Duties and Responsibilities

Administrative Functions

1. Supervise & 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.

2. Ensure that all written policies and procedures that govern the day to day functions of the nursing service department are followed.

3. Ensure that the Nursing Service Procedures Manual is followed in rendering nursing care.

4. Cooperate with other IDT personnel when coordinating nursing services to ensure that the resident's total regimen of care is maintained.

5. Ensure that all nursing service personnel are following their respective job descriptions.

6. Perform administrative duties such as completing medical forms, reports, evaluations, charting, etc., as necessary.

7. Participate in surveys (inspections) made by authorized government agencies.

8. Make written and oral reports\recommendations concerning the activities of your shift as required.

9. Meet with your assigned CNA's, as well as IDT members, in planning the shifts services, programs, and activities.

10. Admit, transfer, and discharge residents as required.

11. Complete accident or incident reports as necessary.

12. Maintain the Daily Census Report and submit to Administration as required.

13. Inform the Charge Nurse of staffing needs when assigned personnel fail to report to work.

14. Develop work assignments, and/or assist in completing and performing such tasks.

15. Report absentee call ins to the Charge Nurse.

16. Make daily rounds of your unit to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem are as to the Charge Nurse.

17. Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the Charge Nurse as required or as may be necessary.

• Provide supervision and leadership to nursing personnel assigned to your unit or shift.

Charting and Documentation

1. Fill out and complete accident or incident reports. Submit to Director as required.

2. Chart all accidents or incidents involving the resident. Follow established procedures.

3. Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.

4. Chart nurses' notes in an informative and objective manner that reflects the care provided to the resident, as well as the resident's response to the care.

5. Complete and file required record keeping forms or charts upon the resident's admission, transfer, and/or discharge.

6. Receive telephone orders from physicians and record on the Physicians' Order Sheet.

7. Record new or changed diet orders. Forward information to the Dietary Department.

8. Transcribe physician's orders to resident charts, medications records, treatment or care plans, as required.

9. Assure that appropriate documentation concerning unauthorized discharges is entered in the resident's medical record in accordance with established procedures.

10. Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Charge Nurse.

11. Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures.

12. Sign and date all entries made in the resident's medical record.

13. Fill out and complete Transfer Forms in accordance with our established procedures.

Drug Administration Functions

1. Prepare and administer medications as ordered by the physician.

2. Assure that prescribed medication for one resident is not administered to another.

3. Verify the identity of the resident before administering the medication or treatment.

4. Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies.

5. Dispose of drugs and narcotics as required, and in accordance with our established procedures.

6. Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hand to meet the nursing needs of the residents. Report needs to the Charge Nurse.

7. Notify the attending physician of automatic stop orders prior to the last dosage being administered.

8. Review medication records for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies.

• Notify the Charge Nurse of all drug and narcotic discrepancies noted on your shift.

Resident Care Functions

1. Review care plans monthly, and as needed should a significant change occur, to ensure that appropriate care is being rendered.

2. Inform the Care Plan Coordinator of any changes that need to be made on the care plan.

3. Ensure that your nurses' notes reflect that the care plan is being followed.

4. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.

5. Ensure that your assigned CNA's are aware of and use the resident care plans in administering care to the resident.

Working Conditions and Qualifications

Be involved with residents, personnel, visitors, government agencies & personnel, etc. Be subject to hostile and emotionally upset residents, family members, etc. Must have patience, tact, cheerful disposition and enthusiasm, as well as be willing to handle residents based on whatever maturity level in which they are currently functioning. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the department.

Education

Must be, as a minimum, a graduate of an approved RN or LPN program and licensed.

Experience

None. On the job training provided.