Job Summary:The Registered Nurse is responsible for providing direct nursing care to the residents. Such care must be delivered 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 designee.

General Functions

• Make written and oral reports/recommendations concerning the patient care activities occurring on your shift as appropriate.
• Cooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.
• Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s discharge plan as appropriate.
• Assist in planning the nursing services portion of the resident’s discharge plan as appropriate.

Admit, transfer, and discharge residents as appropriate

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.

Nursing Care Functions

• Inform nursing 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 participate in the orientation of new residents/family members to the facility.
• Make rounds with physicians as appropriate.
• Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with established procedures.
• Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as appropriate.
• Cooperate with and coordinate social and activity programs with nursing service schedules.
• Notify the resident’s attending physician when the resident is involved in an accident or incident.
• Carry out restorative and rehabilitative programs, to include self-help and care.
• Administer services within the applicable scope of nursing practice
• Take and record TPRs, blood pressures, etc., as appropriate.
• Check foods 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 and Dietary Supervisor.
• Meet with residents, and/or family members as appropriate.
• Admit, transfer, and discharge residents as appropriate.
• Assist in arranging transportation for discharged residents as appropriate.

Drug Administration Functions

• 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.
• 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.

Charting and Documentation

• Receive and record telephone orders, and document the prescribed treatments on the reside
• nt charts, cardex, medication cards, and/or treatment/care plans as appropriate.
• Chart nurses’ notes in professional and appropriate manner that timely, accurately and thoroughly 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..
• Chart all changes in resident condition and the response to those changes.
• Chart all communications with the resident’s attending physician regarding the resident, the resident’s treatment, or the response to that treatment.
• Record new/changed diet orders and communicate information to the Dietary Department.
• 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 and applicable state and federal regulations.
• Sign and date all entries made in the resident’s medical record.

Education

Must possess, as a minimum, a Nursing Degree from an accredited college or university, or be a graduate of an approved LPN/LVN program.

Experience

None. On-the-job training provided.

Specific Requirements

• Must possess a current, unencumbered, active license to practice as an RN or LPN/LVN in this state.
• Must be able to read, write, speak, and understand the English language.
• 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 long-term 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 health.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.