Certified Nursing Assistant

Administrative Functions

Use the wristband or photo in EHR to identify residents before administering any care, serving meals, etc., as necessary.

Record all entries on flow sheets, notes, charts, etc., in an informative and descriptive manner. (POC, Behavioral book, TPR)

Use only authorized abbreviations established by this facility when recording information.

Report all changes in the resident’s condition to the Nurse Supervisor/Charge Nurse as soon as practical.

Report all accidents and incidents you observe on the shift that they occur.

Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.

Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.

Report any known or suspected unauthorized attempt to access facility’s information system.

Admission, Transfer, and Discharge Functions

Ensure that the resident’s room is ready for receiving the resident (i.e., bed made, wrist band, etc.).

Greet residents and escort them to their room. Make resident comfortable (i.e., put to bed, get water, etc.).

Introduce resident to his/her roommate, if any, and other residents and personnel as appropriate.

Inventory and mark the resident’s personal possessions as instructed.

Store resident’s clothing after labeling.

Assist residents with packing their personal possessions when they are being transferred to a new room, or when being discharged.

Transport residents to new rooms or to the receiving area.

Assist with loading/unloading residents from vehicles as necessary.

Review Resident Profile to determine transfer status, fall risk, etc.

Ensure vitals, height and weight obtained on admission, assist nurse with positioning for initial skin assessment.

Personnel Functions

Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors.

Follow work assignments, and/or work schedules in completing and performing your assigned tasks.

Cooperate with inter-departmental personnel, as well as other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents.

Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.

Meet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or the improvement of services.

Report all complaints and grievances made by the resident to Nursing Supervisor or Administration.

Notify the facility at least 2 hours prior to scheduled shift when you will be absent from work, as soon as possible if going to be late.

Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals to your supervisor.

Report known or suspected incidents of fraud to the Administrator or Corporate Compliance officer.

Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.

Pagers – on/functioning; signed out, responsible for returning it at shift end.

Hall assignment log – complete for time off unit and responsible charting group.

Shift Charting – completed for assigned group

Uniform - nametag, gait belt, pager, proper footwear, hand sanitizer.

Personal Nursing Care Functions

Participate in and receive the nursing report upon reporting for duty – completing rounds with off going shift.

Follow established policies concerning exposure to blood/body fluids.

Assist residents with daily dental and mouth care (i.e., brushing teeth/dentures, oral hygiene, special mouth care, etc.).

Assist residents with bath functions (i.e., bed bath, tub or shower bath, etc.) as directed and per resident preferences – offer bathing options.

Give backrubs as requested.

Assist residents with dressing/undressing as necessary; maintain privacy.

Assist residents with hair care functions (i.e., combing, brushing, shampooing, etc.).

Assist residents with nail care (i.e., clipping, trimming, and cleaning the finger/toenails). (Note: Does not include diabetic residents’ feet.)

Shave male residents on bath day and as needed.

Keep hair on female residents’ clean shaven (i.e., facial hair, under arms, on legs, etc.) as instructed on bath day and as needed.

Keep all residents dry (i.e., change gown, clothing, linen, etc., when it becomes wet or soiled).

Ability to make beds (occupied or unoccupied).  Keep linens tight to avoid wrinkles from forming under the resident.

Put extra covers on beds as requested.

Position bedfast residents in correct and comfortable position.

Assist resident with bowel and bladder functions (i.e., take to bathroom, offer bedpan/urinal, portable commode, etc.).

Maintain intake and output records as instructed.

Check and report bowel movements and character of stools as instructed.

Collect specimens as instructed (i.e., urine, sputum, stools, etc.), and store in biohazard bag in specified location.

Assist residents in preparing for medical tests (i.e., lab work, x-ray, therapy, dental, etc.).

Assist residents in preparing for activity and social programs (i.e., church services, parties, visitors, etc.).

Assist in transporting residents to/from appointments, activity and social programs, etc., as necessary.

Assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc.

Assist residents to walk with or without self-help devices as instructed.

Perform restorative and rehabilitative procedures as instructed.

Provide eye and ear care (i.e., warm/cold compresses, cleaning eyeglasses/hearing aids, etc.) as instructed.

