A licensed professional nurse directly under the supervision of the Director of Nursing Services that provides care and services to residents in a long-term care setting.
Qualifications:
• Graduate of an accredited RN school of nursing.
• Current nursing license, in good standing with the State licensing board
• Strong qualities of leadership, communication, and organizational skills. (moved below) Ability to provide quality patient care in accordance with applicable standards, policies, and procedures.
• Possess critical thinking skills to analyze, synthesize, and evaluate clinical data and observations in developing a nursing plan of care.
• Comprehensive knowledge of applicable nursing principles and practices to ensure the quality of care standards for resident’s care.
• Possess the willingness to work with professional and nonprofessional personnel. Proficiency in the English language including the ability to speak, read, write, and comprehend the language with minimal to no difficulty.
• Valid CPR certification
General Duties and Responsibilities:
GENERAL
• Provides nursing care as prescribed by physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures
• Administers professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being utilizing the nursing process of assessing, planning, implementing, and evaluating patient care
CLINICAL
• Admits, transfers, and discharges residents in accordance with policy and procedure
• Orients new residents/families as necessary
• Gives/receives nursing reports upon beginning and ending of assigned shift. Reviews daily patient reports and assignments with Nursing Assistants upon the beginning of the assigned shift.
• Assures that the unit area is maintained in a clean and safe manner for resident comfort and convenience.
• Conducts daily resident rounds to assess and evaluate the resident’s physical, medical and emotional status and to implement or revise nursing interventions to the resident plan of care.
• Records care information accurately, timely and concisely. Completes all required documentation including resident assessments, interventions, and patient response(s) in the medical record in accordance with policy.
• Initiates, reviews, revises, and updates resident Plans of Care as indicated. Evaluates the patient’s progress toward specific goals and adjusts the nursing plan of care, as necessary. Receives and transcribe orders accurately from attending/alternate physician
• Receive and transcribe orders accurately from attending/alternate physician
• Assists in making rounds with the attending physician, as necessary.
• Prepares / administers medications as ordered by the physician and within the legal scope of practice.
• Completes medical treatments as indicated and ordered by the physician.
• Evaluates resident response and reports adverse reactions to medications or treatments in accordance with the policy.
• Assures that narcotic and controlled drugs are secure, inventory counts are accurate and narcotic register documentation is timely and accurate
• Orders prescribed medications, supplies and equipment as established by the facility’s policies and procedures.
• Requisitions and arranges for diagnostic and therapeutic services as ordered by the physician.
• Informs the RN Supervisor or RN in charge of the facility and others as appropriate of resident status and related matters
• Attends various facility meetings (care conferences, stand-up meetings, staff meetings, Medicare meetings, discharge plan meetings, etc.) as required.
• Reports allegations of abuse or unusual occurrence per State and Federal Regulations and facility policy. Assists with a gathering of information relative to the event.
• Initiates emergency procedures (including basic CPR) and provide emergency patient treatments
• Participates in the facility’s infection control program for monitoring communicable and/or infectious disease among residents and staff.
• Participate in procedures for reporting hazardous conditions or equipment.
• Assists in orientation of newly assigned personnel as requested.
• Assumes Charge responsibility following orientation period as requested.
• Performs other position-related duties as assigned.
• Supervise CNAs
SUPERVISION
• Make resident rounds to ensure appropriate care is being rendered, identifying, and making corrections as necessary.
• Meet with nursing personnel to assist in identifying and correcting problem areas and/or the improvement of resident care.
• Assist the Charge Nurse in revision and distribution of nursing assignments as needed.
• Assist in the supervision and direction of nursing personnel.
• Participate in disciplinary action and evaluation of nursing personnel.
CONSUMER SERVICE
• Presents a professional image to consumers through dress, behavior, and speech.
• Treats residents/family members with dignity and respect
• Responds to Resident and family concern(s) and assists in resolving grievances. Records grievances per facility policy
ADDITIONAL DUTIES
• Participate in the facility's Quality Assurance (QA) program as requested or needed. Assist in correcting findings and deficiencies from the Department of Health Services, Consultants, and the Quality Assurance Team as directed by the Director of Nursing. Actively participates in Quality Assurance Performance Improvement teams and activities
• Ensures the protection of health information as required by the Health Insurance Portability and Accountability Act (HIPAA)
