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.