JOB SUMMARY: 

The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by licensed practical nurses and nursing assistants. 

JOB DUTIES & RESPONSIBILITIES: 

Administrative Functions

·        Organize and assign all jobs to be done on tour of duty so that workload is evenly distributed among nursing personnel on the basis of staff qualifications, size and physical layout of the facility.

·        Periodically review department policies, procedures and job descriptions and make recommendations for revisions.

·        Implement established policies and procedures.

·        Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.

·        Meet with your assigned nursing staff and support personnel to plan appropriate services, programs and activities for your shift.

·        Cooperate with other resident services when coordinating nursing services to ensure that the resident’s individual care plans are being followed.

·        Participate in the development, maintenance, and implementation of the facility’s quality assurance program.

·        Request conferences with the Director of Nursing as needed to discuss resident, personnel and facility related business.

·        Participate in facility surveys made by authorized regulatory agencies as requested.

·        Periodically review the resident’s written discharge plan and participate in updating that plan as required.

·        Admit, transfer and discharge residents as required.

·        Place and receive, personally, all calls to and from physicians.

Charting and Documentation

·        Assist in updating the resident care plans as instructed by the MDS/Care Plan Coordinator and/or Director of Nursing.

·        Chart nurses’ notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident’s response to the care.

·        Document status of each resident on the chart at least weekly, more often if significant change occurs or as directed. Follow up with monthly and quarterly summaries as instructed.

·        Make rounds with physician, as directed, and record visits in resident’s chart.

·        Transcribe, accurately and promptly, all physician’s orders.

·        Direct documentation and make weekly detailed evaluation of all resident documentation so that chart reflects progress and condition of resident at all times.

·        Approve and sign charts when observations are made.

·        Insure that all medications and treatments are charted and signed following administration of the medication/treatment, by the administering person.

·        Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc. to the ADON or DON.

·        Complete accurate accident/incident reports as necessary.

·        Fill out and complete transfer forms in accordance with established procedures.

Drug Administration Functions

·        Prepare and administer medications as ordered by physician.

·        Verify the identity of the resident before administering the medication/treatment.

·        Ensure that prescribed medication for one resident is not administered to another.

·        Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hand to meet the nursing needs of the residents. 

·        Order prescribed medications, supplies, and equipment as necessary and in accordance with established policies.

·        Ensure that narcotic records are accurate for your shift.

·        Notify the ADON or DON of all drug and narcotic discrepancies noted on your shift.

·        Prepare, administer and record all parenteral, intramuscular, sub-cutaneous injections.

·        Administer I.V. fluid therapy in accordance with policy and procedure.

·        Administer or supervise all treatments prescribed by physician.

·        Dispose of drugs and narcotics as required and in accordance with established procedures.

Nursing Care Functions

·        Implement and maintain established nursing objectives and standards.

·        Make rounds at least every two (2) hours to ensure that certified nursing assistants are properly administering prescribed care assignments.

·        Make general observation and evaluation of the resident’s physical and emotional status. Make note of any significant changes and communicate those changes to the ADON/DON according to facility policy and protocol.

·        Ensure that direct nursing care is provided by a licensed nurse, a certified nursing assistant, and/or a nurse aide trainee qualified to perform the procedure.

·        Cooperate with and coordinate social and activity programs with nursing service schedules.

·        Notify the resident’s physician and/or next of kin when the resident is involved in an accident/incident or if there is a significant change in the resident’s condition.

·        Cooperate with restorative and rehabilitative programs as requested.

·        Inspect the treatment areas to ensure they are maintained in a clean and safe manner.

·        Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings, packs colostomy and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc. as required.

·        Administer restraints for residents in accordance with physician’s orders, established policies and procedures.

·        Obtain sputum, urine and other specimens for lab tests as ordered.

·        Take and record TPR’s, blood pressures, etc. as necessary.

·        Monitor seriously ill residents as necessary.

·        Check foods brought into the facility by the resident’s family/visitors to ensure it is within the resident’s dietary allowances.  Report problems to the ADON/DON.

·        Ensure that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.

·        Ensure that residents who are unable to call for help are checked frequently.

·        Meet with residents, and/or family members, as necessary.  Report problems/complaints promptly to the ADON/DON.

·        Admit, transfer and discharge residents as necessary.

·        Ensure that discharged residents are escorted to the pick-up area.

·        Inform family members of the death of the resident.

·        Ensure that established postmortem procedures are followed.

·        Conduct week skin checks as assigned.

Human Resource Functions

·        Assist the SDC in developing, planning, conducting and scheduling in-service training classes that meet the skill development and knowledge acquisition needs of your assigned staff.

·        Implement and maintain an effective “unit/shift/floor” orientation for new associates.

·        Assist in standardizing the methods in which work will be accomplished.

·        Respond to need for staffing shortages by arranging replacement staff, as directed.

·        Conduct performance evaluations for your assigned staff according to facility policy i.e., following orientation and annually.

·        Review and evaluate your department’s work force and make recommendations to the ADON/DON.

·        Develop work assignments for nursing staff on your shift.

·        Provide leadership to nursing personnel assigned to your shift.

·        Make daily rounds of your unit to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards.

·        Meet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas and/or improve services.

·        Develop and maintain a good working rapport with inter-departmental personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents.

·        Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm, quiet environment throughout the unit and shift.

·        Review complaints made by your assigned personnel.