Registered Nurse

Job Description

Job Description

QUALIFICATIONS:

• Graduated of an accredited school of nursing and licensed by the state of NJ as a RN.
• Current CPR or certified within 90 days of hire
• Other certifications may be required for other areas of the organization

POSITION SUMMARY:

The RN assumes responsibility for a specific unit or area within the organization to include assessment (under the supervision of the DON/ADON), medication distribution, treatment clinical documentation, and supervision of CNA’s and other staff.

PART I: JOB RESPONSIBILITIES AND STANDARDS

1. Uses dual identifiers to confirm resident/guest identify prior to medication administration and treatments.

2. Practices SBAR (situation, background, assessment, recommendation), the preferred method of communication when interacting with members of healthcare community.

3. Encourages resident/guest to be involved in their own care when possible.

4. Receives full and detailed report from the outgoing nurses to ensure proper communication and necessary follow-up of resident’s/guest’s care.

5. Recognizes and responds competently to changes in resident’s condition and documents appropriately.

6. Initiates Plan of Care on admission. Reviews, evaluates & updates plan & interventions as needed.

7. Interacts and partners with all multidisciplinary service teams, internal and external, to assure continuum of care.

8. Practices Standard Precautions and adheres to infection prevention strategies.

9. Demonstrates compliance to Resident’s Rights.

10. Refers to Nursing/Administration/IV/Emergency Management Policy and Procedures (Public Folders, Hard Copy manual) to assure standard of care. 

11. Transcribes physician orders correctly on MAR & TAR.

12. Faxes POS to Pharmacy provider to ensure timely delivery and administration.

13. Maintains a safe environment for residents/guests and reports unsafe situation for resolution. 

14. Follows chain of command.

15. Adheres to proper hand washing technique.

16. Administers medications according to policy and procedure.

17. Notifies responsible party of changes in patient’s condition.

18. Works closely with Social Worker in trying to resolve residents’/guests/ needs.

19. Checks syringes, and counts narcotics at end of shift.

20. Orders stock medications and prescription medications; as needed.

21. Admits and discharges residents/guests according to facility procedure.

22. Reviews report with CNAs prior to their assignment activation.

23. Performs assessments related to:

1. Skin

2. Cardiac

3. Respiratory

4. GI

5. Neurological

6. Muscular Skeletal

7. Renal

8. Pain

24.Accurately documents on the following forms:

1. Ambulation/Restorative care

2. Pyschotropic Monitoring

3. Pain Management

4. Pressure Ulcer Management/skin assessment

5. Fall Prevention Strategies

6. Antibiotic documentation

7. Incidents/accident

8. Nurses Note day 1-5 and day 6 -Discharge Documentation.

25. Accurate and timely completion of Nursing assessment and data collection upon admission:

1. Fall Risk assessment

2. Side Rail screen

3. Braden Scale

4. Bowel and Bladder

5. Elopement Risk Profile

6. Pain Evaluation

7. Smoking Evaluation

8. Data collection

9. Immunization Record Sheet

26. Contacts physician for admission orders:

1. Reconciles medications

2. Documents legibly onto POS

3. Read back and verifies Telephone Orders

4. Make appropriate referrals

5. Transcribes all orders.

6. Fax back (new admissions)

PART II. FACILITY –WIDE RESPONSIBILITIES & STANDARDS

EMPLOYEE IS REQUIRED TO:

1. Speak English in patient care areas.

2. Attend mandatory and scheduled in-services/meetings.

3. Arrive to work on time as scheduled

4. Demonstrate ability to work with others cooperatively.

5. Demonstrate flexibility in assignment to meet resident/family needs.

6. Wear ID at all times appropriately when working.