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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 res idents and employees.
- Conducts frequent rounds to evaluate effectiveness of care delivery.
- Prepares equipment and a ids 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.
