The primary purpose of this position is to provide direct nursing care to the residents while supervising the nursing activities for the assigned shift.
Duties and Responsibilities
Administrative Functions
§Ensure the facility meets the minimum staffing levels for nurses and nurse aides; complete required posting of nursing staff data as required.
§Ensure that each resident who experiences a significant change in status is assessed using the Resident Assessment Instrument (RAI) process.
§Ensure that all resident rooms, common areas, treatment areas and nurse’s stations are maintained in a clean, safe and sanitary manner.
§Assist to develop a dementia care program involving an interdisciplinary approach with a holistic focus on the needs of the resident living with dementia.
§Verify resident census accuracy and report new admissions, discharges, leaves of absence and bed-holds per facility policies; document census as established for billing and clinical purposes.
§Assist with safe and orderly resident transfers and discharges in accordance with facility policies.
§Coordinate pre-certifications and recertifications in accordance with facility policies for Medicare Advantage and commercial insurance payers.
§Interpret the department’s policies and procedures to personnel, residents, visitors and government agencies as required.
§Participate in developing, maintaining and updating written facility policies and procedures that govern the day-to-day functions of the nursing services department.
§Participate in facility surveys (inspections) made by authorized government agencies as requested.
§Audit nursing documentation in the clinical record for appropriate and relevant entries.
§Attend and contribute in facility “triple check” process for reviewing coding for accuracy.
§Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
§Periodically review the department’s policies and procedures manuals, job descriptions, etc., and make recommendations for revisions to the Director of Nursing.
§Coordinate the completion of resident billable charge sheets in accordance with billing policies.
Committee Functions
§Prepare reports as requested.
§Attend various committee meetings of the facility (i.e., infection prevention and control, policy advisory, pharmaceutical, quality assurance and performance improvement (QAPI), etc.) as required.
§Participate in developing the agenda for committee meetings as necessary.
§Participate in regularly scheduled reviews of the discharge plans.
Nursing Care Functions
§Provide licensed nursing care to residents that is consistent with the written plans of care.
§Communicate with primary care physician and members of the comprehensive care planning team regarding the status of residents; follow up on critical labs, order requests and physician notifications.
§Arrange for an interpreter or translation services in accordance with facility policies for those with limited English proficiency (LEP).
§Obtain orders to provide essential care to the resident consistent with the resident’s mental and physical status upon admission to the facility.
§Ensure that all residents are treated with dignity, respect and consideration and have the right to exercise their choice and self-determination.
§Ensure that residents receive culturally competent trauma-informed care in accordance with professional standards of practice.
§Evaluate residents’ response to care.
§Coordinate nursing care to accommodate resident’s person-centered plan of care including sleep schedule, social activity and participation in other resident-directed activity; minimize interruption of activities as possible.
§Ensure that residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience that are not required to treat the residents’ medical symptoms.
§Assist in coordinating nursing services with other resident services to ensure the continuity of the residents’ plan of care.
§Identify the learning needs of residents and families and provide individualized and comprehensive resident/family education.
§Educate residents and families on the risk and benefits of a treatment or choice when consent is needed.
§Monitor residents for patterns of decreased social interaction or signs of distress.
§Implement individualized approaches to dementia care including meaningful activities addressing the resident’s customary routines, interest preferences and choices.
§Carry out restorative and rehabilitative programs including restorative nursing, activities of daily living (ADLs) teaching, bowel and bladder retraining and education for self-help as appropriate.
§Provide pain management for residents in accordance with established pain management protocols.
§Complete accident/incident reports as necessary.
§Assist the interdisciplinary team (IDT) with establishing nutrition, hydration and body weight parameters for residents; help facilitate the responsibilities of the food and nutrition services department.
§Keep the Director of Nursing informed of the status of residents and other related matters through written/oral reports; document reportable events and notifications in accordance with facility policies.
§Cooperate with and coordinate social and activity programs with nursing services schedules.
§Periodically review the resident’s written discharge plan; participate in updating the resident’s written discharge plan as required.
§Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident including regular re-evaluation to identify changes that require modifications.
§Make periodic checks to ensure that Certified Nursing Assistants (CNAs) are properly administering prescribed treatments and to evaluate the resident’s physical, psychosocial and emotional status.
§Report problem areas to the Director of Nursing; assist in developing and implementing corrective action.
§Arrange for diagnostic and therapeutic services as ordered by the physician and in accordance with established facility procedures.
§Provide information to the QAPI Committee as requested.
§Coordinate transfer or discharge of residents including arranging transportation, compiling the discharge summary, reconciling medication and reviewing upcoming appointments with resident in a language understood by the resident with the goal of a safe discharge.
§Ensure that discharged residents are escorted to the pick-up area.
Charting and Documentation Functions
§Complete and file required recordkeeping forms/charts upon the resident’s admission, transfer and/or discharge; provide notifications to the ombudsman and responsible party per requirements.
§Document reports of accidents/incidents involving residents; follow established procedures.
§Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
§Audit clinical record for appropriate consents and assessments including advance directives, living wills and other documents required for the delivery of person-centered care with respect to rights and choices.
§Record verbal and telephone orders from practitioners on order sheets or in electronic health record (EHR) per facility policies.
Medication Administration Functions
§Review the controlled substance and drug disposal records for accuracy and notify the Director of Nursing and pharmacy of discrepancies.
§Monitor medication administration process and provide appropriate feedback or changes to prevent medication errors.
§Ensure that the medication carts and medication rooms are clean, sanitary and well stocked.
§Assess residents for appropriate self-administration of medication in coordination with the IDT.
§Reconcile medication delivery from pharmacy by verifying the medications, quantity and accuracy.
§Collaborate with the IDT to ensure the safe and appropriate use of medications for all residents.
§Administer medications in accordance with physician orders, regulations and facility policies.
§Support the objectives of the infection prevention and control program including antibiotic stewardship.
§Work with the IDT to review unnecessary medications and coordinate gradual dose reductions as appropriate.
§Reconcile resident medications (pre/post-discharge) as part of the discharge process.
§Order prescribed medications, supplies and equipment as necessary and in accordance with established facility policies.
Personnel Functions
§Meet with assigned nursing staff as well as support personnel in planning the shifts’ services, programs and activities and to assist in identifying and correcting problem areas and/or improving delivery of person-centered care and services.
§Assist the Director of Nursing in directing the day-to-day functions of the nursing activities in accordance with current rules, regulations and guidelines that govern the facility.
§Direct the day-to-day functions of the CNAs in accordance with current rules, regulations and guidelines that govern the facility.
§Coordinate with the scheduler to ensure a Registered Nurse (RN) is on duty at least 8 hours a day/7 days a week and a Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) is on duty 24 hours a day.
§Ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity; this includes proper licensure or certification if required.
§Assess residents for conditions which may be aided by assistive or adaptive devices; recommend/request in accordance with facility policies; monitor for proper utilization and application of assistive devices.
§Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.
§Develop positive professional relationships with nursing students, teachers/pro
