Registered Nurse MDS Coordinator

Job Description

PURPOSE: The primary purpose of your job is to conduct and coordinate the development and completion of the resident assessment in accordance with the requirements of this state and the policies and goals of this facility.

DELEGATION OF AUTHORITY: As Minimum Data Sheet Nurse Coordinator (MDS), you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

JOB FUNCTIONS: Every 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.

GENERAL DUTIES AND RESPONSIBILITIES:

1) Coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation of RAPs and Triggers.

2) Perform administrative duties such as Computer Data entry, completing medical forms, reports, evaluations, studies, etc., as necessary.

3) Implement, and maintain an ongoing quality assurance program for the resident assessment/care plans.

4) MDS Nurse will coordinate and assist with Discharge Planning Coordinator in completing the care plan portion of the resident’s discharge plan.

5) Ensure that all assessments are completed and transmitted in a timely manner Report problem areas to the administrator.

6) Ensure that a current copy of the MDS Instructor’s Manual is available to persons completing portions of the MDS.

7) Maintain an effective, friendly working relationship with health professionals, physicians, consultants, and governmental agencies that may be involved in the resident assessment/care plan functions of the facility.

8) Meet with and solicit advice from department supervisors concerning the resident assessment/care plan functions of the facility.

9) Coordinate the interviewing of each resident for the resident’s assessment.

10) Evaluate each resident’s condition and pertinent medical data to determine any need for special assessment activities or a need to amend the admission assessment.

11)Assist facility directors and supervisors in scheduling the resident assessment/care plan meetings.

12) Contact and assist in scheduling participants by outside members of the care plan team, including the resident’s representative and/or other interested family members.

13) Ensure that the care provided is in accordance with the residents’ wishes.

CARE PLAN AND ASSESSMENT FUNCTION

1) Develop preliminary and comprehensive assessments of the nursing needs of each resident, utilizing the forms required by current rules or regulations and facility policies.

2) Ensure that appropriate health professionals are involved in the assessment.

3) Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the penalties, including civil money penalties, for false certification.

4) Coordinate the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional services is responsible for each element of care.

5) Ensure that the care plan includes measurable objectives and timetables to meet the resident’s medical, nursing, and mental and psychosocial needs as identified in the resident’s admission.

6) Ensure that a comprehensive care plan is completed within twenty-one days of the resident’s admission.

7) Ensure that a complete resident assessment is conducted within fourteen days of a significant change in the resident’s condition.

8) Coordinate the review and revision of the resident’s care plan by the interdisciplinary team after each quarterly review or other assessment, assuring that the care plan is evaluated and revised each time an assessment is done or when there is a change in the resident’s status.

9) Inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).

10) Check and verify that the MDS Coordinator signed and dated the assessment instrument to certify its completion.

11) Ensure that medical and nursing care is administered in accordance with the resident’s wishes, including the implementation of advance directives.