, implement all medications/treatments in timely manner on admission to facility, communicate all current medical orders/ medications/treatments to receiving party in case of transfer or discharge, coordinate with the interdisciplinary team to provide person centered care interventions for newly admitted residents, receive history and transfer documentation on admit of new resident to facility, perform full body inspection of residents with A.D.T. change, and on return for “out on pass” (OOP),Maintain safe environment, communicate changes in resident condition to next of kin involved in Plan of Care, report discrepancies to supervisor/Director of nursing services.R.N. must assess resident on admission, transfer, and /or discharge.

Legal/ Ethical

• Practicing in accordance with legislation affecting nursing practice
• Fulfilling duty of care including recognizing standards of care, clarifying responsibilities foraspects of care with other members of the interdisciplinary team, and recognizing responsibility to prevent harm.
• Recognizing and responding appropriately to unsafe or unprofessional practice
• Identifying and explaining alternative strategies for interventions and their likely outcomes
• Practicing within the professional and ethical nursing framework, practicing in accordance with nursing profession code of ethics, ensuring that personnel values are not imposed on others, recognizes and accepts the rights of others, maintain an effective process when confronted by differing values, beliefs and biases, seeks assistance to resolve situation involving moral conflict.
• Practicing in a way that acknowledges the dignity, culture, values, beliefs, and rights of individuals/groups, demonstrate respect for individuals/groups and legal rights in relation to health care decisions.
• Understanding and practicing within own scope of practice
• Practicing within an evidence based framework, identifying problems that may be investigated through research, considering potential for improvement in outcomes
• Participating in quality improvement through recognizing that quality improvement involves ongoing consideration, use and review of practice in relation to practice outcomes and standards of care, seek feedback from wide range of sources, and participate in case review.

Care Planning

Registered Nurse's (RN) are required to perform the following care planning duties including but not limited to ensuring that nurses notes reflect the plan of care, implement person centered interventions, ensure non licensed care providers understand and implement the resident driven care plan, assess residents on regular basis to ensure plan of care is realistic and reflect resident preferences, update the goals/interventions of care plans regularly, initiate new care plans in timely manner, resolve care plans in timely manner, and provide care plans to resident or next of kin as requested.Provide the Baseline Care Plan Assessment to the resident or next of kin within 48 hours of admission to facility.

Staff Development

Licensed personnel are required to attend all mandatory and assigned in-servicing presentations as scheduled at the facility including but not limited to via online (RELIAS Learning), in-person, webinar, and/or audio conference to maintain certification and remain up to date with facility policies & protocols.

Equipment & Supply Function

Licensed personnel are required to utilize only equipment trained to use and operate all equipment in safe manner.

Specific Requirements

Licensed personnel must be able to read, write, speak, and understand English language, must possess ability to deal tactfully with resident’s and personnel visitors, must not pose a direct threat to the health and safety of other individuals in the workplace, must possess ability to make independent decisions when circumstances warrant such action, and must be able to relay in clear manner resident condition. Licensed personnel must be able to cope with mental and emotional stressors of the job description, must be able to see and hear adequately to ensure the requirements of this position can be fully met, must be willing to assist with all emergency management planning and implementation.Licensed personnel are subject to call back during emergency conditions, subject to exposure to hostile and emotionally upset residents, personnel, and visitors, subject to exposure to chemicals, infectious waste, and diseases.Must have the ability to come to work, read, and think at the level essential for the job functions.