Registered Nurse; RN

JOB SUMMARY:

Under the supervision of the Unit Manager, Assistant Director of Nursing (ADON) and/or Director of Nursing (DON), the Registered Nurse (RN) assumes responsibility and accountability for a group of residents for or a shift of duty. Nursing care is provided through assessment, implementations, and evaluation of the plan of care. The RN adheres to the standards of care for the area, manages the environment to maintain resident safety, and supervises the resident care activity performance by nursing assistants and staff.

Follows all facility policies and procedures. Performs duties as defined by the State Nurse Practice Act.

DUTIES/RESPONSIBILITIES:

• Makes frequent rounds to note resident conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards.

• Provides licensed care to assigned residents as ordered by physician and in accordance with facility, federal, state, and local standards, guidelines, and regulations

• Provides and receives nursing reports upon reporting in and ending shift duty hours.

• Ensures assigned work area (i.e. nurse station, med. Cart, medication room, etc.), resident care rooms, and treatment areas are maintained in a clean and sanitary manner.

• Monitors nursing supplies and orders as needed.

• Attends regularly conducted staff meetings as scheduled by the Director of Nursing/Unit Manager.

• Directs and supervises the day-to-day certified nursing assistant services for assigned units to assure that care is being rendered in accordance with current federal, state, and local standards, guidelines, and regulations.

• Provides required resident assessments/observations and interventions.

• Reviews care plans, at least daily, to ensure appropriate care.

• Appraises the DON / ADON / Unit Manager of resident status changes in condition.

• Informs physician of resident change of condition.

• Takes and records resident's blood pressure and vital signs.

• Administers catheter care to residents as required (may include catheter insertion).

• Administers IV therapy to residents as ordered within license limitations.

• Provides respiratory care, e.g. oxygen, nebulizer treatments.

• Assists the physician in therapeutic measures, as needed.

• Receives and transcribes physician’s orders to resident’s charts, Kardex/Care Medication Administration Record (“MAR”), treatment/care plans, as required.

• Prepares and administers medications and performs treatments as ordered by the physician.

• Charts nurses notes in an informative and descriptive manner that reflects the care provided as

well as the resident’s response to the care.

• Documents all pertinent data as required by Medicare, Medicaid, and facility standards and policies.

• Completes the required forms upon admission, transfer, and/or discharge.

• Counts all controlled drugs with other nurse at shift change and notifies the DON / Unit Manager of all drug and narcotic discrepancies noted on your shift.

• Keeps medication room and medication cart locked according to regulations. Responsible for security of keys.

• Ensures that crash cart is appropriately stocked and in good repair.

• Ensures the resident’s environment is as free from accidents and hazards. Immediately corrects/addresses potential safety risks as prudent and warranted.

• Keeps medication room and medication cart clean and orderly.

• Directs the day-to-day functions of the certified nursing assistants in accordance with current rules, regulations and guidelines that govern long-term care facilities.

• Closely monitors and supervises all facility residents per facility policies and as warranted by good nursing judgment.

• Coordinate overall resident care issues per nursing license, facility policy and as warranted to meet resident needs.

• Makes written and oral reports/recommendations concerning the activities of shift as required.

• Monitors and directs non-licensed ancillary services as deemed necessary to meet professional standards and maintain the highest practicable level of resident care

• Communicate/report information to residents, resident families, physicians, guardians, governmental agencies, and facility personnel as required by facility…