Position Description:

A licensed professional nurse, directly under the supervision of the Director of Nursing Services, provides care and services to residents in a long-term care setting.

General Duties and Responsibilities: 

GENERAL

• Provides nursing care as prescribed by physicians/health care professionals following the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures
• Administers professional services and provides care consistently, allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being, utilizing the nursing process of assessing, planning, implementing, and evaluating patient care

CLINICAL

• Admits, transfers, and discharges residents per policy and procedure
• Orients new residents/families as necessary
• Gives/receives nursing reports upon beginning and ending of assigned shift. Reviews daily patient report and assignments with Nursing Assistants upon the beginning of the assigned shift.  
• Assures that the unit area is maintained cleanly and safely for resident comfort and convenience.
• Conducts daily resident rounds to assess and evaluate the resident’s physical, medical, and emotional status and to implement or revise nursing interventions in the resident's plan of care.
• Records care information accurately, timely and concise manner. Completes all required documentation, including resident assessments, interventions, and patient response(s) in the medical record by policy.
• Initiates, reviews, revises, and updates resident Plans of Care as indicated. Evaluates the patient’s progress toward specific goals and adjusts the nursing plan of care, as necessary. Receives and transcribes orders accurately from attending/alternate physician
• Receive and transcribe orders accurately from attending/alternate physician  
• Assists in making rounds with the attending physician, as necessary.
• Prepares/administers medications as ordered by the physician and within the legal scope of practice.  
• Completes medical treatments as indicated and ordered by the physician.   
• Evaluates resident response and reports adverse reactions to medications or treatments in accordance with the policy.   
• Assures that narcotic and controlled drugs are secure, inventory counts are accurate, and narcotic register documentation is timely and accurate
• Orders prescribed medications, supplies, and equipment as established by the facility’s policies and procedures.
• Requisitions and arranges for diagnostic and therapeutic services as ordered by the physician.
• Informs the RN Supervisor or RN in charge of the facility and others as appropriate, of resident status and related matters
• Attends various facility meetings (care conferences, stand-up meetings, staff meetings, Medicare meetings, discharge plan meetings, etc.) as required.
• Reports allegations of abuse or unusual occurrences per State and Federal Regulations and facility policy.  Assists with gathering of information relative to the event.   
• Initiates emergency procedures (including basic CPR) and provides emergency patient treatments
• Participates in the facility’s infection control program for monitoring communicable and/or infectious disease among residents and staff.
• Participate in procedures for reporting hazardous conditions or equipment.
• Assists in the orientation of newly assigned personnel as requested.    
• Assumes Charge responsibility following the orientation period as requested.
• Performs other position-related duties as assigned.
• Supervise CNAs

SUPERVISION

• Make resident rounds to ensure appropriate care is being rendered, identifying and making corrections as necessary.
• Meet with nursing personnel to assist in identifying and correcting problem areas and/or the improvement of resident care.
• Assist the Charge Nurse in revision and distribution of nursing assignments as needed.  
• Assist in the supervision and direction of nursing personnel.
• Participate in disciplinary action and evaluation of nursing personnel.

CONSUMER SERVICE

• Presents a professional image to consumers through dress, behavior, and speech.
• Treats residents/family members with dignity and respect  
• Responds to Resident and family concerns and assists in resolving grievances. Records grievances per facility policy

ADDITIONAL DUTIES

Quality Assurance Team, as directed by the Director of Nursing. Actively participates in Quality Assurance Performance Improvement teams and activities

Qualifications:

• Graduate of an accredited RN school of nursing.
• Current nursing license, in good standing with the State licensing board
• Strong qualities of leadership, communication, and organizational skills. Ability to provide quality patient care in accordance with applicable standards, policies, and procedures.
• Possess critical thinking skills to analyze, synthesize, and evaluate clinical data and observations in developing a nursing plan of care.  
• Comprehensive knowledge of applicable nursing principles and practices to ensure quality of care standards for residents’ care.  
• Possess the willingness to work with professional and nonprofessional personnel. Proficiency of the English language, including the ability to speak, read, write, and comprehend the language with minimal to no difficulty.
• Valid BLS certification