Objective

Principal Responsibilities

• Demonstrates knowledge and appropriate use of the Company Infection Control Program.
• Notifies other Departments of resident changes, i.e., room changes, LOA, new admits, discharge, etc.
• Conducts family and resident education.
• Demonstrates the ability to administer medications timely and according to facility policy.
• Demonstrates the ability to administer treatments timely and according to facility policy.
• Demonstrates ability to receive, transcribe, and carry out physician orders, if allowed by Nurse Practice Act
• Makes rounds with physicians when necessary.
• Transcribes physician’s orders to resident charts, kardex, medication/treatment cards and care plans, as required.
• Charts progress notes in an informative, factual manner that reflects the care administered as well as the resident’s response to care.
• Follows established procedure for charting and reporting all reports of incident/accidents (residents & employees).
• Identifies and reports changes in condition to supervisor, physician and family.
• Accurately identifies skin changes and follows The Company Skin System.
• Orders and reports diagnostic tests timely.
• Conducts frequent rounds to evaluate effectiveness of care delivery.
• Orders supplies and charges for items ordered through Central Supply.
• Follows established procedures for restraint reduction.
• Follows facility policy and procedures in the event a restraint must be utilized.
• Assures that an adequate supply of personal protective equipment is on hand and are available for staff to perform procedures that involve exposure to body/blood fluids.
• Counts narcotics at the beginning and completion of each shift with the nurse leaving and coming on to the shift.
• Follows Pharmacy policy and procedures for ordering and delivering medications.
• Coordinates resident’s rehabilitation program with therapies to ensure 24-hour rehabilitation needs are met.
• Plans nursing interventions for each resident based on their individual needs and monitor the implementation.

Special Nursing Care Responsibilities-Based on State Nurse Practice Act

• Assists with meal service.
• Consults with dietary regarding the special dietary needs of the residents and follows through on dietary recommendations.
• Monitors residents with significant weight loss and gain and reports this to the physician and dietary.
• Identifies residents at risk for nutritional problems and implements preventative measures.
• Checks items and food that is brought in by family members to assure it complies with resident’s orders, dietary needs, and safety.
• Documents medications, treatments, prn’s per facility policy.
• Completes 24-hour report daily.
• Monitors resident’s intake and output as needed.
• Participates in the monthly medication renewal process.
• Accurately completes and is familiar with the forms used throughout the resident’s chart.
• Documents in progress notes any exceptions to resident’s condition, including daily charting on ill residents, 24, 48, or 72-hour follow up charting on residents with infections, incidents or new admits.
• Interpret Department’s policies and procedures to personnel, residents, visitors, and government agencies as required.
• Assures residents charge slips are completed and forwarded to the appropriate Department for processing.
• Accurately maintains daily census reports and submits to business office daily.
• Performs administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary.
• Records new/changed diet orders. Forwards information to the Dietary Department.
• Reports any discrepancies noted concerning physician’s orders, diet changes, charting errors, etc. to the
• Nurse Manager.
• Assists in completion of the care plans (acute and long term) and is involved in the care conference as deemed necessary.
• Evaluates the effectiveness of the care interventions, identifies problems and trends and develops alternative interventions.
• Participates and conducts (as appropriate) investigations related to any alleged abuse.
• Has knowledge and understanding of Resident Rights.
• Ensures that the progress notes are reflective of the care plan and that the approaches on the care plan are being followed.
• Assures that assigned nursing assistants are aware of the resident care plans (kardex) and ensure that the nursing assistant refers to the care plan (kardex) prior to administering care.

Admission, Discharge and Transfer

• Admission:
• Orients resident to room, facility, policies
• Obtains necessary physician orders
• Completes nursing admission assessments
• Orders necessary medication, supplies and diagnostic test
• Informs nursing personnel of new admissions, expected time of arrival, room assignments, admitting diagnosis, etc.
• Obtains written or verbal report from admitting facility on resident prior to or at the time of admission.
• Discharge: Completes post discharge plan
• Educates resident on post discharge needs
• Completes discharge paperwork
• Informs nursing personnel of planned discharges for their shift.
• Arrange for discharge transportation.
• Transfer:
• Successfully transfers a resident
• Assures documentation is accurately completed for admission, discharge and transfer.

Other Responsibilities

• Demonstrates knowledge of location and how to use Nursing Policy and Procedure Manual.
• Monitors that CNA documentation is completed daily.
• Ensures CNA assignments are completed on time.

• Participates in the orientation of new staff.
• Communicates appropriate information to team members, physicians, families and supervisor.
• Demonstrates a caring attitude toward The Company’s residents, family members, employees, and other company guests as the need arises; Ensures that subordinates are helpful, caring, and responsive to all guests. Devotes adequate time and attention to personal development and training, particularly in the management of people resources.
• Receives, investigates and responds to employee grievances.
• Performs any miscellaneous work assignments as may be required.

Residents Rights

• Knows and respects resident rights
• Ensures protected health information is kept confidential
• Reports complaints made by residents to supervisor
• Reports allegations of resident abuse, neglect and/or misappropriation of resident property

Safety and Sanitation

• Follows established safety policies and procedures Observes safety needs of residents as indicated in care plan
• Wears and/or uses safety equipment and supplies when indicated and properly trained to use
• Demonstrates job-specific knowledge of fire and disaster preparedness during drills or actual situations

Staff Development

• Attends and participates in scheduled in-service training, educational classes and meetings to maintain current certification as applicable and as managed by regulatory agencies and company standards
• Participates in QAPI as needed

Qualifications

• Graduation from an accredited Nursing School and current valid license or registration (LPN/LVN) in the State
• Nursing experience in a long-term care facility is preferred
• Supervising experience is desirable
• Functional literacy in English is required
• Effective communication and interpersonal skills are necessary

Principal Contacts

• Staff and residents.