SUMMARY

Primarily responsible for the delivering nursing care and services to residents in the Health Care Unit. Responsible for monitoring care delivery, to assure that established standards of care are followed, and to ensure that the highest degree of quality care is maintained at all times.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Delivers nursing care in accordance with established Health Care Unit policies and procedures.

Receives report from the previous shift and gives report to the on-coming shift. Report is given in the form of verbal, taped and/or written report.

Reviews new physician orders in the New Order Notebook at the beginning of each shift.

Checks e-mail for nursing messages at least once each shift. Sends e-mail communication to appropriate staff about resident and employee issues as they arise.

Reads department communication book and posted communication board daily.

Administers medications and treatments as prescribed by the physician. Monitors

resident response to medication/treatments. 

Maintains medication cart and medication room in a clean and orderly fashion. Stores

medication properly. Monitors expiration dates.

Conducts narcotic count with off-going/on-coming nurses and sign narcotic control sheet at the beginning and end of each shift.

Monitors I.V. infusions at least once hourly for the following: type of fluid, infusion rate, position, and site appearance. Problems with I.V. site are addressed immediately by an RN.

LPNs will report problem to an RN immediately. IV medications are delivered by RNs.

When no RN is on duty, LPN will verify that RN is available for next medication dose.

Performs a head to toe assessment/evaluation of Medicare skilled residents each shift,

including vital signs. Documents this assessments. 

Documents episodic events, such as resident falls, response to antibiotic therapy, changes in condition, etc. in the resident’s nurse’s notes/Point Click Care system.

Makes rounds with physicians and communicates with physicians about changes in resident’s conditions in the absence of the Charge Nurse/Supervisor. Assures that physician orders/progress notes are documented on the appropriate form and signed.

Takes telephone orders from physicians and records on the Physicians’ Order Form.

Notifies family members when significant events or changes in resident’s conditions.

Makes and modifies assignments for Nurse Technicians to best meet resident needs. Supervises care delivery by Nurse Technicians, including observation of care, providing direction, and having regular on-going communication, to ensure that direct care is being given according to each resident’s Plan of Care and established standards.

Assists Nurse Technicians with direct care, including answering call lights, feeding, and general care when resident needs are high. 

Makes regular rounds in assigned neighborhood to observe and evaluate each resident’s physical and emotional status, and to ensure that resident needs are being addressed.

Assists with feeding in resident dining during meal times.

Develops and maintains a good working rapport with inter-department personnel, as well as other departments within the facility to ensure that nursing services are well coordinated to meet the needs of the residents.

Assists with resident admissions, transfers, and discharges as needed.

Performs documentation and files required record keeping forms/charts upon the resident’s admission, transfer, and/or discharge.

Documents 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 using Point Click Care system.

Provides direct resident care as necessary to meet resident needs.

Transcribes physician’s orders to resident charts, medication administration records, treatment/care plans, etc. Requisitions and arranges for diagnostic and therapeutic services, as ordered by the physician, and in accordance with established procedures.

Documents all reports of accident/incidents involving residents. Follows established procedures including completion, investigation, and reporting of the accident/incident reports. 

Follows established infection control policies/procedures. Uses universal precautions when carrying out job duties.

Follows safety policies/procedures for preventing, identifying, correcting and reporting hazards and incidents.

Is knowledgeable about disaster policies/procedures. Participates in disaster preparedness drills. Takes an active role when a declared disaster occurs.

Is knowledgeable about Wander-gard resident security system. Participates in implementation of the system, in accordance to established policies/procedures. Promptly responds to security alarms.

Provides feedback to charge nurse, Assistant Directors of Nursing, and Director of Nursing about individual staff member’s performance.

Encourages and supports the growth of interdisciplinary teams to improving the quality of life for residents.

Participates in the implementation of the facility’s Continuous Quality Improvement activities.

OTHER JOB DUTIES:

Complies with all company policies/procedures related to resident privacy/ confidentiality and information system security, to insure compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Observes facility policies and procedures, including Resident Rights policies.

Performs job duties in an efficient, productive, and professional manner.

Actively supports the implementation of Hill View’s mission and statement of purpose.

Accepts job assignments with positive spoken word and body language.

SUPERVISORY RESPONSIBILITIES: Supervises daily operations and performance of Nurse Technicians on the assigned shift.

QUALIFICATIONS: Current licensure as a Practical or Registered Nurse in the State of Ohio required.

EDUCATION AND/OR EXPERIENCE: Must be a graduate of an approved LPN or Associate Degree Nursing program.

LANGUAGE SKILLS: Must be able to read and interpret policies and procedures. Must have the ability to respond to inquiries made by staff, managers, physicians, residents, families and regulatory agencies.

MATHEMATICAL SKILLS: Must have ability to add, subtract, multiply, and divide all units of measure using whole numbers, common fractions and decimals. 

REASONING ABILITY: Must have ability to apply common sense understanding to carry out detailed, but uninvolved written or oral instructions. Must have ability to solve practical problems and concrete variables in situations where only limited standardization exists.

PHYSICAL REQUIREMENTS: Frequently required to stand, walk, sit, use fingers, handle or feel, reach with hands and arms, climb or balance. Must be able to speak clearly and hear with minimal or no assistance in order to perform physical evaluations. The employee must frequently lift and/or move up to 50 pounds and occasionally lift/move more than 100 pounds. Specific vision abilities required in this job include close vision, distance vision, peripheral vision, depth perception, differentiation in color, and ability to focus.

WORK ENVIRONMENT: The indoor environment is standard with fluorescent lighting and central heating/cooling. While performing this job, the employee may be subjected to hostile or emotionally upset residents/visitors. The employee may frequently be required to use protective equipment to prevent exposure to blood and body fluids. The employee may encounter frequent interruptions.