Overview

General Statement of Job

This position provides paraprofessional nursing care and treatment for residents of the Edward J. Healey Rehabilitation and Nursing Center, including long term care residents, rehabilitation residents, complex care residents and terminally ill persons This position assists persons in achieving highest physical, mental, and psychosocial level of functioning. Performs duties in accordance with established regulations, policies, nursing standards, and medical instructions.

Responsibilities

Essential Functions:

Performs data collection related to the needs of the resident through skillful interviewing and observation.

Interviews the resident and transcribes their history and immediate nursing needs, and short-term goals are established and documented.

Documents data collection of the body system review of new admissions.

Implements the interim plan of care with the supervision of a registered nurse

Assists the RN as needed in completing process (e.g., data collection, documentation, completion of MDS on computer, participating in meeting).

Ensures that the resident attends activities.

Administers medications and treatment per MD’s orders and documents same.

Follows policy and procedures of the facility (e.g., IV administration,).

Transcribes physicians’ orders for medications and treatment and notes the correct times, dosage, route, start and stop dates. Receives telephone orders; reads back the order and documents that the order was read back. Ensures that orders for medications, treatments or tests have appropriate accompanying diagnosis. Clarifies and carries out the physician’s orders. Records the order on the MARS, TARS, lab book, appointment book, etc. as needed.

Ensures medication orders are within the formulary guideline and when needed, requests changes to stay within the formulary. When needed, begins the special authorization process for specific medications.

Forward order to pharmacy by fax. When orders are needed immediately, telephone to inform pharmacy to send medications stat.

Completes behavior monitoring forms as needed.

Observes the residents for effectiveness and for any side effects from medications and treatments.

Checks, administers, and documents controlled substances and reconciles count with the outgoing and incoming shifts.

Identifies and documents resident problems, symptoms or behavioral changes and notifies supervisor, physician and families as needed.

Observes and documents pressure ulcers weekly.

Completes the plan process according to the established schedule.

Participates in completion of the resident roster; notes condition of the resident monthly.

Charts vital signs, intakes, and outputs, weights, pain, etc.

Completes reports when there is an unusual occurrence and documents a description of what was seen in the nurses’ notes.

Monitors the weight book.

Supervises the care given to the residents by the CNA’s.

Involves the resident and/or family in developing the care plan.

Collects data to determine the resident’s progress towards achieving care plan goals.

Acts as liaison between the resident/family and the physician; acts as educator for the resident/family and staff and documents same.

Investigates problems or concerns reported by the resident/family or staff.

Ensures proper functioning of emergency equipment (e.g., crash cart, emergency medications, suction machine, oxygen).

Gives input into performance evaluations for the CNA’s.

Diffuses problem situations between staff, residents and family.

Participates effectively in department meetings.

Emergency duty may be required of the incumbent that includes working in Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.

Qualifications

Education:

Vocational/technical course study resulting in Licensed Practical Nurse registration by the State required.

Experience:

One (1) year experience preferred.

Certification:

Basic Life Support (BLS) certification from American Heart Association required.

Licensure:

State of Florida, Department of Health Licensed Practical Nurse required.