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:

1. Makes walking rounds at the beginning and end of shift while receiving and/or giving report.
2. Counts narcotics at beginning and end of shift, always initialing the count sheet appropriately ascertaining accuracy of count.
3. Performs fingersticks as ordered by MD scheduled during shift.
4. Administers all medications (oral, s.q., I.M., or I.V.) as ordered by M.D. and according to contracted Facility policies. May administer up to 60 minutes before or after time ordered. Also, administers (hangs) tube feeding as ordered by M.D.; starts I.V.’s as ordered.
5. Checks critical or “sick” patients frequently and documents findings, changes, etc. in Nurses Notes and notifies supervisor and/or M.D. as necessary.
6. 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.
7. Leads, guides, and supervises facility nursing assistants and orderlies.
8. Supervises care and treatments performed by facility nursing assistants and orderlies. (Example: Vital signs, ROM, ambulation, rehabilitative programs, etc.) Monitors documentation of care and treatments performed by nursing assistants and orderlies.
9. Completes incident reports and calls physician if needed.
10. Completes appropriate nursing documentation according to facility policies and procedures. .
11. Admits new patients, completing the following: Nurses Admission Record, Nurses Notes, status change slip, dietary requisition, taking off orders, and checking MAR’s.
12. Transfers and/or discharges patients when ordered by physician.
13. Assists physicians with rounds as needed.
14. Drapes, remains with and cares for patients during MD rounds, physical examinations, and treatments as necessary.
15. Notifies MD of any error administering medication should such occur.
16. Documents PRN medications and also the effectiveness or lack of effectiveness appropriately on PRN sheet.
17. Performs treatments scheduled during shift and documents appropriately.
18. Monitors specific skin tears and/or other skin conditions’ and documents at least weekly or more often if warranted.