Interim HealthCare: Licensed Vocational Nurse, Lvn - Shift Care

DEPARTMENT: Nursing FLSA STATUS : Non-exempt SUPERVISOR: Director of Nursing AREA OF SUPERVISION : LPN/ Nurse assistants/Nurse Aides/Restorative Aide ## DUTIES AND RESPONSIBILITIES Responsible for performing a variety of duty work flow quality nursing care to residents and to coordinate total nursing care for residents; implementing specific procedures and programs; participating with the Director of Nursing in establishing specific goals; determining work procedures and expediting work flow; insuring compliance with all operating policies and procedures and State and Federal regulations; communicating with and supervising appropriate personnel; providing daily reports and other periodic reports. ESSENTAIL FUNCTIONS: 1. Is knowledgeable of resident rights and ensures an atmosphere which allows for the privacy, dignity, and well-being of all residents in a safe, secure environment. 2. Supports, cooperates with, and implements specific procedures and programs for: - Safety, including universal precautions and safe work, practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repairs and maintenance needs. - Confidentiality of all data, including resident, employee, and operations data. - Quality Assurance and compliance with all regulatory requirements. - Compliance with current law and policy to provide a work environment free from sexual harassment and all illegal and discriminatory behavior. 1. Supports and participates in common teamwork: - Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction, including appropriate judgment. - Uses tactful, appropriate communications in sensitive and emotional situations. - Follows up as appropriate with supervisor, co-workers or residents regarding reported complaints, problems, and concerns. - Promotes positive public relations with residents, family members and guests. - Completes requirements for in-service training, acceptable attendance, uniform, and dress codes including personal hygiene, and other work duties as assigned. 1. Perform, various duties to provide quality nursing care to residents to maintain or attain the highest practical level of functioning and to coordinate total nursing care for the residents as illustrated by the following: - Assess residents and analyze obtained information to develop appropriate interventions to prevent decline; record signs of change in condition; notify appropriate staff per facility protocol to evaluate weight loss, decline in ambulation, development of skin breakdown, etc.; observe condition which indicate possible need for restorative nursing programs and then notify appropriate staff per facility protocol of the need for evaluation; inform the physician of changes in assessment when appropriate. - Participate in the MDS process as assigned with the assessments, such as falls, braden, urinary continence, and AIMS. Assist with completion of the MDS and CAAs as requested. - Administer medications and treatments to residents; monitor administration of intravenous fluids; place orders for medication from the pharmacy. - Assess residents upon admission to develop interim care plan and further assess in depth to contribute to the complete care plan. Update care plans as warranted and required. Attend and participate at Plan of Care meetings as scheduled. - Respond to emergencies; assess the condition of the resident; decide on the type of medical attention; notify the physician when a change in condition occurs; call appropriate ambulance service i needed; notify family when resident is transferred or admitted to the hospital or change in condition. - Confer with residents and families; make referrals to other departments when appropriate. - Maintain resident clinical files; keep charts updated; document appropriately; Documentation requirements include but are not limited to: - Changes in medical and physical condition - Response to antibiotic therapy - Report of weight loss or gain and response to change. - Complete accurate, and timely physician's information - Report of PEG tube potency - Report of adverse reactions to medication - Report of unusual behaviors - Report of pressure ulcer condition and weekly response to treatment. - Complete employee and resident incident report forms; complete follow-up investigation forms. - Make rounds to see each resident daily and as needed. - Ensure that residents are aware of the services that are available to them; encourage residents to participate in activities program and provide staff support to enable residents to get to and from and participate in activities. - Maintain accountability for controlled substances; inventory medications at the beginning and end of the shift with another licensed nurse; notify supervisor of discrepancies. - Support the facility's medical supply system; follow procedures for resident charge items - Communicate status of residents to incoming personnel according to established procedures; communicate with physicians; transcribe, clarify, and implement physicians' orders. 1. Supervise the certified nursing assistants and determine work procedures, prepare work schedules, expedite workflow, evaluate, counsel and discipline. 2. Ensures that certified nursing assistants and all supervised personnel adhere to standard job requirements. 3. Perform all duties of the LPN as needed. 4. Ability to use the computer to document care, such as eMAR, eTAR, physician orders, activities of daily living and other areas as instructed. 5. Performs related duties as assigned or as the situation dictates.