RN, Healthcare Nursing, Nursing Home

General Description

Under the direction of the Unit Manager, Assistant Director of Nursing Services or

Director of Nursing Services, responsible for supervision of assigned staff and providing

quality nursing care to residents to maintain or attain the highest practical level of

functioning. Coordinates nursing care in accordance with Facility policies and

procedures, state requirements, Department of Health regulations, and Federal Health

Care Administration regulations.

Essential Duties

1. Contributes to Facility quality assessment and improvement initiatives.

2. Assesses residents upon admission, develops and updates instant and

comprehensive care plans as needed.

3. Transcribes, clarifies, and implements physician's orders.

4. Administers and monitors resident medications and treatments per physician's

orders. Maintains accurate medication administration records and treatment

administration records. Verifies medication cart is secure and clean. Secures

narcotics per Facility policy and state regulations.

5. Communicates status of residents to incoming licensed personnel according to

established procedures at shift change. Performs medication inventory at the

beginning and end of the shift with another licensed nurse and immediately

notifies supervisor of discrepancies.

6. Assesses and documents residents change in condition; develops, documents, and

implements appropriate nursing interventions; and notifies physician and

appropriate persons as needed.

7. Updates and maintains accurate resident clinical files.

8. Conducts personal physical assessment of residents for skin breakdown upon

admission and as assigned.

9. Supervises, trains, and delegates job tasks to certified nursing assistants and unit

clerks.

10. Communicates status of residents, new admissions, scheduled appointments,

assigned baths, restorative instructions, changes in specialized diets, and other

individualized patient instructions to certified nursing assistant staff at shift

change.

11. Verifies resident rooms, therapeutic equipment, and nursing areas are clean and

organized.

12. Responsible for managing resident meal times and providing appropriate

supervision.

13. Verifies supplements, snacks, and fluids are passed per protocol and schedule.

14. Makes daily resident rounds and verifies completion of job tasks assigned to

certified nursing assistants.

15. Responsible for accurate documentation of resident information including, but not

limited to:

a. Resident skin condition;

b. Diet and supplements;

c. Special equipment needs;

d. Continence and protection used;

e. Weight gain or loss;

f. Side rail use and reason for use

g. Assistance required by resident

16. Completes employee and resident incident report forms.

Standard Requirements

1. Supports the Mission, Values and Vision of the Facility.

2. Is knowledgeable of resident rights and supports an atmosphere which allows for

the privacy, dignity and well-being of all residents in a safe, secure environment.

3. Supports, cooperates with, and implements specific procedures and programs for:

OSHA and safety, including standard precautions and safe work practices,

established fire/safety/disaster plans, risk management, and security, report and/or

correct unsafe working conditions, equipment repair and maintenance needs.

4. Adheres to:

a. Confidentiality of all data, including resident, employee and operations

data.

b. HIPAA regulations

c. Quality Assurance requirements and compliance with regulatory

requirements.

d. Compliance with current law and policy to provide a work environment

free from sexual harassment and illegal and discriminatory behavior.

e. Code of Conduct and Compliance Program when performing work

functions.

5. Supports and participates in common teamwork:

a. Cooperates and works together with all co-workers; plan and complete job

duties with minimal supervisory direction, including appropriate

judgment.

b. Uses tactful, appropriate communications in sensitive and emotional

situations; addresses family satisfaction issues immediately and assists in

resolving the matter in a professional manner.

c. Follows up as appropriate with supervisor, co-workers or residents

regarding reported complaints, problems and concerns.

d. Promotes positive public relations with residents, family members and

guests.

e. Completes requirements for in-service training, acceptable attendance,

uniform and dress codes including personal hygiene, and other work

duties as assigned.

f. Participates as assigned in the orientation of new staff and demonstrates a

positive, helpful, and enthusiastic attitude.

6. Immediately reports incidents of alleged resident abuse or neglect or alleged

violations of residents' rights to Director of Nursing or Executive Director.

7. Knowledgeable of age specific developmental factors specific to adult and

geriatric residents (i.e. physical, cognitive and socialization factors) in planning

delivery of care.

8. Maintains current practice standards or changes by participating in educational

opportunities provided by the Facility and outside resources.

Other…