POSITION SUMMARY:

To case manage assigned residents. Conduct and coordinate the development and completion of the residents assessments in accordance with regulations and facility policies and procedures.

QUALIFICATIONS:

REGISTERED NURSE with previous MDS experience

Education:

-A professional nurse, currently licensed in the state of Florida

-Experienced in the long-term care arena working with Minimum Data Sets

-Computer literacy

Essential duties:

-A salaried position

-Successful completion of facility pre-employment physical examination and drug screen

-Ability to ambulate throughout the facility as needed for job duties

-Ability to sit for time required to complete paperwork duties

-Able to work flexible hours

Capabilities:

-Concrete organizational skills

-Outstanding clinical assessment skills

-Excellent communication skills

-Able to work well with staff

-Able to competently understand and complete clinical documentation:

i.Nursing

ii.Therapy

iii.Interdisciplinary notes

JOB DUTIES AND RESPONSIBILITIES:

·Enter residents into computer (Assessments) on the first business day after admission and establish the Assessment Reference Date (ARD) in computer create, update and maintain schedules for upcoming assessments and distribute to interdisciplinary team (IDT) members. Assure that required time frames are met without exception.

·Review admission chart on the first business day after admission and gather information for initial assessment. Finalize initial care plan. Assure reason for admission is care planned. Add any care plans necessary prior to comprehensive care plan meeting.

The on-going resident assessment includes:

-Cognition and communication

-Vision and hearing

-Range of motion/evaluate any deficits

-Skin condition/sound assessment

-Contingency/Bowel & bladder program

-Pain issues-need for continuous or PRBN treatment/other interventions

-Behaviors-need for /effectiveness of interventions such as:

i.Physician ordered psychiatric and or psychological services

ii.If behavior is inhibiting progression of rehabilitation

-Medication and treatment effectiveness

-Diabetic control-observe signs and symptoms and monitor effectiveness of
treatment

Conduct record review of:

-Physician’s orders & progress notes

-Staff notes: nursing, dietary, therapy

-Consultations

-Any wound reports

-ADL documentation

-Laboratory and X-ray results

-Contingency, Bowel & Bladder training documentation

Interview/observe staff regarding resident’s:

-Function/response to rehabilitation

-Behaviors

-Cognition

-Pain control

-Contingency

-Any issues pertinent to the resident

·During the chart review audit the chart for issues that may require follow-up as a secondary admission chart audit source, such as:

-Admission height and weight obtained and documented

-B & B training initiated as appropriate, Foley catheters discontinued if possible with training initiated

-Comprehensive diagnosis documented on physician orders

·Read the 24 hours report each day. Review weekly wound report. Monitor for significant changes that would necessitate an additional assessment. Attend, conduct and keep notes for daily Stand-up meeting for assigned Residents. Re-assess residents as needed.

·Communicate any issues identified as requiring attention during review to appropriate person.

·Assure Pre-MDS Collection Tool is completed at time of initial assessment and annual assessment thereafter.

·Complete required MDS assessments, RAPS and care plans.

·Conduct MDS and care plan meetings with IDT, residents and/or responsible persons and other staff. Have charts, Kardexes, BMRs and flow sheets at meeting for updating if determined necessary at the meeting.

·Complete the interdisciplinary note on the Pre-MDS Collection Tool following the care plan meeting.

·Print assessments, RAPs, care plans, obtain appropriate signatures:

-IDT members present

-Director of Nurses (DON) on care plan signature sheet

-Medical Director on care plan signature sheet for his/her residents

·Transmit assessments, troubleshoot errors and reconcile weekly per policy if assigned.

·Interact with residents, families, staff and physicians as needed to assure appropriate care is rendered to assigned residents.

·Conduct Risks and Benefits meetings with IDT, resident and/or families when necessary and assure proper documentation.

·Update care plans as needed from review of :
- Telephone orders
- Post-Fall Checklists
- Wound reports

·Facilitate utilization review meetings.

·Print and troubleshoot 672/802 reports as directed by DON.

Print Quality Indicators