Charge Nurse RN

Must have a current RN license in the State(s) of practice.

Shifts: Double Weekends 6am-10pm

Position Summaries:

To plan and deliver nursing care to patients/residents requiring long-term care or rehabilitative care.

Essential Duties and Responsibilities:

Position Summary:

To plan and deliver nursing care to patients/residents requiring long-term or rehabilitative care.

Essential Duties and Responsibilities:

• Works using the guidelines established from the Nurse Practice Act, facility Policy and Procedures, use of your nursing judgement.

• Assess, plan and evaluate nursing care delivered to patients/residents requiring long-term or rehabilitation care.

• Implement the patient/residents plan of care and evaluate the patient/residents response.

• Directs and supervises care given by other nursing personnel.

• Provide input in the formulation and evaluation of standards of care.

• Maintain knowledge of necessary documentation requirements.

• Maintain knowledge of equipment set-up, maintenance and use (i.e. monitors, infusion devices, drain devices, etc.).

• Maintain confidentiality and patient/resident rights, regarding all patient/resident and personnel information.

• Provide patient/resident, family/caregiver education as directed.

• Initiate emergency support measures ( CPR, protecting patients/residents from injury)

• Assessment:

o   Admission and routine  resident observations/transfer notes are complete and accurately reflect the patient/resident’s status

o   Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.

o   Nursing history is present in the medical record for all patients/residents

o   Assessment identifies changes in the patient/resident’s physical or psychological condition ( Changes in lab data, Vital signs, mental status).

• Planning of Care:

o   Nursing care plans are initiated/reviewed/individualized on assigned patients/residents monthly and PRN.

o   Pertinent nursing problems are identified.

o   Goals are stated.

o   Appropriate nursing orders are formulated.

• Evaluation of Care:

o   The effectiveness of nursing interventions, medications, etc. is evaluated and documented in the progress notes.

• Care Plans:

o   Evaluation of care plan is noted monthly or as indicated.

o   The care plan is revised and indicated by the patient/resident’s status.

• General Patients/Resident Care:

o   Patient/Resident is approached in a kind, gentle, and friendly manner. Respect for the patients/residents dignity and privacy is consistently provided.

o   Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.

o   Independence by the patient/resident in activities or daily living in encouraged to the extent possible.

o   Treatments are completed as indicated.

o   Safety concerns are identified and appropriate actions are taken to maintain a safe environment.

o   Assist/Grab-bars and height of bed are adjusted.

o   Patient/Resident call light and equipment is within reach.

o   Restraints, if ordered by a Physician, are maintained properly.

o   Rooms are neat and orderly.

• Functional assignments are completed.

• Emergency situations are recognized and appropriate action is taken.

• All emergency equipment can be readily located and operated (Emergency Oxygen Supply, Drug Box, Fire Extinguisher, AED/Crash Cart, etc.)

• Patient/Resident Education/Discharge Planning:

o   The patient/resident and family are involved in the planning of care and treatment (documented on the plan of care).

o   Patient/resident and/or family are provided with information related to all intervention and activities as indicated.

o   Discharge/Death summaries are complete and accurate.

o   Transfer forms are complete and accurate

o   Active participation in patient/resident care management is evident

• Adherence to Facility Procedures:

o   Facility procedure manuals or reference materials are utilized as needed.

o   Procedures are performed according to methods outlined in procedure manual.

o   Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.

o   Safety guidelines established by the facility ( i.e. proper needle disposal ) are followed.

• Documentation:

o   The patients/resident’s full name and room number are present on the chart forms. Allergies are noted on the chart cover.

o   Only approved abbreviations are utilized.

o   TPR graphic is completed properly and timely

o   I&O summaries are recorded and added correctly

o   Blood pressure graphic is completed accurately and timely

o   Progress notes are timed, dated and signed with full signature and title

o   Unit flow-sheets are completed properly (i.e, Wound Care Records, Treatment Records, IV Therapy Record, etc)

• Medication Administrations/ Parenteral Therapy Record

o   Dates that medications are started or discontinued are documented

o   Medications are charted correctly with name, does, route, site, time and initials of nurse

o   Pulse and BP are obtained and recorded when appropriate

o   Medications not given are circled, reason noted and physician notified if applicable

o   Appropriate notes are written for medication not given and actions taken.

o   Name and title of nurse administering medication are documented

o   Patient/residents medication records are labeled with full name, room number, date and allergies.

o   The procedure for administration and counting of narcotics is followed

o   All parenteral fluids are charted with time and date started, time infusion completed, sit of infusion and signature of nurse.

o   All parenteral fluids are administered according to the ordered infusion rate.

o   Parenteral intake is accurately recorded on the unit flow sheet or I&O record.

o   IV sites are monitored and catheters changed according to unit policy

o   IV bags and tubing are changed according to unit policy

o   Appropriate actions are taken related to identified IV infusions problems (infiltration, phlebitis, poor infusion, etc. ) policy

• Coordination of Care:

o   Tests are scheduled and preps are completed as indicated

o   Co-workers are informed of changes in patient/resident condition or of any other changes occurring on the unit.

o   Information is relayed to the member of the Health Care Team (i.e. physicians, respitory therapy, physical therapy, social services, etc)

o   Unit activities are coordinated (i.e. changing patients/residents room for Admission Coordination transfer/discharge forms, etc.)

• Leadership:

o   Equitable care assignments are made prior to shift that are appropriate to patient/resident’s needs

o   Staffing needs are communicated to the nursing supervisors

o   Assistance, direction, and education is provided to unit personnel and families.

o   Problems are identified, data is gathered, solutions are suggested, and communications regarding the problem is appropriate.

o   Transcriptions of all orders is checked

o   All work areas are neat and clean

• Communication:

o   Change of shift report is complete, accurate and concise.

o   Incident reports are completed accurately and in a timely manner.

o   Staff meetings are attended, if on duty, or minutes read initialed if not on duty.

• Cost Awareness:

o   Supplies are used appropriately

o   Charge stickers (or charge system) are utilized appropriately

o   Minimal supplies are stored in resident room

o   Discharged medications are returned to the pharmacy or destroyed in a timely manner

o   Floor-stock medications are charged and re-stocked

o   Participates in the identification of staff educational needs.

o   Serves as a preceptor, as delegated, for new staff

o   Maintains patient/resident care supplies, equipment and environment

o   Participates in the development of unit objectives

o   Participates in the quality assessment and improvement process and activities.