Position Title: Nurse
Department: Nursing
Reports to: Director of Nursing/Designee
Position Summary:
Demonstrate understanding and utilize nursing policies and procedures in the administration of resident care. Direct day-to-day functions of the nursing assistants in accordance with current rules, regulations and guidelines that govern the long-term care facility. Ensure that all nursing personnel assigned to you comply with the written policy and procedures established by the facility. Ensure that residents and families receive the highest quality of service in a caring and compassionate atmosphere. Meet with assigned staff to plan the shifts, services, programs and activities. Follow facility's guidelines for reporting all activity during scheduled shift. Participate in the facility's quality assurance program. Assist in facility surveys (inspections) conducted by authorized government agencies. Admit, transfer, and discharge residents consistent with facility policy. Attend all required training programs.
Charting and Documentation
Complete all required documentation pertaining to resident's admission, transfer and/or discharge. Receive and accurately transcribe telephone orders from Physicians and record on the Physicians' Order Sheet. Complete all required documentation pertaining to accidents, incidents, unusual occurrences and changes in resident's condition in a timely and accurate manner. Report all discrepancies noted concerning physician's order, diet change, charting error and etc. to the DON/designee. Document in the resident's medical record consistent with standards of care and state and federal requirements. Review and complete the 24 Hour Report as required by policy and procedure.
Medication/Treatment Administration Functions
Ensure that narcotic records are completed consistent with standard nursing practice. Notify DON/designee of any drug and narcotic discrepancies noted on your shift. Properly maintain all medications per applicable policies and procedures. Order, prepare and administer medications/treatments as ordered by physician. Report medication/treatment events to DON/designee.
Personnel Functions
Develop work assignments and/or assist in completing and performing such assignments as needed. Make rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report concerns/problems to the DON/designee. Develop and maintain a good working rapport with inter-departmental personnel as well as other departments within the facility to ensure that nursing services and additional services/activities are adequately maintained in order to meet the needs of the residents. Receive/give nursing report at the beginning and end of each shift. Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures.
Nursing Care Functions
Perform nursing duties pertaining to pre-admission, admission and discharge of residents. Make rounds throughout the shift in order to continuously monitor and assess residents conditions including but not limited to residents noted on the 24 Hour Report. Make rounds with physicians as necessary. Consult with physicians with regard to resident's care and perform and/or coordinate resident treatments as ordered the physician. Make periodic checks to ensure that prescribed treatments are properly administered and to evaluate the resident's physical and emotional status. Encourage and assist in coordinating resident participation in social and activity programs. Notify the resident's physician, family and DON/designee when the resident is involved in an accident or incident or when there is a change in a resident's condition. Participate in restorative and rehabilitative programs. Maintain the nursing station, medication rooms, medication carts and general treatment areas in a clean, orderly and safe manner.
Administer standard nursing services including but not limited to catheterizations, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags and other services as required. Ensure that resident care is provided in accordance with the resident's plan of care and general wishes. Ensure that all call lights are answered timely. Ensure that residents who are unable to call for help are monitored frequently.
Safety and Sanitation
Monitor assigned personnel to ensure they are following established safety regulations in the use of equipment and supplies. Ensure that human resource policies and procedures are followed by assigned nursing personnel. Ensure that all resident rooms are maintained in a clean, safe and sanitary manner. Comply with the facility's infection control program. Ensure that all personnel wear and/or use safety equipment and supplies (e.g., gait belts, mechanical lifts, etc,) when lifting or moving residents.
Equipment and Supplies
Ensure that adequate supplies are maintained such as medications, medical supplies, equipment, etc., in order to meet the needs of residents. Participate in the ongoing training and implementation of policies pertaining to the safe operation of all nursing service equipment. Ensure that only trained and authorized personnel operate facility's equipment.
Care Plan and Assessment Functions
Review care plans/care cards to ensure that appropriate and consistent care is being rendered.
Resident's Rights
Comply with facility's policies pertaining to resident's rights. Maintain the confidentiality of all resident information (HIPAA). Report and investigate all allegations of resident abuse and/or misappropriation of resident's property.
Supervision
Responsible to supervise day-to-day activities of assigned CNAs. Participate in CNA employee performance evaluations, determining your shift's staffing requirements, and making recommendations to the Nurse Supervisor concerning employee competency, discipline and commendations. Reinforce the training and orientation of nursing personnel and provide positive reinforcement.
Customer Service
Ensure that the highest degree of quality care is provided at all times. Actively participate in the principles of the SMILE program.
