General Purpose

• Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants.

• Such supervision must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern our facility, and as may also be required by the Director of Nursing to always maintain the highest degree of quality care.

Duties/Responsibilities

• Meet the physical and sensory requirements stated below and be able to work in the described environment.
• Identify and participate in process improvement initiatives that improve the customer experience, enhance workflow, and/or improve the work environment.
• Direct the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the industry.
• Confirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
• Meet with your assigned nursing staff, as well as support personnel, in planning the shift’s services, programs and activities.
• Verify that all nursing personnel comply with the procedures set forth the in the Nursing Policies and Procedures Manual.
• Make written and oral reports/recommendations concerning the activities of your shift, as required.
• Cooperate with other resident services when coordinating nursing services and be certain that the resident’s total regimen of care is maintained.
• Verify that all nursing service personnel follow their respective job descriptions.
• Participate in the development, maintenance, and implementation of the facility’s quality assurance program for the nursing department.
• Participate in surveys (inspections) made by authorized government agencies.
• Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan, as required.
• Assist in planning the nursing portion of the resident’s discharge plan, as necessary.

• Admit, transfer, and discharge residents, as required.
• Complete accident/incident reports, as necessary.
• Complete and file required forms/charts upon resident’s admission, transfer, and/or discharge.
• Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
• Receive telephone orders and transcribe Physicians’ Order.
• Chart nurses’ notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident’s response to care.
• Record new/changed diet orders. Forward information to the Dietary Department.
• Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Nurse Supervisor.
• Fill out and complete transfer forms in accordance with established procedures.
• Enter appropriate documentation concerning unauthorized discharges in the resident’s medical record in accordance with established procedures.
• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
• Sign and date all entries made in the resident’s medical record.
• Write nurses’ notes to reflect that the care plan is being followed when administering nursing care or treatment.
• Prepare and administer medication as ordered by the physician.
• Verify the identity of the resident before administering the medication/treatment.
• Verify that prescribed medication for one resident is not administered to another.
• Verify that adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the Nurse Supervisor.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with established procedures.
• Verify that narcotic records are accurate for your shift.
• Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
• Review medication orders for completeness of information, accuracy in the transcription of the physician’s order and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage being administered.
• Immediately notify the Nurse Supervisor and attending physician of any medication administration errors.
• Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.
• Promptly respond to call lights and assist with other resident needs.
• Make rounds with physicians, as necessary.
• Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.

• Review the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.
• Make periodic checks to confirm that prescribed treatments are being properly administered by CNA’s and to evaluate the resident’s physical and emotional status.
• Notify the resident’s attending physician when the resident is involved in an accident or incident.
• Notify the resident’s attending physician and responsible party when there is a change in the resident’s condition.
• Monitor seriously ill residents, as necessary.
• Review care plans daily to confirm that appropriate care is being rendered.
• Confirm that CNAs are aware of the resident care plans. Verify that the CNA’S refer to the resident’s care plan prior to administering daily care to the resident.
• Other special projects and duties, as assigned.

Skills/Qualifications

• Registered Nurse or Licensed Practical/Vocational Nurse with current state license.
• Must have a current/active CPR certification. (State specific requirements)
• Excellent technical, assessment and documentation skills.
• Effective verbal and written English communication skills.
• Comfortable with computer applications (i.e., Clinical software, Microsoft Word, Excel, Outlook, and Internet).
• Highest level of professionalism with the ability to maintain confidentiality.
• Ability to communicate at all levels of organization and work well within a team environment in support of company objectives.
• Customer service oriented with the ability to work well under pressure.
• Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
• Strong analytical and problem-solving skills.
• Ability to work with minimal supervision, take initiative and make independent decisions.
• Ability to deal with new tasks without the benefit of written procedures.
• Approachable, flexible, and adaptable to change.
• Function independently, and have flexibility, personal integrity, and the ability to work effectively with stakeholders and vendors.

Required Skills/Abilities

• You’ll work mostly indoors on floors that are tiled or carpeted.
• You’ll be around other co-workers, residents, and their guests.
• You’ll have possible exposure to occasional slippery floors, chemicals, sharp objects, and hazardous materials and waste (including human), blood borne pathogens, and communicable diseases.

• You'll be around possible high-stress medical and/or life-threatening situations.

Physical Requirements

• This role requires moderate physical activity.
• Push, pull, move, and/or lift a minimum of fifty (50) pounds to a minimum height of three (3) feet and be able to push, pull, move, and/or carry such weight a minimum distance of fifty (50) feet.
• Standing and/or walking for more than four (4) hours per day.
• Bending and/or stooping for more than two (2) hours at a time.
• Sitting for more than two (2) hours at a time.
• Requires writing and/or computer work with repetitive typing and concentrating on computer screen and/or documents for more than two (2) hours at a time.