Description

JOB SUMMARY:

The primary purpose of the MDS Nurse position (RN or LPN) is to conduct the completion of the Resident Assessment Instrument (MDS), initiate nursing care plans, assure resident safety and the transmission of the MDS within regulatory time frames and requirements.

JOB DUTIES & RESPONSIBILITIES:

Administrative Functions

• Manage RAI process and Care Plans according to VHS standards.
• Complete medical forms, reports, evaluations, and studies as directed.
• Participate in facility surveys and the development of a plan of correction as it relates to deficiencies sited in the resident assessment/care plan areas.
• Schedule resident assessment/care plan meetings and inform appropriate department supervisors accordingly.
• Assist in contacting outside members of the care plan team, including resident’s representative/family members regarding participation in care plan meetings.

Assessment and Care Plan Functions

• Conduct or coordinate the interviewing of each resident for the resident’s assessment. Ensure that appropriate health professionals are involved in the 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.
• Coordinate with the Director of Nursing to inform all assessment team members of the assessment date of newly admitted residents.
• Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment and that they are aware of penalties, including civil monetary penalties for false certification.
• Coordinate the development of a written plan of care (interim and comprehensive) for each resident that identifies the problems/needs, 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, mental and psychosocial needs.
• 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.
• Encourage the resident and family members to participate in the development and review of the plan of care.
• Develop the schedule of activities required for the completion of the Resident’s assessment process.
• Assist the Director of Nursing Services and relevant supervisors in ensuring that all personnel providing direct care to the resident are aware of the plan of care and that they refer to the care plan prior to administering daily care.
• Ensure that quarterly and annual MDS and care plan reviews are completed per the schedule in the RAI Manual.
• Ensure that a complete assessment is conducted within fourteen days of a significant change in the resident’s condition.
• Coordinate the review and revision of the care plan by the interdisciplinary team (including hospice, if appropriate) after each quarterly review to ensure that the care plan is revised to reflect the change in status.
• Assist the DON and other relevant supervisors in maintaining good rapport and morale between and within departments to ensure a team effort in providing consistent quality care.
• Ensure that each portion of the assessment is signed and dated by the person completing that portion of the MDS.
• Sign and date the MDS to certify its completion, RN only.
• Transmits MDS per state and federal regulations.

Committee Functions

• Serve on committees as required or requested by the Administrator or DON.
• Provide written or oral reports as requested by various committees as it relates to resident care planning.
• Evaluate and implement recommendations from established committees that pertain to assessment and/or care plan functions.

Qualifications

JOB REQUIREMENTS:

Education

• Must be a graduate from an accredited Nursing school, or possess a Nursing Degree from an accredited college or university.

Experience

• Must possess a current, unencumbered, active license to practice as an RN or LPN in this state.
• At least one (1) year experience in rehabilitative and restorative nursing or as a staff nurse in a health care facility. Experience in long-term care required.

Specific Requirements

• Must be able to read, write, speak and understand the English language.
• Must possess computer skills and some understanding of documentation software programs.
• Must display professionalism both in appearance and attitude.
• Must possess the ability to solve problems and make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agency 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 the ability and the willingness to work harmoniously with and to coach and/or supervise other personnel.
• Must be able to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult people.
• 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.