Reports to:Director of Nursing and Administrator

Department: Nursing

Purpose of Your Job Position

The primary purpose of your job position is to conduct and coordinate the development and completion of the resident assessment in accordance with the requirements of this state and the policies and goals of this facility.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Duties and Responsibilities

Administrative Functions

• Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation of RAPs and Triggers.
• Maintain and periodically update written policies and procedures that govern the development, use, and implementation of the resident assessment (MDS) and care plan.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, etc., as necessary.
• Develop, implement, and maintain an ongoing quality assurance program for the resident assessment/care plans.
• Assist the resident and Discharge planning Coordinator in completing the care plan portion of the resident’s discharge plan.
• Participate in facility surveys (inspections) made by authorized government agencies.

Committee Functions

• Work with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident.
• Serve on, participate in, and attend various other committees of the facility (e.g., Policy Advisory, Quality Assessment and Assurance) as required, and as appointed by the Administrator.
• Provide written and/or oral reports of the resident assessment/care plan functions as requested or directed by committees.
• Participate in functions involving discharge plans as may be necessary.
• Evaluate and implement recommendations from established committees as they may pertain to the assessment and/or care plan functions of the facility.

Personnel Functions

• Maintain an effective, friendly working relationship with health professionals, physicians, consultants, and governmental agencies that may be involved in the resident assessment/care plan functions of the facility.
• Meet with and solicit advice from department supervisors concerning the resident assessment/care plan functions of the facility.

Nursing Care Functions

• Conduct or coordinate the interviewing of each resident for the resident’s assessment.
• Evaluate each resident’s condition and pertinent medical data to determine any need for special assessment activities or a need to amend the admission assessment.
• Develop and implement procedures with the Director of Nursing Services to inform all assessment team members of the arrival of newly admitted residents.
• Assist facility directors and supervisors in scheduling the resident assessment/care plan meetings.
• Ensure that care provided is in accordance with the resident’s wishes.

Staff Development

• Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that include assessment skills or techniques needed to complete the assessment functions of the facility.
• Assist the Director of Staff Development in developing any training activities needed concerning resident assessment/care plan skills (including, but not limited to initial or refresher courses relative to techniques for interviewing residents, rehabilitation principles, commonly used psychotropic drugs, care plan functions, etc).
• Attend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and bloodborne pathogens standard.
• Attend and participate in advance directive in-service training programs for the staff and community.
• Attend and participate in continuing education programs designed to help you keep abreast of changes in your profession, as well as to maintain your license on a current status.

Care Plan and Assessment Functions

• Develop preliminary and comprehensive assessments of the nursing needs of each resident, utilizing the forms required by current rules or regulations and facility policies.
• Ensure that appropriate health professionals are involved in the assessment.
• Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the penalties, including civil money penalties, for false certification.
• Coordinate the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care.
• Ensure that the care plan includes measurable objectives and timetables to meet the resident’s medical, nursing, and mental and psychosocial needs as identified in the resident’s assessment.
• Ensure that an initial resident assessment is completed within fourteen days of the resident’s admission.
• Ensure that a comprehensive care plan is completed within twenty-one days of the resident’s admission.
• Assist the nursing staff in encouraging the resident and his/her family to participate in the development and review of the resident’s plan of care.
• Develop the schedule of activities required for the resident assessment and plan of care.
• Assist the Director of Nursing Services and relevant supervisors of other departments in ensuring that all personnel involved in providing care to the resident are aware of the resident’s care plan and that nursing personnel refer to the resident’s care plan prior to administering daily care to the resident.
• Ensure that quarterly and annual resident assessments and care plan reviews are made on a timely basis.
• Ensure that a complete resident assessment is conducted within fourteen days of a significant change in the resident’s condition.
• Coordinate the review and revision of the resident’s care plan by the interdisciplinary team after each quarterly review or other assessment, assuring that the care plan is evaluated and revised each time an assessment is done or when there is a change in the resident’s status.
• Assist the Director of Nursing Services and other relevant directors and supervisors in maintaining good rapport and morale between and within departments to ensure that a team effort is achieved in developing and implementing a comprehensive assessment and plan of care.
• Inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).
• Ensure that each portion of the assessment is signed and dated by the person completing that portion of the MDS.
• Sign and date the assessment instrument to certify its completion.
• Ensure that medical and nursing care is administered in accordance with the resident’s wishes, including the implementation of advance directives.

Resident’s Rights

• Maintain the confidentiality of all resident care information.
• Ensure that resident interviews are conducted in private.
• Ensure that all residents are treated fairly, and with kindness, dignity, and respect.
• Ensure that all members of the assessment team and the interdisciplinary care planning/medical and nursing team are knowledgeable of the residents’ responsibilities and rights including the right to refuse treatment.
• Ensure that nursing staff personnel honor the resident’s refusal of treatment request. Ensure that such requests are in accordance with the facility’s policies and procedures governing advance directives. 
• Ensure that the facility’s policies and procedures governing advance directives are reviewed with the resident and/or representative.
• Report and investigate all allegations of resident abuse and/or misappropriation of resident property.
• Review any complaints or grievances made by residents regarding the resident assessment or care plan.
• Ensure that a written record is made of any resident’s complaints or grievances with a full accounting of any actions taken and the current status of the complaint.

Working Conditions

• Works in office area(s) as well as throughout the nursing service area (i.e. drug rooms, nurses’ stations, resident rooms, etc.).
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
• Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.
• Communicates with the medical staff, nursing personnel, and other department supervisors.
• Works beyond normal working hours and on weekends and holidays when necessary.
• Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
• Is involved in community/civic health matters/projects as appropriate.
• Attends and participates in continuing educational programs.
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• May be subject to the handling of and exposure to hazardous chemicals.
• Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.

Qualifications for the Position

Education

• Must possess, as a minimum, a Nursing Degree from an accredited college or university

Experience

• Must have, as a minimum, 6 months experience as a supervisor in a long-term care facility, or other related health care facility.

Specific Requirements

• Must possess a current, unencumbered, active license to practice as a Registered Nurse in the state.
• Must be able to read, write, speak, and understand the English language.
• Must posses the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
• Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
• Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
• Must be able to relate information concerning a resident’s condition.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements (With or Without the Aid of Mechanical Devices)

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write the English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
• Must function independently, and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
• Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination. 
• Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and at time, hostile people within the facility.
• Must be able to push, pull, move, and/or lift a minimum of 50 pound to a minimum height of 3 feet and be able to push, pull, move, and /or carry such weight a minimum distance of 10 feet.
• Must be able to assist in the evacuation of residents during emergency situations.