Registered Nurse

Job Description

Job Description:\n\nEmbassy Healthcare\n \n JOB DESCRIPTION\n \nPOSITION TITLE: RN EFFECTIVE DATE:\n \nDEPARTMENT: Nursing \n \nREPORTS TO: Director of Nursing STATUS: Hourly\n \nDEPARTMENT HEAD APPROVAL_______________________________DATE_________\n \nHUMAN RESOURCE APPROVAL________________________________DATE_________\n \n \n \nPURPOSE OF YOUR JOB POSITION:\n \nThe primary purpose of your job position is to provide direct nursing care to the residents, and to \nsupervise 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.\n \n \nDELEGATION OF AUTHORITY:\n \nAs RN you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties with the RN scope of practice defined by the Ohio Nurse Practice Act/ ORC Chapter 4723.\n \n \nESSENTIAL JOB FUNCTIONS SATEMENT:\n \nEvery 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.\n \n \nSAFETY FACTORS:\n \nRisk Potential to Blood/Body Fluids:\n* Category I: Tasks in this category involve exposure to blood, body fluids, or tissues, and require the use of personal protective equipment.\nCategory II: Tasks in this category involve no exposure to blood, body fluids, and/or tissues, but employment may require performing unplanned category I tasks.\nCategory III: these tasks require no exposure to blood, body fluids, and/or tissues, and category I tasks are not a condition of employment.\n \n \nESSENTIAL JOB FUNCTIONS & RESPONSIBILITIES\n \nAdministrative Functions\n\nDirect 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.\nEnsure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.\nPeriodically review the department’s and unit’s policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.\nMeet with your assigned nursing staff, as well as support personnel, in planning the shift’s services, programs, and activities.\nEnsure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed on the unit.\nEnsure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual.\nMake written and oral reports/recommendations concerning the activities of your unit as required to the Director of Nursing.\nCooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.\nEnsure that all nursing service personnel are in compliance with their respective job descriptions.\nParticipate in the development, maintenance, and implementation of the facility’s quality assurance program of the nursing service department.\nParticipate in facility surveys (inspections) made by authorized government agencies as may be requested.\nPrepare the unit for pending facility surveys (inspections) \nPeriodically review the resident’s written discharge plans. Participate in the updating of the resident’s written discharge plans as required.\nAssist in planning the nursing services portion of the resident’s discharge plan as necessary.\nParticipate in weekly care conferences conducted by the physiatrist.\nInterpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.\nAdmit, transfer, and discharge residents as required\nEnsure accuracy of the accident/incident reports as necessary.\nPerform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.\n\n \n \nCharting and Documentation\n\nComplete 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.\nReview 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.\nEncourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.\nReview physician order process to ensure accuracy.\nTranscribe physician’s orders to resident charts, cardex, medication cards, treatment/care plans based on findings of daily audits.\nReview nurse’s notes to ensure they are written according to facility charting guidelines.\nChart all reports of accidents/incidents involving residents. Follow established procedures.\nReport all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Director of Nursing.\nFill out and complete transfer forms in accordance with established procedures.\nEnsure that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.\nPerform routine charting duties as required and in accordance with established charting and documentation policies and procedures.\nSign and date all entries made in the resident’s medical record.\n\n \n \nDrug Administration Functions\n\nEnsure unit staff prepare and administer medications as ordered by the physician.\nEnsure 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.\nOrder prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.\nEnsure that narcotic records are accurate for the unit.\nNotify the Director of Nursing of all drug and narcotic discrepancies noted on the unit.\nReview medication records for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.\nNotify the attending physician of automatic stop orders prior to the last dosage being administered.\nDispose of drugs and narcotics as required, and in accordance with established procedures.\n\n \n \nPersonnel Functions\n\nParticipate in employee performance evaluations, determining your units staffing requirements, and making recommendations to the Director of Nursing concerning employee dismissals, transfers, etc.\nInform the Director of Nursing of staffing needs when assigned personnel fail to report to work.\nReport absentee call-ins to the Director of Nursing\nReview and evaluate your department’s work force and make recommendations to the Nurse Supervisor.