Summary Description:

To deliver nursing care to patients requiring long-term acute care and/or rehab care.

Essential Functions and Responsibilities:

1. Works under direct supervision in accordance with the state-specific Nurse Practice Act, facility Policies and Procedures and nursing judgment.
2. Delivers nursing care to patients/residents requiring long-term or rehabilitative care.
3. Collects patient/resident data, makes observations, and reports pertinent information related to the care of the patient/resident.
4. According to state-specific regulations, implements the patient/resident plan of care and evaluates the patient/resident response.
5. In accordance with state-specific regulations, directs and supervises care given by other nursing personnel in selected situations.
6. Maintains knowledge of necessary documentation requirements.
7. Maintains knowledge of equipment set-up, maintenance and use, i.e., monitors, infusion devices, drain devices, etc.
8. Maintains confidentiality and patient/resident rights, regarding all patient/resident/personnel information.
9. Provides patient/resident/family/caregiver education as directed.
10. Conducts self in a professional manner in compliance with unit and facility policies.
11. Works rotating shifts, holiday and weekends as scheduled.
12. Initiates emergency support measures (i.e. CPR, protects patients/residents from injury).
13. Data Collection
1. Admission and routine patient/resident observations/transfer notes are complete and accurately reflect the patient’s/resident’s status.
2. Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.
3. Nursing history is present in the medical record for all patients/ residents.
4. Changes in a patient’s/resident’s physical/psychological condition (i.e., changes in lab data, vital signs, mental status), are reported appropriately.
14. Planning of Care: Contributions to the formulation/review of nursing care plans are made as appropriate, under the direct supervision or delegation of an RN.
1. Pertinent nursing problems are identified.
2. Goals are stated.
3. Appropriate nursing orders are recommended.
15. Evaluation of Care
1. Observations related to the effectiveness of nursing interventions, medications, etc., are reported as appropriate and documented in the progress notes.
2. Care Plans:
1. Evaluation of care plan is noted monthly or as indicated.
2. Contributions to care plan revision are made as indicated by the patient’s/resident’s status.
16. General Patient/Resident Care
1. Patient/resident is approached in a kind/gentle and friendly manner.Respect for the patient’s/resident’s dignity and privacy is consistently provided.
2. Interventions are performed in a timely manner.Explanations for delays in answers/responses are provided.
3. Independence by the patient/resident in activities of daily living is fully encouraged possible.
4. Treatments are completed as indicated.
5. Safety concerns are identified, and appropriate actions are taken to maintain a safe environment.
1. Side-rails and height of bed are adjusted.
2. Patient/resident call light and equipment is within reach.
3. Rooms are neat and orderly.
6. Functional assignments are completed.
7. Emergency situations are recognized, and appropriate action is instituted.
8. All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, AED, crash cart, fire extinguisher, etc.)
17. Patient/Resident Education/Discharge Panning
1. Patient/Resident/Family teaching is conducted according to the nursing care plan.
2. Explanations are given to the patient/resident prior to interventions.
3. Discharge/death summaries are complete and accurate.
4. Transfer forms are complete and accurate.
5. Active participation in patient/resident care management is evident.
18. Adherence to Facility Procedures
1. Facility Policy and Procedure Manual or reference materials are utilized as needed.
2. Procedures are performed according to the method outlined in the procedure manual.
3. Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
4. Safety guidelines established by the facility (i.e., proper needle disposal) are followed.
19. Documentation
1. Only approved abbreviations are utilized.
2. Vital signs are properly and timely recorded.
3. I&O summaries are recorded and added correctly.
4. Progress notes are timed, dated and signed.
5. Unit flow sheets are completed properly (i.e. wound care records, treatment records, weight sheets, etc.).
20. Medication Administrations/Parenteral Therapy Record
1. Adheres to state-specific Nurse Practice Act for administration of medication and parenteral therapy.
2. Dates that medications are started or discontinued are documented.
3. Medications are charted correctly with name, dose, route, site, time, and initials of nurse administering.
4. Pulse and blood pressure and obtained and recorded when appropriate.
5. Medications not given are indicated with the reason noted and physician notified if applicable.
6. Appropriate notes are written for medications not given and actions taken.
7. Name and title of nurse administering medication are documented.
8. Patient’s/Resident’s medication record is labeled with full name, room number, date, and allergies.
9. The procedure for administration and counting of narcotics is followed.
10. All parenteral fluids, including additives, are charted with time and date started, time infusion completed, site of infusion and signature of nurse.
11. All parenteral fluids are administered according to the ordered infusion rate.
12. Parenteral intake is accurately recorded on the unit flow sheet or I&O record.
13. Appropriate actions are taken related to identified IV infusion problems (infiltration, phlebitis, poor infusion, etc.).
14. IV sites are monitored, and catheters changed according to unit policy.
15. IV bags and tubings are changed according to unit policy.
16. Successful IV Certification Class completion required within 6 months of hire date.
17. Successful TPN Certification Class completion required within 6 months of hire date.
21. Coordination of Care
1. Tests are scheduled and preps are completed as indicated.
2. Co-workers are informed of changes in patient/resident conditions or of any other changes occurring on the unit.
3. Information is relayed to other members of the health care team (i.e., physicians, respiratory therapy, physical therapy, social services, etc.) and family/responsible party.
4. Unit activities are coordinated (i.e., changing patients/residents rooms for admissions, coordinating transfer/discharge forms, etc.).
22. Leadership
1. Equitable care assignments that are appropriate to patient/resident needs are made prior to the beginning of the shift.
2. Staffing needs are communicated to the nursing supervisor.
3. Assistance, direction, and education are provided to unit personnel and families.
4. Problems are identified, data is gathered, solutions are suggested, and communication regarding the problem is appropriate.
5. Transcription of all orders is checked.
6. All work areas are neat and clean.
23. Communication
1. Change of shift report is complete, accurate and concise.
2. Incident Reports are completed accurately and in a timely manner.
3. Staff meetings are attended.
24. Professionalism
1. Decisions are made that reflect knowledge and good judgment and demonstrate an awareness of patient/resident/family/physician needs.
2. Awareness of our own limitations is evident, and assistance is sought when necessary.
3. The dress code is adhered to.
4. Committee meetings (if assigned) are attended.Reports related to the committee are given during staff meetings.
5. Responsibility is taken for own professional growth.All mandatory and other in-services are attended.
6. Organizational ability and time management is demonstrated.
7. Confidentiality of patient/resident is respected at all times (i.e. when answering telephone and/or speaking to co-workers).
8. Professional behavior is demonstrated.
25. Human Relations
1. A positive working relationship with patients/residents, visitors and facility staff is demonstrated.
2. Authority is acknowledged and response to the direction of supervisors is appropriate.
3. Time is spent with patients/residents rather than other personnel.
4. Co-workers are readily assisted as needed.
26. Cost Awareness
1. Supplies are used appropriately.
2. Minimal supplies are stored in the patient’s/resident’s room.
3. Discharged medications are returned to the pharmacy or destroyed in a timely manner.
4. Floor stock medications are re-stocked appropriately.
27. Participates in the identification of staff educational needs.
28. Serves as a preceptor, as delegated, for new staff.
29. Maintains patient/resident care supplies, equipment and environment.
30. Participates in the development of unit objectives.
31. Provides input in the formulation and evaluation of standards of care.

