Nurse (RN/LPN)

SUMMARY OF POSITION FUNCTIONS
The Nurse assumes, responsibility, and accountability for resident care of a designated shift and in accordance with Federal and State regulations and company/community policies, procedures and Personal Service Plans.

ESSENTIAL POSITION FUNCTIONS

Describes personal service plan and approaches to direct care staff so that plan is consistently implemented on all shifts by all caregivers. Seeks input from personal care assistants about resident condition, functional abilities, preferences, and alternative approaches to care.
Monitors delivery of care and services throughout shift to ensure needs are met, tasks are completed, including complete and accurate resident documentation, and that work of direct care staff is of acceptable quality and quantity.
Coaches and monitors staff performance providing praise and redirection when applicable.
Complies with the community's privacy and confidentiality practices and procedures related to resident and employee records and all state/federal privacy laws.

Administrative:

Completes required documentation of care and services delivered during shift including subjective findings, objective symptoms, interventions, and resident responses to interventions. Completes required documentation of special circumstances including accident/incident reports in compliance with state and federal laws and regulations.
Completes written 24-hour community report. Gives and listens to verbal shift report making special note of significant changes in condition, admissions, transfers, discharges, incidents, medication errors, and any other pertinent information.
Reports relevant information to Wellness Director or Executive Director.
Ensures delivery of compassionate quality care to every resident.

Clinical:

Provides direct patient care, administers medications and specialized treatments and diet as prescribed to residents on unit according to physician orders and in compliance with community policies and procedures. Receives and gives a comprehensive report on all residents.
Makes rounds with physicians, schedules lab, x-ray, and appointments as ordered, reviews lab test results, and notifies physician of the same.
Performs physical assessment of new admissions and current residents as indicated by change in condition or as required by regulation. Completes assigned sections of resident assessment instruments used in the community.
Consults with and refers relevant resident care issues to the Wellness Director.
Respects rights of residents regarding freedom of choice, consent for care and services, refusals of treatment and implementation of advance directives if any. Promptly consults with Wellness Director if unsure of proper course of action that respects resident's rights, complies with company/community policies and procedures and provides consistency with federal and state laws and regulations.
Immediately informs the resident, consults with physician, and notifies the designated family member and/or legal representative when there is an accident involving an injury which has potential for physician intervention; a significant change in the resident's physical, mental, or psychosocial status.
Uses good judgment to prepare, administer and immediately document medications and treatments as ordered by physicians. Maintains awareness of prominent medication interactions and side effects, monitors resident for occurrence of such and notifies physician as needed. Orders timely medications to ensure continuity of administration.
Keeps medication rooms and carts locked when unattended and is responsible for the security of the keys and correct reconciliation of controlled substances during shift. Counts all drugs on Individual Control Drug Records with on-coming charge person at change of shifts. Keeps medication room and cart clean and organized. Insures proper storage of drugs and biological items.
Attends in-service education programs and applies information to job tasks.

Note: The essential functions of this job may be revised or updated as community needs dictate.

NON-ESSENTIAL POSITION FUNCTIONS

Other duties as assigned.

EDUCATION & QUALIFICATIONS

To perform this position successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Graduate of an accredited school of nursing.
One-year providing direct care to residents in residential care environment is preferred.
Prior experience as a Nurse or similar supervisory experience preferred.

KNOWLEDGE, SKILLS, ABILITIES

Knowledge of federal/state regulations.
Ability to interpret and apply knowledge of regulations and policy to direct care staff to insure compliance while maintaining consistency and fairness.
Ability to coordinate numerous activities at any given time and make sound judgments and judicious decision quickly, often under pressure.
Ability to read, analyze, professional journals, technical procedures, or governmental regulations. Ability to write reports. Ability to effectively present information and respond to questions from groups of managers, clients, staff, and the general public.
Ability to add and subtract two digit numbers and to multiply and divide with 10's and 100's. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

CERTIFICATES, LICENSES, REGISTRATIONS

Current active Ohio Registered Nurse or Licensed Practical Nurse.
CPR Certification

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