Description:
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 current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times.
Requirements:
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 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.
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.
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.