Other Duties:

1. As this job description is not intended to be all-inclusive, the employee will be expected to perform other essential functions and duties as assigned.

Standard Responsibilities:

1. Supports the Facility
2. Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment.
3. Supports, cooperates with, and implements specific procedures and programs for:
1. Safety, including precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs.
2. Confidentiality and privacy of all data, including patient/resident, employee and operations data.
3. Compliance with all regulatory requirements.
4. Compliance with and enforcement of current law and policy to provide a work environment free from harassment and all illegal and discriminatory behavior.
4. Supports and participates in common teamwork:
1. Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction, including appropriate judgment.
2. Uses tactful, appropriate communications in sensitive and emotional situations.
3. Reports complaints, problems and concerns regarding co-workers, management or residents in accordance with facility policy.
4. Promotes positive public relations with patients, residents, family members and guests.
5. Completes requirements for in-service training, acceptable attendance, uniform and dress codes including personal hygiene, and other work duties as assigned.
5. Agrees to comply with the Code of Conduct.

Employment Standards:

Education:Graduation from a basic education program in vocational nursing

Experience:A minimum of one year’s nursing experience in a long-term or acute care setting preferred.

License/Other:Must have a current license to practice profession in state.Must have a reliable source of transportation.Must have a valid driver license and automobile insurance.

Working Conditions:

Works in office areas as well as throughout the facility.Must be able to move about intermittently during working hours including standing, lifting, bending, stooping, twisting, pushing and pulling.Must be able to read, write and speak the English language.Must be able to transfer residents and assist in emergency evacuations.Interacts with residents, family members, staff, visitors, government agencies/personnel, etc., under all conditions/circumstances.Must be able to relate and work with the disables, ill, elderly, emotionally upset and at times, hostile people within the facility.May be involved in community/civic health matters/projects.May be exposed to infectious waste, diseases, conditions, etc., including exposure to the AIDS and hepatitis B viruses.Must be able to effectively communicate with the management staff, medical staff, nursing staff and other unit supervisors.Maintains a liaison with residents, their families, support staff, etc. to assure that the residents’ needs are continually met.