Description

Position Summary

The Care Plan Nurse cares for people who are sick, injured, convalescent or disabled. This position identifies resident issues and/or conditions including the resident’s unique characteristics, strengths, and needs. The Care Plan Nurse works under the direction of the Director of Nursing ; the nature of the direction and supervision required varies by job setting.

Position Responsibilities

• Care Plan Nurses are responsible for resident assessment and effective clinical decision-making. The Care Plan Nurse follows the current standards of clinical practice providing a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. Common responsibilities of Care Plan Nurse include (but are not limited to): 
• Promotes and maintains a focus of patient-centered care
• Adheres to laws, rules & regulations and practices ethical integrity and interpersonal skills
• Maintains compliance with long-term care regulations including federal, state and health regulations
• Looks at each resident as a whole human being with unique characteristics and strengths
• Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident’s functional status (MDS)
• Gives the IDT a common understanding of the resident
• Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers)
• Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process)
• Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow up
• Reflects the resident’s /resident representative’s input, goals and desired outcomes
• Provides information about how the causes and risks associated with issue and/or conditions can be addressed to provide for a resident’s highest practicable level of well-being (care planning)
• Re-evaluates the resident’s status as prescribed intervals using the RAI and then modifies the individualized care plan as appropriate and necessary
• Review and revise the current care plan, as needed
• Communicate with the resident or his/her family or representative regarding the resident care plans, and their wishes
• Assist the resident in achieving his/her goals. Offering alternative treatments, as applicable
• Individualized interventions that honor the resident’s preferences
• Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence
• Evaluates treatment of measurable objectives, timetables and outcomes of care
• Respects the resident’s right to decline treatment
• Records all care information concisely, accurately and completely, in a timely manner in the appropriate computer system, format and on the appropriate forms
• Performs position duties in a manner as to assure resident safety and rights are priority
• Adheres to the facility corporate compliance program and promotes the program in a positive and effective manner
• Performs other position-related duties as assigned, depending on assignment/shift setting

Other Responsibilities

• Follows facility OSHA safety rules and procedures
• Follows facility policies and procedures and adheres to federal and state regulations for long-term care
• Respects cultural and religious practices of patients
• Upholds HIPAA regulations
• Maintains a punctual and dependable attendance record
• Position Requirements
• Graduate of an accredited LPN or RN program
• Current LPN or RN license, in good standing with the State licensing board
• Minimum of (2) years LTC experience
• Federal, State, and MHI required credentials current and on file
• Cognitive skills as related to the position

Working Conditions

Because the patients need round-the clock care, working hours include days, nights, weekends and holidays. The number of patients assigned per shift will vary with facility and specialty, if applicable. Care Plan Nurses must guard against back injury because they may have to assist CNA's in patient lifts and transfers; they must follow proper company procedures as it relates to the use of mechanical patient lift devices . Employees are encouraged to safely move patients requesting assistance to roll/lift/transfer patients. Care Plan Nurses may face hazards from exposure to chemicals and infectious diseases. In addition, the population cared for will contain patients that are confused, irrational, agitated, and/or uncooperative.

Physical Demands

• Prolonged periods of standing, bending, and reaching
• Ability to lift fifty (50) pounds. Moving, lifting or transferring of patients may involve lifting of up to one- hundred (100) pounds
• Fine motor skills
• Visual acuity

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. While performing the duties of this job, the employee is regularly required to stand and talk or hear. The employee is frequently required to walk; use hands to finger, handle, or feel; and reach forward with hands and arms. The employee is occasionally required to sit and stoop, kneel, or crouch. The employee must frequently lift and/or move up to 50 pounds and may lift and/or move 100 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Physical Demand Ratings are an estimate of the overall strength requirements that are consider to be important for an average, successful work performance of a specific job. The overall physical demand rating for a Care Plan Nurse falls within the Medium classification. However, due to the resident population, this position has been classified as Heavy (exerting 50 to 100 pounds of force occasionally, and/or 20 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly to move objects). Physical Demand requirements are in excess of those for Light Work.