RN

DEPARTMENT: Nursing Services

WORK AREA: Entire Facility

PURPOSE: The purpose of this position is to assist the Director of Nursing Service in assessing resident care needs and implementing appropriate action. Implement nursing policies and procedures. Supervise staffing for the nursing department and supervise the quality of nursing care provided to residents.

WORKING HOURS: Hours of work are 0 to 80 hours per pay period plus or minus as business needs and assigned by the Director of Nurses.

THIS PERSON REPORTS TO: Director of Nursing

HIPAA MINIMUM NECESSARY:

Responsible to adhere to HIPAA MINIMUM NECESSARY guidelines and safeguard protected health information.

WORKING CONDITIONS: Well-lighted, well-ventilated office area and rooms. May stand, stoop, bend and walk intermittently during the work day. May have to deal with emotional disturbances of residents, residents family and staff. May be subject to falls, burns from equipment, scratches, and kicks from confused residents. May be exposed to infectious diseases and odors, personality peculiarities of the aged. Required to follow the No Lift Policy and must be on constant alert for prevention of resident injuries.

DUTIES:

• Report promptly to nursing unit assigned to receive report from nursing personnel or previous shift.
• Oversees nursing care of residents within an assigned unit as designated by Director of Nursing.
• Each shift Charge Nurse must complete narcotic and other control drug count. Sign narcotic drug sheet.
• Observes residents for any change in condition and reports any change to physician, Director or Nursing and Administrator.
• Perform venipuncture, administers I.V. solution and maintains I.V. lines.
• May administer or assist Medication Nurse in administering medication and documents medications given. Observes for any adverse effects and reports to Physician and Director of Nursing services and medication reactions.
• May restock treatment carts and emergency equipment.
• Maintain records reflecting residents condition and other pertinent information.
• Cooperates with other members of medical care team and personnel of other departments in providing for residents total needs. Processes Physicians orders completely.
• May assist in orientation of new personnel.
• Attend specific in-service classes and assigns nursing personnel within his/her responsibility to attend in-service classes and provide coverage on floor.
• Visits residents frequently to insure maximum care.
• Assists in teaching residents good health habits.
• Participates and sees that resident care plans and nursing care plans are carried out.
• Attend staff meeting as assigned.
• Successfully completes a 90-day probation period.
• Supervises and helps evaluate licensed and non-licensed nursing personnel. Make recommendations to Supervisors regarding disciplinary measures.
• Assumes the responsibility for staff on assigned shift and provides for adequate staffing of the following shift.
• Notes all absences and tardiness by facility employees; issues reprimands where appropriate; obtains substitutes as thought necessary.
• Makes work assignments to Nursing Assistants based upon an evaluation of the Assistants abilities and experience.
• Assigns breaks for employees on the unit.
• Verifies actual time worked by facility employees when time clock is not used or is inoperable.
• Authorizes overtime of employees for overtime work and initials time cards.
• Responsible for adherence by employees to all company rules and policies and is authorized to administer discipline as appropriate based upon evaluation of the circumstances surrounding incidents.
• Listens to grievances of employees and intervenes with concerns on the unit.
• Assist the nursing units as needed, i.e., doctors rounds, supervises and assists with meal delivery.
• Authorizes other employees to alter working schedules based upon an evaluation of the present and future needs of the unit for the shift.
• Completes resident and employee occurrence reports and issues to Director of Nursing. Evaluates injuries and notifies those necessary accordingly.
• Participates in on call rotation as assigned.
• Demonstrate competency using current clinical software system.
• Adheres to No Lift Policy.
• Other duties as may be deemed necessary by the Director of Nursing.

ROLE OF THE LICENSED NURSE WORKING WITH THE MEDICATION AIDE:

• Familiar with, understands and supportive of the role of the Medication Aide in medication administration.
• Readily available to answer questions, offer clarification of physician orders and/or assist with decision making regarding the administration of PRN medications, determining PRN results and change in resident condition (whether medication related or not).
• Transcription and verification of new and/or change in medication and/or treatment orders.
• Activation of Physician Interim / Standing Orders.
• Administers injections, IV fluids / medications and medications per feeding tube.
• Administers feeding tube flushes.
• Completes all nursing documentation for the assigned work area (i.e., Medicare, Open Window, Acute, MD visits, etc.) other than medications administered by the Medication Aide by the following routes: oral, eye, ear, nasal, inhalant, transdermal, topical, vaginal and rectal.
• Completes Incident / Accident Reports.
• Completes Medication Error Reports.
• Understands and respects the limitations of the role of the Medication Aide as outlined in his / her job description and as prescribed by the NC Board of Nursing and NC Laws governing Medication Aides GS 131E-114.2, GS 131E-217 and GS 90-171.56.