Purpose of Your Job Position
The primary purpose of this position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the Nursing Assistants and Licensed Practical Nurses in accordance with the Nurse Practice Act; current federal, state, and local standards; guidelines and regulations that govern the Facility; and as may be required by the Director of Nursing Services or Assistant Director of Nursing to ensure the highest degree of quality care is maintained at all times
Delegation of Authority
As a Registered Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.
Job Function
Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is an essential function of the position.
Duties and Responsibilities
• Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care Facility.
• Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this Facility.
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedure Manual.
• Expected to supervise nursing staff while abiding by scope of practice per position.
• Make written and oral reports/recommendations concerning the activities of your shift as required.
• Cooperate with other resident services when coordinating nursing services to ensure that the residents' total regimens of care are maintained.
• Participate in Facility surveys (inspections) made by authorized government agencies as may be requested.
• Assist in planning the nursing services portion of the residents' discharge plans as required.
• Admit, transfer, and discharge residents as required.
• Complete accident/incident reports, as necessary.
• Complete all record keeping upon residents' admissions, transfers, and/or discharges into the electronic health record (EHR).
• Receive telephone orders from physicians and transcribe as required by Facility policy.
• Chart Progress notes in an informative and descriptive manner that reflects the care provided to residents as well as the residents' responses to the care.
• Perform routine and required documentation/charting duties in accordance with established policies and procedures.
• Sign and date all entries and electronically sign all entries in the EHR.
• Prepare and administer medications as ordered by the physician in accordance with federal, state, and local regulations and as required by Facility policy.
• Order prescribed medications, supplies, and equipment as necessary and in accordance with established policies.
• Ensure that narcotics are handled in accordance with federal, state, and local regulations and as required by Facility policy and that narcotic records are accurate for your shift.
• Participate in associate performance evaluations and making recommendations to the Nurse Supervisor concerning associate dismissals, transfers, etc.
• Develop work assignments.
• Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards.
• Meet with the nursing personnel on your shift on a regularly scheduled basis to assist in identifying and/or improving services.
• Understand and implement the Disciplinary Policy and Procedures. Instigate and/or escalate disciplinary actions for resolution. Ensure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
• Make rounds with physicians, as necessary.
• Consult with the residents' physicians in providing the residents' care, treatment, rehabilitation, etc. as necessary.
• Implement and maintain established nursing objectives and standards.
• Notify the residents' attending physicians and next-of-kin when there are changes in the residents' conditions or if the residents are involved in an incident or accident.
• Administer professional services such as catheterizations, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, etc. as required.
• Ensure that personnel providing direct care to residents are providing such care in accordance with the residents’ care plans and wishes.
• Attend and participate in all Facility in-service programs as required.
• Maintain professional competence through participation in continuing education programs, seminars, and training programs.
•
• Monitor assigned personnel to ensure established safety regulations are followed in the use of equipment and supplies.
• Ensure that established departmental policies and procedures are followed by self and assigned personnel.
• Ensure work area, unit, resident care rooms, treatment areas, etc. are maintained in a confidential, safe, and sanitary manner.
• Ensure self and assigned personnel follow established infection control procedures.
• Review care plans to ensure that appropriate care is being rendered.
• Ensure nursing documentation reflects that the care plan is being followed when administering nursing care or treatment.
• Ensure assigned Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) are aware of and carry out resident care plans.
• Assist the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising the MDS, including the implementation of CAAs and triggers.
Resident Rights
· Ensure that all nursing service personnel including assigned CNAs/GNAs are knowledgeable of the residents’ responsibilities and rights including the right to refuse treatment.
· Review complaints and grievances made by the resident and make a written or oral report to the Nurse Supervisor indicating what action(s) were taken to resolve the complaint or grievance. Follow the Facility’s established procedures.
· Maintain a written record of the resident’s complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint.
· Report and investigate all allegations of resident abuse and/or misappropriation of resident property.
· Ensure that nursing staff personnel including assigned CNAs/GNAs honor the resident’s refusal of treatment request. Ensure that such requests are in accordance with the Facility’s policies governing advance directives.
· Must adhere to all HIPAA requirements.
Miscellaneous
· Provide data to the Quality Assurance & Assessment Committee as requested.
Working Conditions
· Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.).
· Involved with residents, personnel, visitors, government agencies or personnel, etc., under all conditions and circumstances.
· May be subject to hostile and emotionally upset residents, family members, and visitors.
· Communicate with the medical staff, nursing personnel, and other department directors.
· May be required to work beyond normal working hours, and in other positions temporarily, when necessary.
· May be subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
· Attend and participate in continuing educational programs.
· May be subject to the handling of and exposure to hazardous chemicals.
· Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.
Education
· Must possess, at a minimum, a Nursing Degree from an accredited college or university
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