The primary purpose of this job is to provide for the daily care, health needs, safety and comfort of the residents. This includes providing professional assessments and documentation of the resident's health and assisting with the management of the assigned unit, Charge Nurse, RNs, LPNs, CNAs and QMAs.

Primary Responsibilities

Supervising unit, performing and providing written/ verbal care assignments, routine skills and procedures to ensure the quality of care to residents. 

• Providing supervison, direction, and evaluation of nursing staff on a designated unit, which may include charge nurses:
• Supervising and participating in the development and implementation of resident care plans/MDS, maintaining up to date nursing care plans/MDS, documenting progress, and making recommendations for revisions to care plans/MDS, according to facility policy and procedure.
• Assisting the DON/ADON with the co-ordination, management and monitoring of the review of nurse's notes to determing if the care plan in being followed;
• Making daily and periodic resident visits to observe for sysmptoms, reactions to medication and/ or treatments, changes in condition, gauging unexpressed needs and ascertaining the need for additional or modified services. This includes ensuring that staff is doing the same.
• Supervising staff in monitoring each resident's psychological functions, fluid balance, elimination, electrolyte status, laboratory results, respiratory status, neurological status and nutritional status to detect deviations from normal and gage progress;
• Ensuring that safe staffing levels are maintained through staff absenteeism according to facility policy and procedure;
• Supervising the obtainment and documentation of vital signs, intake and output, weights, diet supplements and replacements, cultures, etc. according to facility policies;
• Notifying physician, family and supervisor if changes occur in resident's health or mental state, in accordance with facility policies, and taking appropriate actions;
• Receiving, documenting and following physician orders according to facility policies and ensuring staff is doing the same;
• Making rounds with the physician;
• Supervising and being responsible for preparing and administering medications, including parenteral and not parenteral, as well as contacting pharmacy to place physician ordered perscriptions/refills;

Providing medical record documentataion in accordance with facility policy and procedures:

• Completing (24) hour reports, end of shift reports, shift narcotic counts, and documenting the destruction of outdated/discontinued medicaitons in the medication destruction record according to facility policy and procedure;
• Completing necessary documentation and teaching of residents for residents' admissions, transfers and discharges according to policy and procedures;
• Maintaining up to date resident medical records, according to policy and procedures on nursing observations and actions taken (i.e. medicaitons/treatments given, daily pertinent nursing notes, weekly/monthly summaries of resident status and all nursing assessment forms):
• Coordinating assignments for Charge Nurses, RNs, LPNs, CNAs, and QMAs
• Performing an inventory on supplies daily and reporting needs to the nurse in charge or person responsbile for acquiring supplies;

Complying with safety requirements, infection control measures, and maintaining a clean work environment in accordance with facility policy as indicated by:

• Using protective devices (side rails, soft limb restraints, Geri chairs, and posseys) appropriately and supervising their use;
• Abiding by all emergency protocols for cash carts, resident codes, fire safety, missing residents, tornado perparation, violent residents, wander guard alarms, door alarms, and other facility policies as assigned.

Must possess specific educational and experience requirements such as:

• High School Diploma or GED
• A Graduate of an accredited school of nursing and possess a valid RN or LPN license in good standing according to State and Federal requirements.
• Have a thorough understanding of the principles of safe effective nursing practices within the State of Indiana.
• Must Possess managerial and interpersonal skills such as:

The ability to follow written and verbal instructions, function independently and make independent decisions when circumstances warrant such actions;

Personal integrity and ability to deal tactfully with residents, family members, vistitors, government agencies, and personnel;

The ability to work harmoniously with professional and non - professional personnel;

Requires judgment in prioritizing the performance tasks, duties and responsibilities in accordance with established standards, policies, and procedures

The ability to be discrete and protect the integrity of confidential information and stay within Corporate Compliance and HIPPA;

Patience, a cheerful disposition, ethusiam and a willingness to handle residents based on whatever maturity and physical level in which theya re currently functioning;

The ability to adhere to professional code of ethics;

The ability to relate information concerning a resident's condition to the appropriate staff members.