Registered Nurse; RN

Essential Job Functions:

Nursing Care Functions

• Conduct the daily nursing functions in accordance with current rules, regulations, and guidelines that govern the long-term care facility/assisted living communities.
• Ensure that all nursing personnel assigned to you comply with the written policies and procedures including the safety program.
• Admit, transfer, and discharge residents with documentation regarding care and service provided.
• Participate in the orientation of new residents/family members to the facility.
• Make rounds with health care provider as needed.
• Utilize nursing personnel qualifications according to the resident’s care plan, service plans and health care provider orders.

• Complete daily clinical and environmental rounds to evaluate resident care being provided and report significant events.
• Meet and resolve issues with residents and/or family members. Report significant issues to the supervisor.
• Participate in facility surveys (inspections) as requested by management.
• May be responsible for clinical programs as directed, e.g., dementia, wound care, quality assurance, infection control, admissions.
• Complete an initial assessment and assist or develop interim care plan/service plans.
• Update, review, and transcribe the care plan that identifies the goals, problems, approaches, and revisions based on nursing needs and new health care provider orders.
• Assist with service plans as directed by the Director of Nursing.
• Communicate with health care provider to review treatment plans, complete orders, progress notes, etc., in accordance with established policies.
• Review the resident’s medical record for specific treatments, medication orders, diets, labs etc., as for implementation and follow up.
• Requisition and arrange for diagnostic and therapeutic services, as ordered by the health care provider, and in accordance with our established procedures.
• Communicate the department’s policies and procedures to personnel, residents, and visitors.
• Communicate with written (24-hour report) and oral reports/recommendations concerning any changes in resident condition and other activities of your shift to nursing management.
• Fill out and complete accident/incident reports involving residents and submit to Director of Nursing.
• Complete assessments and all other medical record documentation as required to provide care services.
• Provide resident and family information for care conferences or other meetings.
• Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the supervisor.
• Complete clinically accurate documentation according to policy.
• Review the resident medical documentation and progress notes from the interdisciplinary team to determine if the care plan/service plans are being followed. Report any concerns to your supervisor.
• Inform nursing personnel of new admissions and the resident’s care needs. Ensure that rooms are ready for new admissions. Greet newly admitted residents upon admission.
• Notify the resident’s attending health care practitioner and family when there is a change in the resident’s condition.
• Assist in arranging transportation for residents and other third-party services.

• Prepare and administer medications ordered by the health care provider.
• Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the supervisor.
• Review medication administration record for completeness of information, accuracy in the transcription of the health care provider’s order. Report concerns to your supervisor.
• Dispose of drugs and narcotics as required, and in accordance with established procedures.

• Supervise your nursing unit to ensure that all personnel are performing their work assignments in accordance with acceptable nursing standards.
• Work with the Director of Nursing to resolve staff performance issues including those that may lead to termination.
• Review complaints and grievances, and work with the Director of Nursing for a plan of action and resolution.

• Assure and…