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Reporting/Communications

• Receives verbal report on residents from the previous charge nurse when reporting for duty. Gives a complete report to oncoming nurse prior to leaving duty.
• Makes rounds on all residents when arriving on duty, and throughout the shift. Reviews the condition of residents with staff on the unit and communicates pertinent information to others involved with the resident care.
• Counts controlled substances/narcotics with the previous Med. Nurse when arriving on duty and when leaving tour of duty. Ensures that all medications are properly stored, counted, and locked. Orders and destroys meds as per policies and procedures of Mary Immaculate .
• Notifies the Nurse Manager/Shift Supervisor to report changes in condition, transfers to hospitals, incidents and accidents, abnormal lab results and follow up, etc.
• Evaluates residents and consults the physician when necessary. Coordinates the scheduling and related transportation of appointments for referrals to clinics and other doctors.
• Arranges for transfers to hospitals as needed.
Informs the necessary persons in the event of accident, injury, change in condition, treatment plan, transfers or death.

Supervision

• Checks the assignment sheet at the beginning of each shift to ensure that the Nursing Assistants have been assigned the specific residents, unit care duties and responsibilities, breaks and mealtimes.
• Supervises the work performance of unit nursing personnel to ensure thoroughness and assists as necessary to ensure:
• Orderliness and safety of the facility including nursing station, medical rooms and resident rooms.
• Assistance with meals and nourishment is provided.
• Showers, bathing, and personal care is accomplished.
• Residents are supervised and attended to, and call lights are answered in a timely fashion.
• Lifting, moving, turning, positioning, and transporting residents is done safely. Assists when necessary.
• Restorative nursing procedures are carried out according to the care plan.
• Residents are comfortable and safe, and restraints are applied correctly and released as indicated.
• Residents are clean and dressed in appropriate clothing.
• Residents are positioned properly in accordance with turning schedules, if appropriate.
• Notifies the Nursing office of the need for supplies and equipment for nursing care on the unit.

Resident Care

• Evaluates residents and carries out nursing care in accordance with the physician's orders and the facility policies and procedures in areas including but not limited to
• Medication administration
• Treatment and dressings
• Enteral feedings and needed feeding tube changes/ insertions
• Intravenous therapy. IV Medications that are required to be mixed on site to be done by RNs only.
• Indwelling catheter insertions/changes/irrigat ions
• Oxygen therapy
• Supportive respiratory therapy (suction, trach care)
• Colostomy/ileostomy care, vaginal douches, enemas, etc.
• Emergency care
• Pronounce resident’s death with physician’s order.
Communicates and cooperates with members of other departments for coordination of resident care.

Documentation

Documents resident care in accordance with facility policies and procedures, including but not limited to the following:

• Transcripting and noting of physician orders.
• Completion of admission, transfer, or discharge documentation.
• Health monitoring activities (vital signs, weights, intake and output, foley catheter output, diabetic monitoring).
• Health care interventions (medications, treatments, PROM, turning and positioning).
• Resident response to treatments, the use of PRN medications, specific behavior interventions.
• Diet order and diet change slips.

Charts each shift, on the condition and response of residents listed, on the 24-hour nursing log

• New admissions
• Incidents and accidents.
• Changes in condition
• Transfers to hospital, ER visits
Follow through on problems stated - until resolved

Completes nursing summary on each resident monthly. Summary will reflect the resident's ADL participation as well as response to staff interventions or progress towards goals identified in the interdisciplinary care plan:

• Pressure ulcer prevention and treatment
• Restorative nursing programs
• Bowel and bladder management
• Fall/Accident prevention
• Special health needs

Checks the documentation done by CNAs for completeness and accuracy, including the following:

• Intake and output
• Weights
• Vital Signs
• NA daily flow record
• Catheter output
• Restraints
• Positioning
• BM record
• Bath record
Meal intake record

Staff Development

• Attends and encourages staff to be present at Inservice education programs presented within and outside the facility.
• Assists in orientation and on-the-job training of staff. Teaches and supervises nursing personnel, CNAs and Bedma kers.