MDS Nurse (RN)

LPN/LVN Position

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.

Administrative Functions:

• Administer patient assessments, oversee the assessment process, setting the assessment schedules and assuring that assessments are done in an accurate and timely manner.
• Coordinates the care plan as according to regulatory requirements.
• Create the schedule for all Medicare and Medicaid. They also start Medicare coverage for newly qualified patients or send out denial letters.
• They remain updated on changes in Medicare coverage and help determine documents needed for Medicaid reimbursement.
• Direct the day to day functions of the 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 policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.
• Meet with your assigned nursing staff, as well as support personnel, in planning the shifts' services, programs, and activities.
• Ensure that the Nursing Service Procedures Manual is current and reflects the day to day nursing procedures performed in this facility.
• 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 shift as required.
• 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 for the nursing service department.
• Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
• Periodically review the resident's written discharge plan. Participate in the updating of the resident's written discharge plan as required.
• Assist in planning the nursing services portion of the resident's discharge plan as necessary.
• Interpret the department's policies and procedures to personnel, residents, visitors, and government agencies as required.
• Admit, transfer, and discharge residents as required. Complete accident/incident reports as necessary.
• Write resident charge slips and forward to the Business Office. Maintain the Daily Census Report and submit to the Business Office as required.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
• Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
• Report any known or suspected unauthorized attempt to access facility's information system.

Charting and Documentation:

• Complete and file required recordkeeping forms/charts upon the 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, cardex, medication cards, 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 the care.
• Fill out and complete accident/incident reports. Submit to Director as required.
• Chart all reports of accidents/incidents involving residents. Follow established procedures.
• Record new/changed diet orders. Forward information to the Food Services Department.
• Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor.
• 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:

• Prepare and administer medications as ordered by the physician.
• Verify the identity of the resident before administering the medication/treatment.
• Ensure that prescribed medication for one resident is not administered to another.
• 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 Nurse Supervisor.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
• Ensure that narcotic records are accurate for your shift. Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
• Review medication cards 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 shift's staffing requirements, and making recommendations to the Nurse Supervisor concerning employee dismissals, transfers, etc.
• Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work. Report absentee call ins to the Nurse Supervisor.
• 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/shift. Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Nurse Supervisor.
• Ensure that all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program. 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 department 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 and shift.
• Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the Nurse Supervisor 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 upon reporting in and ending shift 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. Report known or suspected incidents of fraud to the Administrator.
• Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen saver activates within established facility policy guidelines.

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. Greet newly admitted residents upon admission. Escort them to their rooms as necessary.
• Participate in the orientation of new residents/family members to the facility. Make rounds with physicians as necessary. Requisition 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.
• Make periodic