Purpose

The primary purpose of this position is to direct nursing care to the residents, and to supervise the daily nursing activities. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be required by the supervisor.

Essential Job Functions Duties and Responsibilities

Nursing Care Functions

1. Direct and supervise the daily functions of the nursing staff in accordance with current rules, regulations, and guidelines that govern the long term care facility.
2. Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility. Communicate the department’s policies and procedures to personnel, residents, and visitors.
3. Meet with your assigned nursing staff, as well as support personnel, in planning the shift’s services, programs, and activities and monitor that tasks are completed as directed.
4. Communicate with written (24 hour report) and oral reports/recommendations concerning any changes in resident condition and other activities of your shift.
5. Cooperate with other members of the disciplinary team when coordinating services to ensure that the resident’s total regimen of care is maintained.
6. Admit, transfer, and discharge residents.
7. Inform nursing personnel of new admissions and the resident’s care needs. Ensure that rooms are ready for new admissions. Greet newly admitted residents upon admission. Participate in the orientation of new residents/family members to the facility.
8. Requisition and arrange for diagnostic and therapeutic services, as ordered by the health care practitioner, and in accordance with our established procedures.
9. Consult with the resident’s health care practitioner in providing the resident’s care, treatment, rehabilitation, etc. Make rounds with health care practitioner.
10. Review the resident’s medical record for specific treatments, medication orders, diets, labs etc., as for implementation and follow up.
11. Notify the resident’s attending health care practitioner and family when there is a change in the resident’s condition.
12. Completes daily clinical and environmental rounds to evaluate resident care being provided and report significant events.
13. Provide direct nursing care.
14. Meet and resolve issues with residents and/or family members. Report significant issues to the supervisor.
15. Assist in arranging transportation for residents and other third party services.
16. Participate in facility surveys (inspections) as requested by management.

Charting and Documentation

1. Communicate with health care provider to review treatment plans, complete orders, progress notes, etc., in accordance with established policies.
2. Accurately transcribe orders from health care provider. Record and process to appropriate department.
3. Complete and file assessments and all other medical record documentation as required to provide care services.
4. Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the supervisor.
5. Ensure that pertinent clinical documentation is completed according to policy including accident/incidents reports involving residents.

Drug Administration Functions

1. Prepare and administer medications ordered by the health care provider.
2. Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the supervisor.
3. Review medication administration record for completeness of information, accuracy in the transcription of the physician’s order. Report concerns to your supervisor.
4. Handle and dispose of drugs and narcotics in accordance with established procedures.

Personnel Functions

1. Participate in employee performance evaluation, determining your shift’s staffing requirement, and making recommendations to the supervisor concerning employee assignments.
2. Inform the supervisor of staffing needs when assigned personnel fail to report to work.
3. Review and evaluate your unit’s work process and make recommendations to the supervisor.
4. Develop work assignments and/or assist in completing and performing such assignments.
5. Ensure that nursing personnel qualifications is utilized according to the resident’s need.

Care Plan and Assessment Functions

1. Periodically review the resident’s written care plan. Participate in the updating of the resident’s written care plan as required. Ensure that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.
2. Complete an initial assessment and develop interim care plan with new admissions. Participate with updating and reviewing care plan that identifies the goals, problems, approaches, and revisions based on nursing needs.

Required Knowledge, Skills and Abilities

Must possess the ability to make independent decisions, follow instructions, and accept constructive criticism. Must be able to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public. Must be able to work with ill, disabled, elderly, emotionally upset, and potentially hostile people within the facility. Must be able to speak, write and understand English in a manner that is sufficient for effective communication with supervisors, employees, residents, and families.

Education and Experience

Prefer supervisory/leadership experience.

Licensing/Certifications

Must possess an active license to practice as an RN or LPN/LVN in this state.

Physical Requirements

All requirements are subject to possible modification to reasonably accommodate individuals with disabilities. Individuals who pose a direct threat or significant risk to the health and safety of themselves or others in the work place will not be considered qualified for employment if physical requirements cannot be eliminated or reduced by reasonable accommodation.

Essential functions are carried out in a variety of positions including standing and sitting. To meet residents’ needs, all positions require the ability to move freely through the building. Other physical demands are required as described below.

Equipment and Tools

List equipment and tools operated and the frequency of use:

(Those that cannot be delegated to a co-worker.)

Facility Vehicles: Equipment: Computer and personal communication devices
Medical and safety equipment within scope of practice

Tools: Other:

Working Conditions

Check which working conditions the employee is subject to:

Physical Conditions:

Extreme temperatures Noise Wet and/or humid Vibration

Workplace Hazards:

 X Blood, body fluids and/or infectious disease Hot Water Mechanical Electrical

X Chemical Gasses Other___________