Registered Nurse; RN Weekend Position

SUMMARY

Under the general supervision of the Director of Nursing, the Registered Nurse performs a variety of resident care functions and closely observes residents for changes in medical status. This position also uses independent judgment and discretion in maintaining the delivery of quality resident care by assuring that the nursing and medical care plan is followed, and makes supervisory decisions. In the absence of the Director of Nursing, this position assumes full responsibility for the resident care.

Administers nursing care as indicated by the nursing care plan and in compliance with all Regulatory Agencies.

• (1) Reviews all resident histories to determine course of illness and all co morbidities for integration into the care plan.
• (2) Demonstrating the ability to assign meaning to resident symptoms and initiating appropriate action.
• (3) Ensuring that problems/concerns regarding activities in the facility/department are communicated appropriately.
• (4) Effectively assessing, planning, implementing, and evaluating nursing care for residents.
• (5) Educating residents, families and significant others regarding treatment, tests, special procedures, medications and safety.
• (6) Consistently monitoring resident condition and initiates appropriate nursing intervention.
• (7) Initiating and conducting emergency measures (including CPR) required to stabilize patient's condition.
• (8) Prioritizing residents’ needs, expediting treatment for acutely ill residents to include CPR.
• (9) Consistently documenting resident care and reports pertinent clinical observations and reactions to the appropriate individual.
• (10) Actively participating in development and assessment of resident care issues as they relate to Performance Improvement activities for the department.

Initiates the plan of care within 24 hours of admission and consistently updates care plan with changes in resident needs or condition.

Performs and accurately documents the resident admission assessment, completing within 24 hours of admission.

Consistently and accurately performs reassessments during each shift and when the resident condition changes.

Completes other assessment tools as defined in policy when appropriate (i.e., pain assessment, pressure ulcer protocol, fall assessments, etc.).

• (1) Administering medications as ordered by physician using age specific monitors.
• (2) Ensuring medications are ordered, received and transcribed on a routine basis and in a timely manner.
• (3) Appropriately transcribing, administering and documenting medications according to policy and procedures and age specific considerations.
• (4) Monitoring and removing any discontinued or expired medications from medication carts.
• (5) Maintaining a current, accurate listing of all resident medications.
• (6) Demonstrating knowledge and ability to intercede in repetitive prescriptions or contradictory medications.
• (7) Reordering emergency medications from emergency box (e-kit) as needed.
• (8) Completing appropriate forms and returning unused medication to the pharmacy in a timely manner.

Appropriately and safely administers IV therapy and documents according to policy and procedure.

Participates in interdisciplinary team conferences and relays treatment plan decisions to the other members of the nursing team.

Reports all abnormal test results to physician in a timely manner; triages activities based on borderline and/or abnormal and/or unusual findings.

Demonstrates ability to understand and react effectively to unique/special needs of adults, and/or elderly residents.

Initiates approved regimes of care as established by policy. Reports all findings to physicians. Assures proper follow-up resolution of resident clinical complaints.

Demonstrates leadership, communication and teaching skills.

Serves as an education resource for staff, sharing information in an accurate, cooperative and professional manner.

Practices appropriate infection control and isolation techniques to maintain a safe environment and control the spread of infection.

Writes and reviews progress notes according to policy and procedures.

• (1) Appropriately transcribing, administering, and documenting medications according to P&P and age specific considerations.
• (2) Documenting nursing interventions and resident responses including physical and psychological response.
• (3) Documenting resident needs, problem capabilities, limitations and progress.
• (4) Ensuring documentation is legible and neat and that records are appropriately signed (i.e., first initial, last name, title, and date).
• (5) Documenting any teaching done with…