Nurse, Nursing Home

Nurse

The Nurse assumes responsibility and accountability for resident care of a designated shift and in accordance with federal and state regulations and company/community policies, procedures and Personal Service Plans.

Essential Position Functions:

• Coordinates patient care and non-patient care by developing and distributing written nursing assignments for each employee which outlines residents to be cared for and other duties to be executed during the shift.
• Describes personal service plan and approaches to direct care staff so that plan is consistently implemented on all shifts by all caregivers.
• Monitors delivery of care and services throughout shift to ensure needs are met, tasks are completed, including complete and accurate resident documentation, and that work of direct care staff is of acceptable quality and quantity.
• Makes daily rounds on assignment at least at beginning and end of shift to observe, examine, or interview residents to verify information from ongoing shift, to monitor regulatory compliance, and to determine or rotate staff assignments and make adjustments according to qualified staff availability and resident needs.
• Provides orientation, trains, and develops staff by identifying learning needs while taking opportunities to teach on the unit. Updates employees regarding changes in resident needs. Instructs personnel on use of equipment.
• Coaches and monitors staff performance providing praise and redirection when applicable. Issues disciplinary actions to staff, when needed, in a fair and consistent manner in conjunction with federal and state laws and company policies and procedures.
• When necessary, schedules employees to work and replaces call-ins for the following shift. Ensures correct number of staff on duty, schedules lunch and rest breaks, approves or denies requests to leave early.
• Monitors and trains staff and corrects deficiencies for compliance with OSHA mandates on workplace safety including hazard communication, blood borne pathogens, and infection control procedures. In cases of work place exposure, coordinates immediate first aid, insures proper documentation and refers employee for post-exposure treatment.
• Monitors restorative measures provided by staff in daily care of residents (i.e. range of motion, self-help skills, positioning and body mechanics).
• Performs duties as assigned in Community Fire and Disaster Plan that may include taking charge of evacuation, drills, and transportation of residents.
• Receives, investigates and responds to employee problems and complaints.
• Complies with the community's privacy and confidentiality practices and procedures related to resident and employee records and all state/federal privacy laws.
• Completes required documentation of care and services delivered during shift including subjective findings, objective symptoms, interventions, and resident responses to interventions. Completes required documentation of special circumstances including accident/incident reports in compliance with state and federal laws and regulations.
• Writes comprehensive weekly/monthly summaries reflective of patient's status, abilities/disabilities, and specifically addressing problems identified on the patient Personal Service Plan. Initiates and updates patient Personal Service Plans as needed with appropriate problems, resident-oriented goals, and approaches based on resident needs.
• Completes written 24-hour community report. Gives and listens to verbal shift report making special note of significant changes in condition, admissions, transfers, discharges, unnecessary use of any drug, incidents, unexplained injuries, medication errors, loss of resident property, or evidence of resident or family dissatisfaction.
• Reports relevant information to Wellness Director including interdisciplinary team functioning and communication, regulatory compliance issues, resident risk factors, sudden changes in resident behavior, expressed dissatisfaction by resident or family, refusals of treatment, unexplained injuries, positive or negative staff behavior, staffing needs, equipment and supply needs, and opportunities to revise policies or procedures and improve quality.
• E…