Nurse (RN/LPN)

Primary Purpose of this Position

The primary purpose of this position is to provide direct nursing care to the residents while supervising the nursing activities for the assigned shift.

Shift:

Monday-Friday 7a-3p

Monday-Friday 3p-11p

Duties and Responsibilities

Administrative Functions

• Ensure the facility meets the minimum staffing levels for nurses and nurse aides; complete required posting of nursing staff data as required.
• Ensure that each resident who experiences a significant change in status is assessed using the Resident Assessment Instrument (RAI) process.
• Ensure that all resident rooms, common areas, treatment areas and nurse's stations are maintained in a clean, safe and sanitary manner.
• Assist to develop a dementia care program involving an interdisciplinary approach with a holistic focus on the needs of the resident living with dementia.
• Verify resident census accuracy and report new admissions, discharges, leaves of absence and bed-holds per facility policies; document census as established for billing and clinical purposes.
• Assist with safe and orderly resident transfers and discharges in accordance with facility policies.
• Coordinate pre-certifications and recertifications in accordance with facility policies for Medicare Advantage and commercial insurance payers.
• Interpret the department's policies and procedures to personnel, residents, visitors and government agencies as required.
• Participate in developing, maintaining and updating written facility policies and procedures that govern the day-to-day functions of the nursing services department.
• Participate in facility surveys (inspections) made by authorized government agencies as requested.
• Audit nursing documentation in the clinical record for appropriate and relevant entries.
• Attend and contribute in facility "triple check" process for reviewing coding for accuracy.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
• Periodically review the department's policies and procedures manuals, job descriptions, etc., and make recommendations for revisions to the Director of Nursing.
• Coordinate the completion of resident billable charge sheets in accordance with billing policies.

Duties and Responsibilities

• Carry out restorative and rehabilitative programs including restorative nursing, activities of daily living (ADLs)teaching, bowel and bladder retraining and education for self-help as appropriate.
• Provide pain management for residents in accordance with established pain management protocols.
• Complete accident/incident reports as necessary.
• Assist the interdisciplinary team (IDT)with establishing nutrition, hydration and body weight parameters for residents; help facilitate the responsibilities of the food and nutrition services department.
• Keep the Director of Nursing informed of the status of residents and other related matters through written/oral reports; document reportable events and notifications in accordance with facility policies.
• Cooperate with and coordinate social and activity programs with nursing services schedules.
• Periodically review the resident's written discharge plan; participate in updating the resident's written discharge plan as required.
• Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident including regular re-evaluation to identify changes that require modifications.
• Make periodic checks to ensure that Certified Nursing Assistants(CNAs)are properly administering prescribed treatments and to evaluate the resident's physical, psychosocial and emotional status.
• Report problem areas to the Director of Nursing; assist in developing and implementing corrective action.
• Arrange for diagnostic and therapeutic services as ordered by the physician and in accordance with established facility procedures.
• Provide information to the QAPI Committee as requested.
• Coordinate transfer or discharge of residents including arranging transportation, compiling the discharge summary, reconciling medication and reviewing upcoming appointments with resident in a language understood by the resident with the goal of a safe discharge.
• Ensure that discharged residents are escorted to the pick-up area.

Charting and Documentation Functions

• Complete and file required recordkeeping forms/charts upon the resident's admission, transfer and/or discharge; provide notifications to the ombudsman and responsible party per requirements.
• Document reports of accidents/incidents involving residents; follow established procedures.
• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.

Duties and Responsibilities

• Audit clinical record for appropriate consents and assessments including advance directives, living wills and other documents required for the delivery of person-centered care with respect to rights and choices.
• Record verbal and telephone orders from practitioners on order sheets or in electronic health record (EHR) per facility policies.

