POSITION PURPOSE:

Organizes and directs assigned unit duties to provide quality nursing care to residents.

ESSENTIAL FUNCTIONS OF POSITION:

• Responsible during the shift for the total nursing care of residents in the assigned unit.
• Assumes responsibility for compliance with Federal, State, Local, and company regulations.
• Explains procedures and treatments and care plan to resident.
• Administers prescribed medications and treatments in accordance with approved nursing techniques.
• Transcribes physician’s orders.
• Charts progress notes in an informative, factual manner that reflects the care administered as well as the resident’s response to care.
• Receives/gives report from/to nurse he/she is relieving/coming on and records sufficient information and implements appropriate follow-up action as necessary
• Follows established procedures for charting and reporting all reports of incident/accidents for residents and employees.
• Conducts frequent rounds to evaluate effectiveness of care delivery.
• Prepares equipment and aids Physician during treatment and examination of resident.
• Maintains awareness of comfort and safety needs of resident.
• Observes resident, records significant conditions and reactions, and notifies supervisor or Physician of resident’s condition and reaction to drugs, treatments, and significant incidents.
• Takes temperature, pulse, blood pressure, and other vital signs to detect deviations from normal and assess condition of resident.
• Responds to emergency situations based upon nursing standards, policies, procedures, and protocol.
• Assists in completion of the care plans (acute and long term) and is involved in the care conference as deemed necessary.
• Participates, reports to DON/ Administrator and conducts (as appropriate) investigations related to any alleged abuse.
• Ensures that documentation is reflective of the care plan and that the approaches on the care plan are being followed.
• Assures that assigned CNA’s are aware of the resident care plan, and ensure that the nursing assistant refers to the care plan prior to administering care.
• Monitors that CNA’s documentation is completed daily.
• Takes report form CNA’s to facilitate accurate documentation in resident medical record.
• Follows company policy and procedure in the event a restraint must be utilized.
• Coordinates residents’ rehabilitation program with therapists to ensure 24 hour rehabilitation needs are met.
• Identifies residents at risk for nutritional problems and implements preventative measures.
• Records new/changed diet orders. Forwards information to the Dietary Department.
• Makes beds, bathes and feeds resident, when necessary.
• Assures documentation is accurately completed for admission, discharge and transfer.
• Supervises and evaluates implementation of the “Resident’s Rights”.
• Participates in department or unit quality improvement activities.
• Follows facility procedure requesting supplies and charges for items ordered through Central Supply.
• Participates and attends periodic in-services and staff meetings.
• Perform additional duties as assigned.

EDUCATION / REQUIREMENTS:

Current State of LVN/LPN with a minimum of 2 years related experience; or equivalent combination of education and experience. Good standing in the state registry is required.