Employment Type : Full-Time
Purpose of the Job Position The primary purpose of the job position is to provide direct nursing care to the residents, and to 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 be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. Charting and Documentation Prepare and administer medications as ordered by the physician. Ensure that narcotic records are accurate for your shift, notifying the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift. Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies. Dispose of drugs and narcotics as required, and in accordance with established procedures Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures. 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. Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and/or a nurse aide trainee qualified to perform the procedure. Notify the resident’s attending physician when the resident is involved in an accident or incident. Administer professional services such as; catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required. Obtain sputum, urine and other specimens for lab tests as ordered Take and record TPRs, blood pressures, etc., as necessary. Monitor seriously ill residents as necessary. Ensure that residents who are unable to call for help are checked frequently. Admit, transfer and discharge residents as necessary. Ensure that all personnel performing tasks that involve potential exposure to blood/body fluids participate in appropriate in-service training programs prior to performing such tasks. Ensure that an adequate supply of personal protective equipment are on hand and are readily available to personnel who perform procedures that involve exposure to blood or body fluids. Ensure that your assigned personnel follow established handwashing and hand hygiene technique in the administering of nursing care procedures. Participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel. Care Plan and Assessment Functions Inform the Nurse Supervisor of any changes that need to be made on the care plan. Ensure that your nurses’ notes reflect that the care plan is being followed when administering nursing care or treatment. Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect. Maintain a written record of the resident’s complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint. Report and investigate all allegations of resident abuse and/or misappropriation of resident property. Ensure that nursing staff personnel honor the resident’s refusal of treatment request. Ensure that such requests are in accordance with the facility’s policies governing advance directives. Working Conditions Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.). Moves intermittently during working hours. Is subject to frequent interruptions. Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances. Is subject to hostile and emotionally upset residents, family members, personnel, and visitors. Communicates with the medical staff, nursing personnel, and other department directors. Works beyond normal working hours, and in other positions temporarily, when necessary. Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.). Attends and participates in continuing educational programs. Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants. Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses. May be subject to the handling of and exposure to hazardous chemicals. Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs. Physical and Sensory Requirements Must be able to move intermittently throughout the workday.
Delegation of Authority
An LPN / RN is delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties.
Administrative Functions
Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
Admit, transfer, and discharge residents as required.
Complete accident/incident reports, medical forms, reports, evaluations, studies, charting, etc. as necessary.
Complete and file required recordkeeping forms/charts upon the resident’s admission, transfer, and/or discharge.
Receive telephone orders from physicians and record on the Physicians’ Order Form.
Transcribe physician’s orders to resident charts, cardex, medication cards, treatment/care plans, as required.
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 the care.
Fill out and complete accident/incident reports, and chart accidents/incidents involving residents. Submit to Director as required.
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.
Drug Administration Functions
Verify the identity of the resident before administering the medication/treatment.
Ensure that prescribed medication for one resident is not administered to another.
Nursing Duties and Responsibilities
Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
Nursing Care Functions
Make rounds with physicians as necessary.
Safety and Sanitation
Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies.
Review care plans daily to ensure that appropriate care is being rendered.
Resident Rights
Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information.
Miscellaneous
Provide data to the Quality Assurance & Assessment Committee as requested.
(With or Without the Aid of Mechanical Devices)
Must be able to speak and write the English language in an understandable manner.
Must be able to cope with the mental and emotional stress of the position.
Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination.
Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.
Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.
May be necessary to assist in the evacuation of residents during emergency situations.