SUMMARY

Under the general supervision of the Director of Nursing, the Registered Nurse performs a variety of resident care functions and closely observes residents for changes in medical status. This position also uses independent judgment and discretion in maintaining the delivery of quality resident care by assuring that the nursing and medical care plan is followed, and makes supervisory decisions. In the absence of the Director of Nursing, this position assumes full responsibility for the resident care.

ESSENTIAL RESPONSIBILITIES AND JOB FUNCTIONS

Nursing Care: Administers nursing care as indicated by the nursing care plan and in compliance with all Regulatory Agencies.

Administration of Resident Care: Demonstrates ability to provide appropriate and quality nursing care to residents, including but not limited to:

(1) Reviews all resident histories to determine course of illness and all co morbidities for integration into the care plan.

(2) Demonstrating the ability to assign meaning to resident symptoms and initiating appropriate action.

(3) Ensuring that problems/concerns regarding activities in the facility/department are communicated appropriately.

(4) Effectively assessing, planning, implementing, and evaluating nursing care for residents.

(5) Educating residents, families and significant others regarding treatment, tests, special procedures, medications and safety.

(6) Consistently monitoring resident condition and initiates appropriate nursing intervention.

(7) Initiating and conducting emergency measures (including CPR) required to stabilize patient's condition.

(8) Prioritizing residents’ needs, expediting treatment for acutely ill residents to include CPR.

(9) Consistently documenting resident care and reports pertinent clinical observations and reactions to the appropriate individual.

(10) Actively participating in development and assessment of resident care issues as they relate to. Performance Improvement activities for the department.

Resident Plan of Care: Initiates the plan of care within 24 hrs. of admission and consistently updates care plan with changes in resident needs/condition.

Resident Admission Assessments: Performs and accurately documents the resident admission assessment, completing within 24 hours of admission.

Resident Re-assessments: Consistently and accurately performs reassessments during each shift and when the resident condition changes.

Other Resident Assessments: Completes other assessment tools as defined in policy when appropriate (i.e. pain assessment, pressure ulcer protocol, fall assessments etc).

Resident Medications: Demonstrates ability to provide appropriate nursing medication management including, but not limited to:

(1) Administering medications as ordered by physician using age specific monitors.

(2) Ensuring medications are ordered, received and transcribed on a routine basis and in a timely manner.

(3) Appropriately transcribing, administering and documenting medications according to policy and procedures and age specific considerations.

(4) Monitoring and removing any discontinued or expired medications from medication carts.

(5) Maintaining a current, accurate listing of all resident medications.

(6) Demonstrating knowledge and ability to intercede in repetitive prescriptions or contradictory medications.

(7) Reordering emergency medications from emergency box (e-kit) as needed.

(8) Completing appropriate forms and returning unused medication to the pharmacy in a timely manner.

IV Therapy: Appropriately and safely administers IV therapy and documents according to policy and procedure.

Team Conferences: Participates in interdisciplinary team conferences and relays treatment plan decisions to the other members of the nursing team.

Reporting/Triaging Abnormal Test Results: Reports all abnormal test results to physician in a timely manner; triages activities based on borderline and/or abnormal and/or unusual findings.

Age Specific Special Needs: Demonstrates ability to understand and react effectively to unique/special needs of adults, and/or elderly residents.

Triaging Resident Complaints: Initiates approved regimes of care as established by policy. Reports all findings to physicians. Assures proper follow-up resolution of resident clinical complaints.

Leadership Skills: Demonstrates leadership, communication and teaching skills.

Education Resources for Staff: Serves as an education resource for staff, sharing information in an accurate, cooperative and professional manner.

Infection Control and Isolation Techniques: Practices appropriate infection control and isolation techniques to maintain a safe environment and control the spread of infection.

Progress Notes: Writes and reviews progress notes according to policy and procedures.

Documentation: Demonstrates ability to appropriately document resident care, including but not limited to:

(1) Appropriately transcribing, administering, and documenting medications according to P&P and age specific considerations.

(2) Documenting nursing interventions and resident responses including physical and psychological response.

(3) Documenting resident needs, problem capabilities, limitations and progress.

(4) Ensuring documentation is legible and neat and that records are appropriately signed (i.e., first initial, last name, title, and date).

(5) Documenting any teaching done with resident family and/or significant other.

(6) Ensuring accuracy regarding transcribing of physician orders.

(7) Ensuring appropriate documentation regarding resident response to medications.

Charting Forms: Utilizes the appropriate charting forms and documents appropriately and legibly using charting by exception.

