RN

Job Description

Job Description:\n\nDay Shift 7a-7p Purpose of Your Job Position 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 the Florida Nurse Practice Act current federal, state & local standards, guidelines, and regulations that govern our facility, and as may be directed by the Director of Nursing or Nurse Supervisor/Unit Manager to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority As a Registered Nurse/ Floor Nurse, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Job Functions 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. Duties and Responsibilities Administrative Functions Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulation, 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. Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual. Participate and cooperate in facility surveys (inspections) by local, state and federal governmental agencies. Admit, transfer, and discharge residents in accordance with facility protocols, as required. Make written and oral reports/recommendations concerning the activities of your shift as required. Cooperate with other resident services/departments when coordinating nursing services to ensure that the resident's total regimen of care is maintained. Participate in facility surveys (inspections) made by authorized government agencies as may be required Periodically review the resident's written discharge plan. Participate in updating the resident's written discharge plan as required. Assist in planning the nursing service portion of the resident's discharge plan as necessary. Complete accident/incident reports as necessary. Submit to the Director of Nursing or designee. Charting and Documentation Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge. Receive telephone orders from physicians and record in the EMR system. Transcribe physician's orders to resident charts, card-ex, medication cards, treatment care plans in electronic format or paper 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. Chart all reports of accidents/incidents involving residents. Follow established procedures. Record new/changed diet orders. Forward information to the Dietary Department. Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor/Unit Manager. 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. Drug Administration Functions Prepare and administer medications as ordered by the physician in accordance with federal, state and local laws and regulations and facility policy. 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 need to the Nurse Supervisor/Unit Manager. Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies. Ensure that narcotics are handled in accordance with federal, state and local laws and facility policies. Ensure that narcotic’s records are accurate for you shift. Notify the Nurse Supervisor/Unit Manager 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/Unit Manager 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/Unit Manager. Develop work assignments, and/or assist in completing and performing such assignments. Monitor Nursing Assistants to ensure that care and services are being provided to residents in accordance with the resident’s plan of care. Report problem areas to the Nurse Supervisor/Unit Manager. Develop and maintain a good working rapport with inter-department 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/Unit Manager as required or as may be necessary. Follow facility's established procedures. Receive/give the nursing report upon reporting in and ending shift duty hours. Report occupational exposures to blood, body fluid, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures governing accident and incidents. Nursing Care Functions Inform nursing service 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 and escort them lo their rooms as necessary. Conduct and document a thorough assessment of each patient's medical status upon admission and throughout the patient's course of treatment. 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 physicians 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 checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status. Ensure that direct nursing care is provided in accordance with the resident’s plan of care and wishes. Notify the resident's attending physician 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. Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, range of motion exercises, and care for the dead/dying, etc., as required. Use restraints only when prescribed and in accordance with established policies and procedures. Obtain sputum, urine and other specimens for Jab tests as ordered. Take and record TPRs, blood pressures, etc., as necessary. Monitor seriously ill residents as necessary. Check 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 Nurse Supervisor/Unit Manager and Dietary Supervisor. Promptly respond to call bells. Promptly and courteously respond to requests for assistance from residents, staff, resident family members and visitors Ensure that residents who are unable to call for help are checked frequently. Meet with residents, and/or family members, as necessary. Report problems to the Nurse Supervisor/Unit Manager. Admit, transfer and discharge residents as necessary. Assist in arranging transportation of discharged residents as necessary. Ensure that discharged residents are escorted to the pick-up area. Inform family members of the death of the resident. Call funeral homes when requested by the family. Ensure that established post-mortem procedures are followed. Act in compliance with established regulatory and professional standards and guidelines. Staff Development Attend and participate in all facility in-service trainings/programs, as required. Attend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and blood borne pathogens standards. Attend and participate in advance directive in-service training program for the staff and community. Attend 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. Safety and Sanitation Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies. Ensure that established departmental policies and procedures are followed by self and assigned personnel. Ensure that your assigned work areas (i.e., nurses' stations, medicine preparations rooms, etc.) are maintained in a clean and sanitary manner. Ensure that your unit's resident rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner. Ensure that you and your assigned personnel follow established safety polices and procedures. Ensure that you and your assigned personnel follow established hand-washing procedures. Ensure that you and your assigned personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner. Ensure that you and your assigned personnel follow established infection control procedures when isolation precautions become necessary. Ensure that you and your assigned personnel follow established infection control procedures. Ensure that you and your assigned personnel wear and/or use safety equipment and supplies (e.g., gait belts mechanical lifts, etc.) when moving or lifting a resident. Report missing/illegible labels and MSDSs to the safety officer or other designated person. Equipment and Supply Functions Recommend to the Nurse Supervisor/Unit Manager the equipment and supply needs of your unit/shift. Ensure that an adequate stock level of medications, medical supplies, equipment, etc. is maintained on your shift at all times to adequately meet the need of the resident. Ensure that only trained and authorized personnel operate your unit/shift's equipment. Ensure that all personnel operate nursing service equipment in a safe manner. Care Plan and Assessment Functions Review care plans daily to ensure that appropriate care is being rendered. Inform the Nurse Supervisor/Unit Manager of any changes that need to be made on the care plan. Ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. Ensure that your assigned Licensed Practical Nurses (LPN) and certified nursing assistants (CNAs) are aware of the resident care plans and carry out the resident's care plan. Assist the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising the MDS, including the implementation of RAPs and Triggers, as directed. Resident Rights Maintain the confidentiality of all resident care information. Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect. Ensure that all nursing care is provided in privacy and that nursing service personnel knock before entering the resident's room. Ensure that all nursing service personnel are knowledgeable of resident rights and responsibilities, including the right to refuse treatment. Review complaints or grievances made by the resident and make a written/oral report to the Nurse Supervisor/Unit Manager indicating what action(s) were taken to resolve the complaint or grievance. Follow facility's established procedures. Maintain a written record of the resident's complaints and/or grievances that indicates the action to resolve the complaint and the current status of the complaint. Report all allegations of resident abuse and/or misappropriation of resident property. Honor the resident's refusal of treatment request. Ensure that such requests are in accordance with the facility's policies governing advance directives. Miscellaneous Adhere to facility and departmental policies and procedures. Other duties as assigned. Working Conditions7p-7a shift - will require a rolling two-week schedule that will include every other weekend. Works throughout the nursing service area (i.e., drug rooms, nurses' stations, resident rooms, etc.), as well as other parts of the facility. Moves intermittently during work hours. ls subject to frequen