Purpose:

To assure quality nursing care for patient by following physician’s orders, state and federal regulations and this Facility’s policies and procedures.

Essential Job Functions and Requirements:

Employee work shifts as scheduled. Must be willing to work other variable hours when necessary.

1. Assists in direction of nursing services for unit/hall, in accordance with the Nursing Practice Act, and under the supervision of a Registered Nurse.
2. Delegates duties to professional nurses and non-professional nursing personnel and monitoring work performance under the supervision of a Registered Nurse.
3. Makes walking rounds at the beginning and end of shift while receiving and/or giving report.
4. Counts narcotics at beginning and end of shift, always initializing the count sheet appropriately ascertaining accuracy of count.
5. Checks Bowel Movement/E care dashboards to compile a laxative and/or enema list.
6. Performs fingersticks scheduled, gives oral hypoglycemics and insulins per MD order.
7. Administers all medications (oral, s.q., I.M., IV (if properly trained)) as ordered by M.D. an according to Facility policies. May administer up to 60 minutes before or after time ordered. Also, administers (hangs) tube feeding as ordered by M.D. May start I.V.’s as ordered, but only if trained to do procedure.
8. Check critical or “sick” patients frequently and documents findings, changes, etc. in Nurses Notes and notifies supervisor and/or M.D. as necessary.
9. Observes patients for symptoms and/or reactions, including general physical and/or mental condition for signs, which may be indicative of adverse change. Reports these to supervisor and/or MD as necessary. Documents in nurses notes and places on charting list and calendar. Also notifies patient’s family as necessary of any significant change in patient’s condition.
10. Completes required documentation according to Documentation policies and procedures.
11. Completes incident reports and calls physician if needed.
12. Completes monthly summary for each patient following the summary schedule.
13. Admits new patients, completing the following: Nurses Admission Record, Nurses Notes, (as appropriate), status change slip, dietary requisition, taking off orders, and checking MAR’s.
14. Transfers and/or discharges patients when ordered by physician.
15. Assists physicians with rounds as needed.
16. Drapes, remains with and cares for patients during MD rounds, physical examinations, and treatments as necessary.
17. Notifies MD of any error in administering medication should such occur.
18. Documents PRN medications and also the effectiveness or lack of effectiveness appropriately on PRN sheet.
19. Performs treatments scheduled during shift and documents appropriately.
20. Monitors specific skin tears and/or other skin conditions and documents at least weekly or more often if warranted.
21. Assists with post-mortem care and provides emotional support for families as needed.
22. Cleans and restocks medication and treatment carts every shift.
23. Orders medications from pharmacy as needed, checks medications when received and places in medication carts, following Facility procedures. Counts, documents on return sheet, and returns medication to pharmacy as needed.
24. Obtains and signs for supplies as needed.
25. Completes requisitions for dietary requests and/or maintenance repairs as needed.
26. Obtains lab specimen ordered.
27. Maintains infection control measures as necessary.
28. Assists in ensuring availability of supplies and equipment. Assesses needs for additional equipment or repair and maintenance of current equipment.
29. Assists with Infection Control for unit/hall. Adheres to all regulations pertaining to cleanliness, infection control, and Universal Precautions.
30. Assists with research related to the quality of nursing care, as assigned.
31. Assists with records, orders, and assessment of new admissions unit/hall. Assists with assuring the initial Nursing Assessment is completed within 24 hours of admission and initiates Patient Care Plan.
32. Periodically reviews Care Plans and makes recommendations for change in care as needed.
33. Attends Quality Assurance meetings when assigned. Completes Quality Assurance monitors as assigned to unit/hall monthly and submits findings and averages at least two days prior to Quality Assurance meeting. Follows up when needed of concerns or problems found through Quality Assurance.
34. Assists with monitoring and measuring decubiti weekly and completing Integument Watch records accurately.
35. Serves on other committees as needed or assigned.
36. Works directly with other departments to implement needs for the unit/hall and needs of patients on the unit/hall.
37. Reports any possible performance issues by employees within the facility to the RN for determination if disciplinary action is required. May be asked by the RN to send an employee home for the remainder of the shift if the RN determines that further investigation is needed. May document the performance concern on the appropriate form for review and use by the RN in the disciplinary process.
38. Assists with lab requests as ordered per Facility policy using appropriate techniques. Responsible for reporting laboratory work as ordered on unit, reviewing results, and notifying attending physician when deemed necessary.
39. Assists with emergencies arising while on duty. Performs CPR if needed. Assists with emergencies on other units if needed.
40. Assists with notifying attending physician of emergencies and death of patients in the unit. Implements orders of changes in orders as instructed or ordered by physicians.
41. Performs other duties as assigned.