Clinical RN weekend

Job Description

Job Description

o   Supervises nursing care in area of assignment.  Makes rounds to assess resident’s needs, then evaluate and provide improvements for the resident(s), unit(s), nursing services being administered;

o   Provides for the physical, emotional, and spiritual comfort and environmental safety of all residents;

o   Provides clinical services under RN Scope of Practice;

o   Interprets and assures compliance with nursing policy and procedure with staff.  Serves as a clinical resource to staff.  Assures compliance with Nursing Standards of Care;

o   Supervises development, use, and update of resident care plan, as needed;

o   Reviews, investigates, and reports (via EMR) incident reports (A&I’s), with follow-up as appropriate.  Reports these instances with unit manager;

o   Effectively interacts with residents, families, and team members while maintaining standards of professional nursing.  Provides health teaching and health counseling to residents, and their families;

o   Administers medications and medical treatments, according to facility policy and procedure;

o   Administration of tube feedings;

o   Assists with diabetic management, through finger-sticks and glucometer tests and readings;

o   Administration of medical treatments and procedures to residents, within RN Scope of Practice;

o   Complete skin assessments, and provide wound care as necessary.  Completes all EMR skin/wound documentations in EMR.  May participate in weekly skin rounds;

o   Completes all resident accident and incident reports in a timely, with quality efficiency, and submits to the unit manager;

o   Completes all diagnostic paperwork;

o   Completes all resident assessments, as necessary or assigned, for annual and quarterly reports;

o   May complete MDS Assessments and progress, as needed;

o   Enters and follows physician orders;

o   Respects resident’s rights and provides for resident dignity;

o   Assures resident safety, by following all facility policies and procedures, addressing care needs, following nursing instructions, and following all applicable NYS and Federal regulations;

o   Follows all standard precautions and infection control policies and procedures for safe care of all residents;

o   Coordinates the smooth operational functioning of the assigned unit(s);

o    Directs all LPN’s and CNA’s in the performance of their job duties.  Addresses issues where necessary.  Reports any concerns to the unit manager, nursing services manager, or director of nursing;

o   Assesses, evaluates, and reports any significant resident signs/symptoms and/or changes in health care status to the unit manager, clinical manager, or physician, as appropriate and necessary, as observed through unit rounds;

o   Utilizes the nursing process to provide quality care through:

·         Resident assessments;

·         Resident evaluations;

·         Updates the comprehensive care plan, based upon resident outcomes and progress;

·         Updates the nurse aide assignment sheets;

·         Notifies the unit manager of all changes.

o   Documents resident care in Electronic Medical Record (EMR), in compliance with facility policy and mandated regulations; including, but not limited to:

·         Nurses notes;

·         Medication Administration (MAR);

·         Treatment Administration (TAR);

·         Wound/skin assessments (including Quick Rounds)

o   Notifies Director of Nursing, or designee, of existing or potential clinical problems involving staff or residents, suggesting resolutions, and verifies follow through is completed;

o   Demonstrates and is responsible to assure the correct and safe techniques in all clinical competencies, and the use of all unit equipment.  Corrects and notifies Unit Manager and Director of Nursing of any staff clinical corrections necessary;

o   Cooperates with other departments to facilitate good nursing care, and maintain an atmosphere to comply with policy/procedure, and facility standards;

o   Participates in and meets annually all staff development requirements, including but not limited to: Annual mandatories, plan off correction training and in-services, department competencies of skills, and other required in-services and workshops;

o   May assist with collection of data for quality assurance;

o   Provides supportive and restorative resident care under the direction of the Unit Manager;

o   Provides and or assists with direct care giving services as necessary; including but not limited to: feeding, toileting, cleaning, transferring, and other ADL’s;

o   Assigns resident caseloads to appropriate team members, include coordinating staff their 30 minutes unpaid meal breaks and short paid breaks;

o   Completes Nursing Unit(s) rounds, monitors staff for completion of resident care as per CNA/LPN assignments, and assigned unit duties.  Counsels staff to provide and complete unit duties, for the provision of Superior Quality of Care;

o   Addresses and reports to the Unit Manager or Building Supervisor, any problems identified with staff, which may be a potential disciplinary issue;

o   Oversees the completion of the shift-to-shift report, to ensure follow-through on all issues of concern related to the health status of all residents;

o   May assist with or be responsible for the completion of the admission or discharge assessment, via EMR;

Additional duties ass needed to fulfill the needs of the department or facility