Registered Nurse

Registered Nurse

The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or to ensure that the highest degree of quality care is maintained at all times.

Administrative Functions

• Direct the day-to day functions of the nurses and nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
• Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
• Periodically review the department's and unit's policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.
• Meet with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs, and activities.
• Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed on the unit.
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual.
• Make written and oral reports/recommendations concerning the activities of your unit as required to the Director of Nursing.
• Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained.
• Ensure that all nursing service personnel are in compliance with their respective job descriptions.
• Participate in the development, maintenance, and implementation of the facility's quality assurance program of the nursing service department.
• Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
• Prepare the unit for pending facility surveys (inspections)
• Periodically review the resident's written discharge plans. Participate in the updating of the resident's written discharge plans as required.
• Assist in planning the nursing services portion of the resident's discharge plan as necessary.
• Participate in weekly care conferences conducted by the physiatrist.
• Interpret the department's policies and procedures to personnel, residents, visitors, and government agencies as required.
• Admit, transfer, and discharge residents as required
• Ensure accuracy of the accident/incident reports as necessary.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge maintaining compliance with the center's Medical records system- Electronic or traditional paper medical record.
• Review all new admission charts for accuracy and completeness. Follow up on all identified areas and forward summary of findings and actions to Director of Nursing.
• Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
• Review physician order process to ensure accuracy.
• Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans based on findings of daily audits.
• Review nurse's notes to ensure they are written according to facility charting guidelines.
• Chart all reports of accidents/incidents involving residents. Follow established procedures.
• Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Director of Nursing.
• Fill out and complete transfer forms in accordance with established procedures.
• Ensure that appropriate documentation concerning unauthorized discharges is entered 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 and date all entries made in the resident's medical record.

Drug Administration Functions

• Ensure unit staff prepare and administer medications as ordered by the physician.
• Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the Director of Nursing.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
• Ensure that narcotic records are accurate for the unit.
• Notify the Director of Nursing of all drug and narcotic discrepancies noted on the unit.
• Review medication records for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage being administered.
• Dispose of drugs and narcotics as required, and in accordance with established procedures.

Personnel Functions

• Participate in employee performance evaluations, determining your units staffing requirements, and making recommendations to the Director of Nursing concerning employee dismissals, transfers, etc.
• Inform the Director of Nursing of staffing needs when assigned personnel fail to report to work.
• Report absentee call-ins to the Director of Nursing
• Review and evaluate your department's work force and make recommendations to the Nurse Supervisor.
• Develop work assignments and/or assist in completing and performing such assignments.
• Provide leadership to nursing personnel assigned to your unit.
• Make daily rounds of your unit to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas and Plan of Action to the Director of Nursing.
• Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.
• Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services.
• Ensure that unit personnel, residents, and visitors follow the department's established policies and procedures at all times.
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the residents.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit.
• Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the Director of Nursing as required or as may be necessary. Follow facility's established procedures.
• Ensure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
• Receive/give the nursing report for the unit upon reporting in and ending duty hours.
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures governing accidents and incidents.

Nursing Care Functions

• Inform nursing personnel of new admissions, their expected time of arrival, room assignment, etc.
• Ensure that rooms are ready for new admissions.
• Participate in the orientation of new residents/family members to the facility.
• Make rounds with physicians as necessary.
• Request and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.
• 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.
• Implement and maintain established nursing objectives and standards in accordance with the plan of care.
• Make periodic checks to ensure that prescribed treatments are being properly administered by the nurses and certified nursing assistants and to evaluate the resident's physical and emotional status.
• Cooperate with and coordinate social and activity programs with nursing service schedules.
• Notify the resident's attending physicians when the resident is involved in an accident or incident.
• Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition.
• Carry out restorative and rehabilitative programs, to include self-help and care.
• Inspect the