Description

JOB SUMMARY:

Responsible to administer resident care, medications, treatments, and ongoing assessments of residents. Ensures that nursing staff on their unit provides effective, efficient nursing care as prescribed by the physician and as required by the philosophy, objectives, policies and procedures of Resident Care Services. Supervises CNAs and other personnel in the delivery of nursing care. 

OTHER SKILLS AND ABILITIES REQUIRED:

• Demonstrates current knowledge of nursing skills, including bedside care, medications, and treatments.
• Able to lift at least 50 pounds using proper lifting techniques.
• Ability to effectively communicate orally and in written format.
• Ability to get along with peers and supervisor and promote a team environment.
• Continuing education in nursing and gerontology.
• Knowledge of state and federal regulations and laws governing long-term care.
• Regular and punctual attendance
• Ability to work as part of a team
• Willingness and ability to implement facility policy & procedures
• See physical demands list

JOB RESPONSIBILITIES
Performs all functions according to facility policy and procedures, the nurse practice act, and current nursing standards of practice

Resident Assessment

• Adhere to state rules and regulations concerning delivery of care and assure that effectively quality nursing care is delivered which is outcome focused through utilization of the nursing process.
• Effectively interviews the resident/responsible party to obtain information required for developing and implementing a plan of a care. 
• Demonstrate ability to perform physical assessment through observation, inspection, palpation, percussion and auscultation. 
• Identify needs and provide input for discharge planning and follow up throughout the resident’s length of stay. 

Resident Plan of Care

• Protects the rights, privacy and property of residents.
• Participates in the development of an individualized plan of care in collaboration with the resident/responsible party and interdisciplinary team by documenting problems, statements, goals and approaches in collaboration with other members of the interdisciplinary care team.
• Seek CNA input when developing and/or updating the plan of care.
• Define realistic and obtainable long and short term goals for the residents. 
• Initiate appropriate nursing interventions with time frames for outcome evaluations and document appropriately in medical record. 
• Revise plan of care with input from resident/responsible party and interdisciplinary care team.
• Implement teaching with resident/responsible party consistent with interdisciplinary plan of care.
• Participates in resident care conferences as needed. 

Implement Patient Care

• Implement plan of care consistently, effectively and cost efficiently with focus on resident centered outcomes.
• Identify rationale and anticipated outcomes for each nursing intervention.
• Assume responsibility for care interventions consistent with skill level and professional standards of care. 
• Coordinates and supervises resident care on the unit. 
• Carries out physician orders as prescribed. 
• Utilize time efficiently to assure completion of duties and responsibilities in allotted time frame.
• Utilize professional and sound judgment in delivery of care, which is cost efficient but does not jeopardize safe, effective care delivery.
• Follow facility policies and procedures to ensure a safe, caring, comfortable and clean environment.
• Utilize all appropriate, available resources for resident/family/responsible party counseling and discharge planning.
• Keep physician and/or other health care professionals (Nurse Practitioner, Physician Assistant, podiatrist, dentist, etc.) informed of resident's condition; and notify physician and/or other healthcare professionals immediately of significant changes of condition, falls and skin issues.

Delivery of Resident Care

• Demonstrate strong ethical practices regarding individual/resident rights and demonstrate both sensitivity and appropriate responsiveness to resident needs and preferences.
• Support resident autonomy and choice.
• Delivers and maintains optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.
• Transcribe physician and/or other health care professional’s orders appropriately and accurately. Ask for clarification of questionable orders from the ordering physician and/or other health care professionals.
• Administers medications as ordered and monitors for signs and symptoms of adverse effects.
• Performs prescribed treatments and documents all findings in the resident’s medical record. 
• Assesses resident grooming, general care performed, and environment, performed by nursing staff during rounds.
• Monitors and documents resident intake and output, as needed.
• Monitor weekly and monthly resident weights, and notifies MD is significant change occurs. 
• Follow-through with pharmacist consultant recommendations.
• Follow-through with dietitian recommendations.
• Recognize normal and abnormal lab values and communicate same in appropriate manner to physician, and other interdisciplinary team members as appropriate.
• Promptly respond to call lights and other resident needs. 
• Follows up on resident change of conditions. Documents all findings and communicates with the physician.
• Notify physician and/or other health care professionals if orders are not carried out and document event appropriately.
• Demonstrate working knowledge of infection control practices.
• Follow company, facility and departmental policies and procedures, and appropriately utilize nursing judgment. 

Supervision

• Organizes work assignments as needed.
• Supervise CNAs, other nurses and possibly other personnel.
• Coach, counsel and assign CNA and other Nurses to provide quality resident care.
• When necessary, appropriately discipline or participate in the discipline of CNA and other Nurses for violations of work rules, policies or poor performance. Provide input to the Director of Nursing, Director of Staff Development, and/or Unit Manager.
• Assign CNA’s and other Nurses specific duties for resident care and direct their work. Assign hours, breaks and meal periods to CNA’s and other Nurses. 
• Train and/or assist in the orientation of new associates.
• Attempt to effectively resolve CNA and other Nurses problems/complaints. 
• Incorporate CNA and other Nurses in a work team to meet resident needs.
• Attend and participate in supervisory meetings. 
• Support and follow through with management team goals.
• Perform other management duties as assigned

Customer Service

• Provide compassionate resident care services.
• Establish and maintain positive interactions with internal and external customers, including residents, families, co-workers, vendors and other associates. 

Continuing Education

• Recognize self-evaluation and self-development as important tools in maintaining high standards of care and professionalism.
• Seek and provide peer support and consultation. 
• Participate in facility/department in services.
• Attend continuing education programs to maintain the standards the professional license.
• Attend facility/department/staff meetings as required.

Physical and Sensory Requirements

• Must be able to move intermittently throughout the workday.
• Must be able to read and write the English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must possess sight/hearing senses or use of prosthetics that will enable these senses to function adequately so that the requirements of the position can be fully met.
• Must function independently, have flexibility, personal integrity, and the ability to work effectively with residents, personnel and support agencies.
• Must be in good health and demonstrate emotional stability.
• Must be able to relate to and work with ill, disabled, elderly, emotionally upset and at times hostile people within the facility.
• May be required to lift, carry, push, pull and move office equipment, supplies, etc., in excess of twenty-five (25) pounds.
• Must be able to assist in the evacuation of residents.