Medication Administration Functions

• Review the controlled substance and drug disposal records for accuracy and notify the Director of Nursing and pharmacy of discrepancies.
• Monitor medication administration process and provide appropriate feedback or changes to prevent medication errors.
• Ensure that the medication carts and medication rooms are clean, sanitary and well stocked
• Assess residents for appropriate self-administration of medication in coordination with the IDT.
• Reconcile medication delivery from pharmacy by verifying the medications, quantity and accuracy.
• Collaborate with the IDT to ensure the safe and appropriate use of medications for all residents.
• Administer medications in accordance with physician orders, regulations and facility policies.
• Support the objectives of the infection prevention and control program including antibiotic stewardship.
• Work with the IDT to review unnecessary medications and coordinate gradual dose reductions as appropriate.
• Reconcile resident medications (pre/post-discharge) as part of the discharge process.
• Order prescribed medications, supplies and equipment as necessary and in accordance with established facility policies.

Personnel Functions

• Meet with assigned nursing staff as well as support personnel in planning the shifts' services, programs and activities and to assist in identifying and correcting problem areas and/or improving delivery of person-centered care and services.
• Assist the Director of Nursing in directing the day-to-day functions of the nursing activities in accordance with current rules, regulations and guidelines that govern the facility.
• Direct the day-to-day functions of the CNAs in accordance with current rules, regulations and guidelines that govern the facility.
• Coordinate with the scheduler to ensure a Registered Nurse (RN) is on duty at least 8 hours a day/7 days a week and a Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN)is on duty 24 hours a day.

Duties and Responsibilities

• Ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity; this includes proper licensure or certification if required.
• Assess residents for conditions which may be aided by assistive or adaptive devices; recommend/request in accordance with facility policies; monitor for proper utilization and application of assistive devices.
• Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.
• Develop positive professional relationships with nursing students, teachers/professors and other visitors.
• Prepare and deliver nursing report at change of shift or in situations requiring a coordinated effort.
• Assist in the grievance process in coordination with the grievance officer; assist residents with filing grievances, investigating allegations and coordinating an appropriate response; respond to resident or family grievances in accordance with facility policies.
• Review complaints and grievances made or filed by your assigned personnel; make appropriate reports to the Charge Nurse/Nurse Supervisor as required or as necessary.

Staff Development Functions

• Collaborate with the Staff Development Coordinator for team member training, skill development and competencies in accordance with facility policies(e.g.,proper hand-washing techniques, proper operation of Hoyer lift or assistive device); educate in a manner or format understood by the team member.
• Assist in training department personnel.
• Assist the Director of Nursing in planning clinical supervision for nurse aide trainees, nursing students and newly hired nurses.
• Attend continuing education program or training as needed to provide competent nursing care; assist with coaching and training with nursing team members in unit/facility.

Safety and Sanitation Functions

• Ensure that all nursing services personnel comply with established departmental policies and procedures.
• Ensure that all personnel wear and/or use safety equipment and supplies (e.g., back brace, mechanical lifts, etc.) when lifting or moving residents in accordance with plan of care and facility policies; order and stock personal protective equipment (PPE)as necessary.
• Ensure that the resident environment remains as free of accent hazards as possible and that each resident receives adequate supervision and assistive devices to prevent accidents.
• Ensure that nursing services personnel follow established infection prevention and control procedures.

Equipment and Supply Functions

• Maintain list(s) of equipment repairs or needs required for resident care.
• Recommend to the Charge Nurse/Nurse Supervisor the equipment and supply needs of your unit/shift.
• Ensure that appropriate safety data sheets (SDSs)are on file for hazardous chemicals used in the nursing services department.
• Participate in the development and implementation of the procedures for the safe operation of all nursing services equipment.

Education

Must possess, as a minimum, a nursing degree from an accredited college or university, or be a graduate of an approved Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)program.

Experience

• Must have, as a minimum, one (1) year of experience as a supervisor in a hospital, nursing care facility, or other related health care facility.
• Must have training in rehabilitative and restorative nursing practices.

Specific Requirements

• Must possess a current unencumbered active license to practice as a Registered Nurse(RN)or LPN/LVN in the state.
• Must be able to read, write, speak and understand the English language.
• Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.
• Must be a supportive team member, contribute to and be an example of team work and team concept.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
• Must be knowledgeable of nursing and medical practices and procedures as well as laws, regulations and guidelines that pertain to nursing care facilities.
• Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
• Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures, etc., that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm as well as the willingness to handle difficult residents.
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
• Must be able to relate information concerning a resident's condition.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.