LICENSE PRACTICAL CHARGE NURSE

Berkshire Nursing and Rehabilitation Center -

TITLE : LICENSE PRACTICAL CHARGE NURSE

RESPONSIBLE TO : NURSE SUPERVISOR

POSITION SUMMARY :

The purpose of your job as a Licensed Practical Nurse is to perform a variety of care practices under the direction of the Registered Nurse and / or Supervisor of the unit / shift. This includes, but not limited to taking charge of a unit and administering medication as ordered.

JOB FUNCTION :

Every effort has been made to make your job description as complete as possible. 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 a logical assignment to the position.

QUALIFICATIONS :

1. Currently licensed by the State of New York.

2. Mentally and physically capable of performing job duties.

3. Possesses leadership and supervisory qualities.

4. Possesses observation skills that enable the recognition of condition changes in the resident.

5. Ability to coordinate all functions in the operation of a resident unit through effective team nursing assignments.

6. Maintain meaningful and accurate documentation of services provided.

PERSONAL APPEARANCE :

1. Required uniform is to be worn.

2. Wear clean, well-fitting uniform with name tag and title.

3. Shoes must be clean, white rubber soled, and nursing regulation.

4. Makeup must be in good taste and moderate in amount.

5. Hair, hands, fingernails must be neat, well-kept and clean.

6. Jewelry should be restricted to simple ring and wristwatch.

7. Proper, acceptable, personal hygiene must be maintained at all times.

RESPONSIBILITIES :

1. Count and sign for controlled drugs with the nurse going on / off duty. Report any discrepancies to the supervisor immediately. Do not pre-sign for the end of your shift and do not pre-pour medications.

2. Receive report via EMR and nurse going off duty. Be sure you have the keys. Be present for the Charge Nurse’s report to the CNA’s.

3. Check temperature of the medication refrigerator as well as expiration dates on medications in the refrigerator (temperatures should range between 36 and 46 degrees). Never store food items or specimens in medication refrigerator.

4. Sign for medications delivered by vendor pharmacy.

5. Observes, records and reports to head nurse or supervisor, as indicated, all pertinent changes in medical condition and / or incidents which involve residents, staff or visitors.

6. Review physician’s orders for any changes and check to see that these changes have been carried over in EMR or other appreciate records.

7. Be aware of residents who are fasting for lab work, etc., making certain that this information is communicated to the staff. Tube feeders that receive insulin will require their coverage following lab work.

8. Assemble supplies for medication administration including fresh water, juice, and applesauce, which must be dated. Supplies will also include hand spray for hand washing in between each resident, souffl cups, medicine cups, drinking cups, straws, spoons, tissues, paper towels, etc.

9. Maintain a system to check all medication labels for incorrect labeling and / or expired dates.

10. Medication that has been discontinued must be removed from the medication cart or other areas and brought to the Nursing office as soon as possible for return to the pharmacy. Expired medication is handled in the same manner. Vaccines and PPD does that have expired or vials that are empty are discarded into the used needle and syringe container.

11. Medication and Treatment carts are to remain closed and locked when not in use and keys are to be carried on your person at all times.

12. Wash your hands before starting out with medication cart.

13. The resident’s arm band and or positive identification of the resident are to be made prior to medication administration. Medications are to be administered individually (one at a time) and then documented in EMR. All rules and protocols for medication administration are to be followed. Never pre-pour medications. Medication is not to be left at bedside. Do not administer medications that are poured by another nurse.

14. PRN medications are documented in EMR. Medication refusals are to be documented in EMR.

15. Hand washing must take place in between each resident receiving medication. Hand washing using soap and water is required in between dispensing ENT medications following glove removal.

16. Discipline subordinate staff when necessary.

17. ENT medications are to be dispensed at separate times from oral medication. Eye drops are to be administered at least five minutes apart. Gloves are to be worn when administering eye medications.

18. No medications are to be left on top of the medication and / or treatment cart or at the bedside at any time.

19. When administering medications via feeding tube, injections or performing finger-sticks, privacy of the resident must be maintained. Take the resident back to his / her room, a private area or use a screen to allow for privacy in common areas.

20. Perform finger-sticks as ordered and provide insulin coverage if ordered and document the results via EMR.

21. Assist in feeding of the residents during meal times.

22. No medications are to be administered during meal times unless they indicated / ordered to be given during meals.

23. The medication room is to be kept locked at all times.

24. Perform all treatments and document via EMR.

25. Medication and Treatment cart are to be left clean and re-stocked at the end of the shift.

26. Soiled dressings are to be discarded in a red plastic bag.

27. Administer tube feeding as per procedure and physician order.

28. Assist with documenting and picking up orders via EMR.

29. Attend in-service classes and staff meetings when scheduled. Assist in the orientation of new nursing personnel.

30. Check emergency drug box as per procedure. Check the used syringe boxes, cap them off when full, and order replacement.

31. Report any medication incidents that are unusual and / or refusals to the supervisor. Assist in filling out any required forms pertaining to this or any accident / incident which may occur.

32. Will assume charge nurse responsibility when necessary.

33. Must know the action / side effects of the medications she / he is dispensing and follow the list of non-crushable medications as per manufacture directions.

34. Perform other nursing functions as designated by your supervisor.

35. During inclement weather or emergencies, staff is to remain on duty until adequate staff has arrived and the Supervisor approves dismissal.

36. Medication is not to be administered without a physician / NP / PA order.

37. Discard any medications that have fallen on the floor. When wasting control drugs, a witness must be present when discarded and both parties must sign the control sheet.

38. All liquid medications are to be shaken adequately and poured at eye level away from the label.

39. Pill crusher is to be cleansed after each use. Use two cups to crush medications.

40. PRN medications that have not been administered for long periods of time; the physician is to be notified for the order to be discontinued.

41. All newly opened vials of injectable medications are to be dated.

42. Allergies are to be entered in EMR.

43. Notify Supervisor immediately upon discovery of missing medications and / or any other discrepancies in dosage.

44. All open vials of injectable medications are to discarded after thirty days.