\nDevelop work assignments and/or assist in completing and performing such assignments.\nProvide leadership to nursing personnel assigned to your unit.\nMake 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.\nEnsure that all nurse aide trainees are under the direct supervision of a licensed nurse.\nMeet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services.\nEnsure that unit personnel, residents, and visitors follow the department’s established policies and procedures at all times.\nDevelop 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.\nCreate and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit.\nReview 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.\nEnsure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.\nReceive/give the nursing report for the unit upon reporting in and ending duty hours.\nReport occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility’s policies and procedures governing accidents and incidents.\n\n \n \nNursing Care Functions\n\nInform nursing personnel of new admissions, their expected time of arrival, room assignment, etc.\nEnsure that rooms are ready for new admissions.\nParticipate in the orientation of new residents/family members to the facility.\nMake rounds with physicians as necessary.\nRequest and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.\nConsult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.\nReview the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.\nImplement and maintain established nursing objectives and standards in accordance with the plan of care.\nMake 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.\nCooperate with and coordinate social and activity programs with nursing service schedules.\nNotify the resident’s attending physicians when the resident is involved in an accident or incident.\nNotify the resident’s attending physician and next-of-kin when there is a change in the resident’s condition.\nCarry out restorative and rehabilitative programs, to include self-help and care.\nInspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.\nAdminister professional services such as; catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required.\nUse restraints when necessary and in accordance with established policies and procedures in accordance with the plan of care.\nEnsure sputum, urine and other specimens for lab tests are obtained as ordered.\nTake and record TPRs, blood pressures, etc., as necessary.\nMonitor seriously ill residents as necessary.\nCheck food brought into the facility by the resident’s family/visitors to ensure that it is within the resident’s dietary allowances. Report problem areas to the director of Nursing and Dietary Supervisor.\nEnsure that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.\nEnsure that residents who are unable to call for help are checked frequently.\nMeet with residents, and/or family members, as necessary. Report problem areas to the Director of Nursing.\nAdmit, transfer and discharge residents as necessary.\nAssist in arranging transportation for discharged residents as necessary.\nEnsure that discharged residents are escorted to the pick-up area.\nInform family members of the death of the resident.\nCall funeral homes when requested by the family. Ensure that established post-mortem procedures are followed.\n\n \n \nStaff Development\n\nParticipate in developing, planning, conducting, and in-service training classes that provide instructions on “how to do the job,” and ensure a well-educated nursing service department.\nImplement and maintain an effective orientation program that orients the new employee to your shift, its policies and procedures, and to his/her job position and duties.\nAssist in standardizing the methods in which work will be accomplished.\nAssist in training department personnel in identifying tasks that involve potential exposure to blood/body fluids.\nAttend and participate in outside training programs.\nAttend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and blood borne pathogens standard.\nAttend and participate in advance directive in-service training programs for the staff and community.\nAttend and participate in continuing education programs designed to keep you abreast of changes in your profession, as well as to maintain your license on a current status.\n\n \n \nSafety and Sanitation\n\nMonitor the unit personnel to ensure that they are following established safety regulations in the use of equipment and supplies.\nEnsure that established departmental policies and procedures, including dress codes, are followed by all unit personnel.\nAssist the Director and/or Infection Control Coordinator in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks in which there is potential exposure to blood/body fluids are properly identified and recorded.\nEnsure that all personnel performing tasks that involve potential exposure of blood/body fluids participate in appropriate in-service training programs prior to performing such tasks.\nEnsure that an adequate supply of personal protective equipment are on hand and are readily available to personnel who perform procedures that involve exposure to blood/body fluids.\nEnsure that your assigned work areas (i.e., nurse’s stations, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner.