Charge Nurse (LPN/RN) 7 a to 7 p

Job Description

Job Description

Charge Nurse Position 12hr Rotation

Day and Night Position Available

Ranch Terrace Skilled Nursing

Sapulpa, OK

We offer a competitive wage, as well as, a comprehensive benefits package including health, dental, vision and life insurance . 1 year plus experience preferred.

General Purpose:

Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants and CMAs. Such supervision must be in accordance with the Nurse Practice Acts and current Federal, State, and Local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to maintain the highest degree of quality care at all times.

Administrative Functions

• Direct the day-to-day functions of the nursing assistants and CMAs in accordance with the Nurses Practice Acts and 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.
• Make written and oral reports/recommendations concerning the activities of your shift, as required.
• Cooperate with other resident service Participate and cooperate with any facility surveys (inspections) and investigations as requested by the Administrator or Director of Nursing Services.
• Assist in planning the nursing portion of the resident’s discharge plan, as necessary.
• Admit, transfer, and discharge residents, as required.
• Complete accident/incident 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/EHR, medication cards, and treatment/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 care.
• Chart communication with physician, other professionals providing care to the resident and pertinent family communications
• 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 Supervisor.
• Fill out and complete transforms 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, date and time 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.
• Verify the identity of the resident before administering the medication/treatment using the 5 Rights of medication administration.
• 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 administration records for completeness of information, accuracy in the transcription of the physician’s order and adherence to stop order policies.
• Immediately notify the Nurse Supervisor and attending physician of any medication administration errors and/or adverse reactions to medications.

Nursing Care Functions

• 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 and responsible party 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 and CMAs are aware of the resident care plans. Verify that the CNAs and CMAs refer to the resident’s care plan prior to administering daily care to the resident.

Other Duties

• Attend in-service education programs in order to meet facility educational requirements.
• Be familiar with Standard Precautions, Exposure Control Plan, Fire Drill and Evacuation Procedures and know how to use the information.
• Maintain confidentiality of resident and facility records/information.
• Protect residents from neglect, mistreatment, and abuse.
• Protect the personal property of the residents of the facility.
• Others as directed by the supervisor or administrator.

Minimum Qualifications:

• Licensed Practical Nurse with current state license.
• Excellent technical, assessment and documentation skills.
• Good Leadership qualities.
• Organized and detailed in work performance.
• Ability to multitask and work under pressure.
• 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