Description

General Description: Responsible for the supervision and provision of all nursing care activities on his/her unit during each shift. Organizes and assigns resident care workload based on the acuity of the resident, number of available personnel, and capabilities of personnel.

Duties and Responsibilities: include the following. Other duties may be assigned.

• Supervises, evaluates, and ensures that resident needs are met in accordance with the regulations of the Texas Department of Aging and Disability Services, instructions of the primary physician, and Holly Hall administrative policies and procedures.

• Makes rounds on all assigned residents on a daily basis and is familiar with residents' physical and emotional needs/concerns. Makes specific resident assignments for CMAs and CNAs, to include meal times and special duties. Supervises and ensures that CMAs and CNAs are rendering appropriate care in a timely manner according to the resident’s individualized plan of care.

• Recognizes both subtle and significant changes in a resident’s condition and takes prompt, appropriate action. Documents resident changes and nursing interventions in the nursing record. Notifies RN Supervisor, ADNS, and/or DNS of any significant resident changes, incidents, or deaths. Documents in the resident’s record at intervals to clearly reflect the progress, decline, and condition of the resident at all times.

• Notifies the primary care physician of any changes in resident condition and documents notification in resident record. Records all verbal and telephone orders on the physician order sheet according to established practice. Transcribes all physician orders according to established practice and implements orders within the designated time frame. Notifies the laboratory, dining services, and/or pharmacy of any new orders or changes in existing orders. Communicates changes in resident status to oncoming nurse at change of shift report and to DNS on the 24 Hour Report Form.

• Ensures that all medications are administered according to physician order and facility policy and procedure. Administers or supervises the preparation and administration of prescribed medications. Orders new medications and/or refills as needed per facility protocol. Gives all initial doses of medication and observes for side effects if noted, takes appropriate action and documents all relevant information in the resident’s record. Supervises CMAs and is aware of limitations and capabilities. Assists CMAs with decision-making and problem-solving as needed. Notifies RN Supervisor, ADNS, or DNS of any medication discrepancies immediately to facilitate prompt resolution.

• Ensures that all treatments are completed and documented as prescribed by the physician.

• Serves as a role model to other nursing personnel through visible compliance with all facility policies and procedures and ensures that personnel under his/her direct supervision are also in compliance. Notifies RN Supervisor, ADNS, or DNS of repeated employee non-compliance with facility policies and procedures.

• Responds to residents, family members, physicians, nurse practitioners, and others in a professional and courteous manner. Works cooperatively with other departments to resolve problems and minimize disruptions. Assists in resolving resident complaints and concerns within realistic limitations by meeting with residents and family members. Notifies RN Supervisor, ADNS, or DNS if additional management support is needed to resolve the issue. Notifies Security personnel and DNS if there is a situation requiring law enforcement support.

• Completes incident/unusual occurrence reports for all incidents occurring on the unit. Ensures that all relevant information is documented on the form, inclusive of the QA follow-up information. Documents the incident in the resident record per established practice. Ensures that resident receives appropriate and timely nursing care for all incidents. Notifies DNS immediately 24 hours a day if incident is suspicious or may require investigative follow-up and reporting to TDADS.

• Transfers residents to acute care settings when the resident’s condition can no longer be managed in the facility. Notifies the physician or nurse practitioner of the impending transfer. Notifies the responsible party of the impending transfer and the need to transfer. Contacts an ambulance service for transport and notifies Security of the transfer and where to send the ambulance. Verifies that all necessary documentation is sent with the resident to the acute care setting to facilitate continued care. Notifies other departments of the resident name, date, time and destination of transfer. Documents transfer notes in the resident record.

• Responsible for providing the oncoming shift with all relevant information concerning resident care for the previous shift. Completes narcotic count according to established procedures. Informs the oncoming shift of any tasks not completed which will be delegated to the next shift. Ensures that all resident care has been completed for the shift.

• Reviews and signs off on all new monthly physician orders, medication administration records, treatment records, and ADL documentation records for accuracy prior to use. Notifies DNS of any discrepancies which require correction.

• Maintains a high level of safety awareness for potential threats to resident/employee safety and takes prompt action to report or resolve the problem. Notifies RN Supervisor, ADNS, or DNS of persistent, unresolved safety issues which could affect resident and/or employee safety.

• Adheres to all infection control guidelines for body fluid exposure and prevention of disease transmission and ensures that subordinates also adhere to guidelines. Notifies RN Supervisor, ADNS, or DNS of employee non-compliance with infection control guidelines.

• Compliant with LVN licensing standards as governed by the Texas Board of Nursing. Maintains licensure in an uninterrupted manner and provides proof of licensure to DNS at the time of renewal. Responsible for obtaining necessary continuing education to maintain current licensure.

Supervisory Responsibilities: Manages CMA and CNAs in the assigned unit. Is responsible for all direct care provided on the unit during one shift; carries out supervisory responsibilities in accordance with TDADS regulations and Holly Hall policies and procedures; and delegates task to CMAs and CNAs in accordance with the established delegation rules of the Texas Board of Nursing.

Qualifications

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Education and/or Experience: Licensed Vocational Nursing certification from a college or technical school; one to two years related experience and/or training in long term care; or equivalent combination of education and experience.

Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals; ability to write legible, comprehensible nurses notes; and ability to speak effectively with residents, family members, physicians, other departments, and employees of Holly Hall.

Mathematical Skills: Must be able to calculate appropriate medication dosages and ranges for geriatric residents.

Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form; ability to deal with problems involving several variables in a variety of situations; ability to apply critical thinking skills during an urgent or emergent situation in order to appropriately direct other personnel.

Certificates, Licenses, Registrations: Current licensure as a Licensed Vocational Nurse in the state of Texas.

Physical Demands: The physical demands described here are representative of those that 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 essential functions.

Employee is regularly required to talk or hear; frequently required to stand and walk; use hands to handle or feel; reach with hands and arms; stoop, kneel or crouch; and taste or smell. Employee is occasionally required to sit. Employee must regularly lift and/or move up to 50 pounds. Specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Other Skills and Abilities: Must display a pleasant, cooperative, service-oriented attitude at all times with residents, families, physicians, and facility personnel; and must be team-oriented and able to work cooperatively in groups to accomplish a common goal.

Requirements:

• Must have an interest in the elderly.
• Must be able to speak, read and understand verbal and written instructions in English; and must be able to be understood clearly and easily by residents as English is the prevailing language at Holly Hall Retirement Community.
• Must be able to make independent decisions when circumstances warrant such action.
• Must be able to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the public.
• Must be able to work harmoniously with and supervise professional and nonprofessional personnel.
• Assist in developing, implementing, and coordinating department policies and procedures, job descriptions, etc.
• Works beyond normal working hours, on weekends, and in other positions temporarily, when necessary.
• Sits, stands, bends, lifts, and moves intermittently during working hours.
• Is subject to frequent interruptions.
• Must be able to cope with the mental and emotional stress of the position.
• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
• Must function independently and have flexibility, personal integrity, and the ability to work effectively with other staff.
• Must be in good general heath and demonstrate emotional stability.
• Must be able to lift, push, pull, move, and manipulate at least 50 pounds.
• Must be able to assist in the evacuation of residents.

General Statement: It is understood that this document may be changed in the future in the best interest of Holly Hall and/or those served. Any changes will be discussed with the incumbent.