Job Description: Licensed Nurse / Medication / Treatment Nurse

Description of Position:

The primary purpose of your job is to provide direct nursing care to the residents including medication management and skin care treatments, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and facility policies and procedures and as may be required by the Station Manager, RN Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times.

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

• Direct the day-to day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
• Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
• Meet with your assigned nursing staff, as well as support personnel, in planning the shifts’ services, programs, and activities.
• Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this facility.
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual and in compliance with their respective job descriptions.
• Make written and oral report/recommendations concerning the activities of your shift as required.
• Cooperate with other resident services when coordinating nursing services to ensure that the residents’ total regimen of care is maintained.
• Participate in the development, maintenance, and implementation of the facility’s quality assurance program for the nursing service department.
• Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
• Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan as required.
• Assist in planning the nursing services portion of the resident’s discharge plan as necessary.
• Admit, transfer, and discharge residents as required.
• Complete accident/incident reports as necessary.
• Write resident charge slips for supplies and forward to the Business Office.
• Maintain the Daily Census Report and submit to the Business Office as required.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. (i.e. 24 hour reports, care plans, weekly summaries) as necessary.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon the resident’s admission, transfer, and/or discharge.
• Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
• Receive telephone orders from physicians and record on the Physicians’ Order Form and as otherwise required. Notify Responsible Party.
• Transcribe physician orders to resident charts, medication administration records, treatment/care plans, as required.
• Chart nurses’ notes in an informative, descriptive and legible manner that reflects the care provided to the resident, as well as the resident’s response to the care.
• Fill out and complete accident/incident reports. Submit to Director as required.
• Chart all reports of accidents/incidents involving residents. Submit reports to the Accident/Incident Coordinator. Update care plans with new interventions as needed. Follow established procedures.
• Record new/changed diet orders. Forward information to the Dietary Department.
• Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Station Manager/ RN Nurse Supervisor.
• Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.
• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
• Sign and date/time all entries made in the resident’s records.

Staff Development

Assist the Station Manager, RN Supervisor & Director of Staff Development, as needed, in the development, planning, conducting, and scheduling in-service training classes that provide instructions on “how to do the job” and ensure a well-educated nursing service department. 

Safety and Sanitation

• Ensure that nursing service personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner.
• Participate in the development, implementation and maintenance of the procedures for reporting hazardous conditions or equipment. 
• Monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies.
• Ensure that all personnel wear and/or use safety equipment and supplies (e.g. mechanical lifts, etc.) when moving or lifting a resident. 
• Report missing/illegible labels and MSDSs to the safety officer or other designated person.
• Participate in the maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel.
• Assist the Infection Control Coordinator in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks in which there is potential exposure to blood/body fluids are properly identified and recorded.
• Ensure that all personnel performing tasks that involve potential exposure to blood/body fluids participate in appropriate in-service training programs prior to performing such tasks.
• Ensure that an adequate supply of personal protective equipment is on hand and readily available to personnel who perform procedures that involve exposure to blood or body fluids.
• Ensure that nursing service personnel follow established infection control procedures when isolation precautions become necessary.
• Monitor nursing service work areas (i.e., nurses’ station, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner. Ensure that all resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner. 

Equipment and Supply Functions

• Recommend to the Station Manager, RN Nurse Supervisor the equipment and supply needs of the department. 
• Ensure that an adequate stock level of medications, medical supplies, equipment, etc., is maintained on premises at all times to adequately meet the needs of the resident.
• Assist the Maintenance Director in developing a preventive maintenance program for maintaining the nursing department’s equipment and supplies in a safe and operable manner.
• Participate in the development and implementation of the procedures for the safe operation of all nursing service equipment.
• Ensure that only trained and authorized personnel operate the department’s equipment. Ensure that all personnel operate nursing service equipment in a safe manner.
• Ensure that appropriate MSDSs are on file for hazardous chemicals used in the nursing department.

Experience

• 1 year experience in a skilled nursing facility is preferred

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.
• May be necessary to assist tin the evacuation of residents during emergency situations.