Purpose of this position

The purpose of this position is to supervise, provide and coordinate nursing care in compliance with facility policies and procedures and to assess residents’ care needs and take appropriate action.

Qualifications

• Must have current license.
• License must be free of any encumbrances
• Must not have any disqualifying findings barring employment as stated by State or Federal regulations.

Delegation of authority

• Take appropriate action to assure adequate staffing to provide resident care.
• Supervise and assess resident care and take appropriate action.
• Implement facility procedures to provide resident care.

Primary Functions and Responsibilities

1. Follow established standards of nursing practices and implement facility policies and procedures.
2. Interpret existing policies and procedures to nursing assistants, restorative nursing assistants, residents, families and physicians.
3. Supervise and evaluate all direct resident care and initiate corrective action as necessary.
4. Obtain report from nurse being relieved and record sufficient information to implement appropriate follow-up action as necessary.
5. Provide report to nurse coming on duty, including sufficient information for follow-up action as necessary.
6. Take appropriate action to assure adequate staffing to meet residents’ needs.
7. Conduct resident rounds daily, reporting problems to nursing supervisor and initiating corrective action.
8. Identify safety hazards and initiate corrective action immediately.
9. Identify resident problems and emergency situation and initiate emergency care and “life-saving” measures in the absence of a physician.
10. Follow, supervise and evaluate implementation of the Residents’ Rights Program.
11. Participate in facility education programs.
12. Provide supervision to Nursing Assistant providing direct resident care.
13. Attend staff meetings, interdisciplinary team meetings, rehabilitation meetings, in- service classes and committee meetings as assigned.
14. Follow staffing guidelines and make nursing assignments according to qualifications of staff and characteristics of the resident population.
15. Assume responsibility for compliance with federal, state and local regulations within the assigned unit.
16. Counsel Nursing Assistants and recommend disciplinary action to the Director of Nursing Service, when necessary.
17. Participate in the employee evaluation process by providing information on the performance of Nursing Assistants.
18. Administer and document direct resident care, medications and treatments per physicians’ orders and accurately record all care provided.
19. Provide instruction for appropriate nursing care to licensed nurses and Nursing Assistants.
20. Perform comprehensive assessment of residents as assigned.
21. Document comprehensive assessment of residents as assigned.
22. Develop and implement an accurate comprehensive care plan based on each resident’s needs and his/her comprehensive assessment.
23. Promptly report changes in residents’ conditions to the physician, Director of Nursing Service and responsible party, and take follow-up action as necessary.
24. Follow facility admission procedures and communicate resident admission to other departments, physicians and ancillary service providers.
25. Competently perform basic nursing skills.
26. Follow facility discharge /transfer procedure and coordinate discharge/transfer with other departments, physicians and ancillary service providers.
27. Complete documentation related to the resident’s discharge/transfer.
28. Supervise response to resident’s call for assistance.
29. Listen to resident, family, or physician concerns and initiate corrective action and/or report concerns to Nursing Supervisor.
30. Count narcotics, check emergency kit and exchange keys.
31. Check meal trays and nourishment to ensure proper diet is served and residents are assisted as necessary.
32. Supervise the application and removal of all restraints and devices used to position and enable residents to function as independently as possible.
33. Order, receive and store medications appropriately.
34. Notify physician, when necessary, of changes in residents’ conditions, weight, medication errors, medication not available, abnormal laboratory/X-Ray results and any other unusual observations.
35. Document resident progress notes as required.
36. Document daily notes on unstable residents, Medicare residents and recently admitted residents.
37. Consistently work cooperatively with residents, nursing staff, physicians, families, consultant personnel, community agencies and ancillary service providers.
38. Obtain continuing education required to maintain licensure.
39. Be responsible for the safety of residents under his/her supervision.
40. Observe all facility safety policies and procedures.
41. Come to work in a clean, neat uniform and consistently present an appropriate professional appearance.
42. Come to work as scheduled and consistently demonstrate dependability and punctuality.
43. Assume accountability for data contained in the employees’ handbook.
44. Perform all duties assigned in an effective, cooperative, timely and professional manner.
45. Observe infection control procedures.
46. Follow Residents’ Rights policies at all times.
47. Be responsible for the safety of residents under his/her supervision.
48. Observe all facility policies and procedures.
49. Perform other related duties as directed by his/her supervisor.
50. Consistently work cooperatively with residents, residents’ representatives, facility staff, physicians, consultants and ancillary service providers.
51. Assure that feeding assistants are adequately supervised.
52. Periodically review the department’s policies, procedure manuals, job descriptions, etc. Make recommendations, as needed for revisions.
53. Meet with your assigned nursing staff, as well as support personnel, in planning the shifts’ services, programs, activities and changes in routine or policies.
54. Agree not to disclose assigned user I.D. code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Supervisor.
55. Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Supervisor.
56. Notify the DON or designee of all drug and narcotic discrepancies.
57. Report and investigate all allegations of resident abuse and/or misappropriation of resident property.
58. Ability to work other shifts as needed.
59. Complete all duties assigned by his/her supervisor.