A.RESIDENT ASSESSMENT

Duties:Adhere to the state and federal regulations concerning delivery of care and assure that effective quality nursing care is delivered through utilization of standards of nursing practices. Effectively interview the resident/responsible party to obtain information required for developing and implementing a plan of care. If applicable, is involved in and accurately completes the RAI process. Identify needs and provide input for discharges planning and follow-up throughout length of stay.

B.DEVELOPS PLAN OF CARE

Duties: Develops plan of care incollaboration with the resident/responsible party and interdisciplinary care team by documenting problems, statements, goals, and approaches. Seek Certified Nursing Assistant input when developing plan of care. Define realistic and obtainable short and long-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 as needed with input from resident/responsible party and interdisciplinary care team. Initiate training with resident/responsible party consistent with interdisciplinary plan of care.

C.IMPLEMENTS PLAN OF CARE

Duties:Implement plan of care consistently, effectively and cost efficiently on resident centered outcomes. Identify rationale and anticipate outcomes for each nursing interventions. Assume responsibility for care interventions consistent with skill level and professional standards of care. Utilize time efficiently to assure completion of duties and responsibilities in allotted time frame. Utilize professional and sound judgment in delivery of care assuring safe, effective care delivery. Follow the Center’s 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. Notify physician and/or other health care professional immediately of significant changes of condition. Work in collaboration with physicians and/or other health care professionals by sharing information relevant to changing plan of care.

D.RESIDENT CARE

Duties:Deliver and maintain optimum residentcomfort by demonstrating knowledge and skills of current nursing practices. Transcribe physician and/or other health care professional’s orders appropriately and accurately.Seek clarification of physician orders and/or other health care professionals as needed. Perform only those activities that are within the scope of RN nursing practice. Notify physician and/or other health care professionals if orders are not carried out and document event appropriately. Follow company, facility, and departmental policies and procedures, and appropriately utilize nursing judgment. Ensure accurate documentation of all medical records and reporting forms. Promptly respond to call lights and other resident needs.

E.CUSTOMER SERVICE

Duties:Provide compassionate resident careservices. Establish and maintain positive interactions with residents, families, visitors and staff.Take responsibility for resolving Certified Nursing Assistants, Nurse, and other customer’s issues and concerns to achieve positive outcomes.

F.RESIDENTS RIGHTS

Duties:Understand, comply with, train and promote compliance regarding Residents’ the Rights.Promote positive relationships with resident, visitors, and regulators, to include presenting a professional appearance and attitude.

G.RESIDENT COMFORT AND SAFETY

Duties:Demonstrate safe practices in regard to resident’s comfort and safety by applying knowledge of proper body alignment for self and resident. Practice and promote adherence to facility safety policy. Promote a restraint-free environment.

H.PHARMACY KNOWLEDGE

Duties:Maintain an updated knowledgebase in pharmacology. Demonstrate knowledge of policies governing medication administration and documentation. Demonstrate knowledge of drug reactions and sensitivities and nursing interventions. Assure that narcotics are secured and accounted properly. Educate individuals, family members or responsible party regarding the resident’s medication regimen.

I.LAB VALUES

Duties:Recognize normal and abnormal lab values and communicate to physician, and other interdisciplinary team members as appropriate.

J.INFECTION CONTROL

Duties:Demonstrate working knowledge of infection control practices. Monitor, educate and evaluate Certified Nursing Assistants and other nursing personnel on utilization of standard practices on infection control.

K.SAFETY

Duties:Comply with, support, and enforce Center’s policies involving all safety and infection control procedures to include the proper use of mechanical lifts, gait belts and other necessary personal protective equipment.

Ensure equipment and work areas are clean, safe and orderly, and hazardous conditions are addressed.Ensure universal precautions and infection control, isolation, fire, safety and sanitation practices and procedures are followed.

L.ETHICS AND COMPLIANCE

Duties: Exhibits expected ethical and legal standards. Reinforces through example and where applicable, conducts training on the expectation that all employees conform to these ethical and legal standards, including matters related to resident abuse or neglect.

When in doubt about whether a particular activity is proper, refrains from the activity and obtains guidance from their supervisor, the Director of Nursing or the Administrator.

Reports promptly problems observed or reported by other employees.Assist in planning, implementing and monitoring corrective action, when problems including ethics and compliance problems and resident abuse or neglect are identified.

Maintains compliance in promoting patient privacy, HIPPA regulations and confidentiality in the delivery of care.Safeguards patients’ medical, financial and personal information.