Performance Improvement: Participates in performance improvement activities. (i.e. – Infection Control Surveillance; weights loss/gain; diabetic management and pressure ulcer management.

Resident Care Information: Exchanges and communicates resident care information with interdisciplinary team.

Clarity: Demonstrates an understanding of the legal implications of clarity.

Audits: Corrects audit deficiencies of medical record within allotted time frames.

Contacting DON/Administrator: Follows guidelines regarding contacting administrator and DON regarding real or potential abuse situations.

Responsibilities during Director of Nursing Absence: Assumes responsibilities for operations of the unit and personnel in the absence of the Director of Nursing.

Emergencies: Initiates emergency measures in event of disaster or threat to the facility as per emergency plans and protocols.

Input from Director of Nursing: Seeks the assistance of the Director of Nursing regarding areas of concern or conflicts with families, co-workers or residents in a professional proactive and courteous manner.

Participation in unit based data collection for Q.I ( Quality Improvement )

Resident Advocate: Demonstrates ability to serve as a resident advocate; demonstrates compassion and empathy with residents and their families.

This position serves as a member of the overall facility treatment team and as such is required to maintain a positive attitude towards all team members and residents. This position must function as a role model for LVN’s and CNAs as well as other team members. In addition, this position must function as a positive supporter of the facility policies and procedures at all times following the lead of the management team, administrative team and the facility administrator.

Other Duties: Seeks out additional duties during slow periods and/or assists others in completion of duties.

Assignment of Other Duties: Performs other duties as assigned.

EDUCATION/EXPERIENCE

To perform this job successfully, an individual must be able to fulfill each essential duty with a strong degree of professionalism. This position requires a detail-oriented professional with excellent communication skills. The requirements listed below are representative of the knowledge, skill and/or ability required.

· Minimum of H.S. degree or equivalent.

· Long-Term care experience preferably in a skilled nursing setting.

· Current Licensure as a Registered Nurse by the State of California.

· Must be certified in CPR.

· IV certification.

· Must maintain current licensure in good standing during employment with this facility in accordance to the State Board.

LANGUAGE/REASONING AND INTERPERSONAL SKILLS

· Must possess ability to speak, read and write English effectively.

· Must possess emotional maturity, reliability, tact, integrity, and good judgment.

· Must possess an understanding of facility’s goals and philosophy.

· Must possess good problem solving skills with ability to plan, organize, and execute work activities independently.

· Must possess ability to interact effectively with team members, residents, families and visitors.

· Must possess knowledge of accreditation and licensing standards as they apply to resident care and safety.

PHYSICAL DEMANDS/WORK ENVIRONMENT

The demands and environment described here are representative of those that must be met by an employee to successfully perform the functions of this job, Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

· The physical demands and work environment described herein is representative of those that generally must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

· Work primarily involves standing, walking, twisting, reaching, bending/stooping, pushing/pulling, and carrying/lifting potentially up to 40 lbs. or more occasionally, up to 25 lbs. or more frequently, and up to 10 lbs. or more regularly.

· This position requires using arm, leg and back muscles frequently and for extended periods of time, and also involves using both hands and legs regularly.

· Vision abilities required by this job includes good vision and depth perception, both near and far as well as ability to distinguish basic shades and colors.

· The noise level in the facility work environment is usually moderately quiet; however, at times, due to the nature of clients treated at this facility, occasional loud outbursts by residents may be expected.

· The employee is required to hear within normal range and at a conversation level.

· The employee is required to have the ability to express or exchange ideas frequently and the ability to understand communication of others with or without adaptive devices.

· This position requires performing simple repetitive tasks regularly and performing complex or varied tasks often.

· This position requires that employee have the ability to make generalizations, evaluations or decisions using independent judgment without immediate supervision.

· This position requires the employee to occasionally work with hands in water and with or near chemicals.

· This position requires the employee to regularly work with equipment with moveable parts.

· This position does not require: use of hand tools, working with ladders/scaffolding, working below ground.

· This position requires the employee to work 8 hours per day up to five days per week. Additional hours may be requested by the employer based upon staffing need

· This position may require the use of a computer for up to 6 - 8 hours in a day

EXPOSURE/INFECTION CONTROL:

This position has a Personnel Exposure Risk Index rating of “High” for potential exposure to blood borne pathogens. See facility Exposure Control Plan for more information on the Personnel Exposure Risk Index along with identified personal protective equipment required to be worn by employees with a “High” rating for potential exposure.

In addition, this position requires that employee:

· Must be knowledgeable of and practice infection control techniques and standard (Universal) precautions at all times.

· Must obtain a tuberculosis test at the time of hire and on an annual basis thereafter.