Assist with the application of nonsterile (moist and dry) warm/cold compresses.

Assist in preparing the resident for a physical examination.

Weigh and measure residents as instructed.

Measure and record temperatures, pulse, and respirations (TPRs), as instructed.

Answer resident calls as promptly as feasible.

Ensure that residents who are unable to call for help are checked frequently.

Check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes.

Assist with the care of the dying resident.

Provide post-mortem care as instructed.

Rounds with off-going/on-coming shifts.

Notify nurse before leaving unit for any breaks.

Special Nursing Care Functions

Observe and report the presence of pressure areas and skin breakdowns to prevent decubitus ulcers (bedsores).

Report injuries of an unknown source, including skin tears and bruises promptly to nurse.

Provide indwelling catheter care.

Provide daily perineal care.

Assist with the application of slings, elastic bandages, binders, etc.

Ensure heel protectors, geri-sleeves, TED hose, positioning devices in place as ordered.

Give tepid sponge baths as directed.

Provide daily Range of Motion Exercises. Record data as instructed.

Turn bedfast residents at least every two (2) hours or as instructed by nurse.

Observe disoriented and comatose residents. Record and report data as instructed.

Turn all medications found in the resident’s room/possession over to the Nurse Supervisor/Charge Nurse.

Watch for and report any change in room temperature, ventilation, lighting, etc.

Evaluate residents for need for slide sheet for repositioning.

Food Service Functions

Prepare residents for meals (i.e., take to bathroom, wash hands, comb hair,  position at tables, offer clothing protectors/washcloth, take to/from dining room, remove/replace foot pedals for transport as needed, etc.).

Explain meal selections and offer resident preferences in all food and drink.

Serve food in timely manner according to resident preference. Assist with feeding as indicated (i.e., cutting foods, feeding, assist in dining room supervision, adaptations as indicated, etc.).

Review and prepare meals with appropriate diet needs and liquid thickening.

Assist residents with identifying food arrangements (i.e., informing resident with sight problem of foods that are on his/her tray, where it is located, if it is hot/cold, etc.).

Record the resident’s food/fluid intake on Smart card and in POC. Report changes in the resident’s eating habits.

Keep residents’ water pitchers clean and filled with fresh water (on each shift), and within easy reach of the resident.

Encourage between meal and bedtime snacks of resident preference.

Perform after meal care (i.e., clear tables, clean resident’s hands, face, clothing, take to bathroom, brush teeth, clean dentures, etc.).

Check rooms for any food, keep it in sealed bag or container.

Wear gloves when handling any food product for residents.

Perform hand hygiene between residents or between clean/dirty activities.

Staff Development

Attend and participate in scheduled orientation programs and activities.

Attend and participate in facility in-service training programs as instructed.

Safety and Sanitation

Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood/body fluids.

Wash hands before and after performing any service for the resident.

Ensure call light within easy reach of the resident.

Maintain employee badge and utilize when entering and exiting facility, report lost badge to HR office as soon as possible.

Immediately notify the Nurse Supervisor/Charge Nurse of any resident leaving/missing from the facility.

Follow established safety precautions in the performance of all duties.

Keep residents’ personal possessions off the floor and properly stored.

Ensure all medicine cabinets locked and any item labelled “hazardous for children” kept in locked cabinet.

Keep floors dry. Report spills immediately.

Keep excess supplies and equipment off the floor. Store in designated areas

Clean, disinfect, and return all resident care equipment to its designated storage area after each use.

Perform routine housekeeping duties (i.e., clean bedrails, over bed table, night stand, etc., that relate to nursing care procedures).

Clean up broken glass using tongs and broom and dispose of in proper container.

Ensure trash bags are not overfilled, start new bag when ½ full, notify housekeeping with any housekeeping issues or needs.

Before leaving work area for breaks, or at the end of the workday, store all tools, equipment, and supplies.

Monitor areas with Caution safety signs, follow guidelines when in use. 

Utilize safety mirrors for blind corners.

Report all hazardous conditions and equipment or safety violations to the Nurse Supervisor/Charge Nurse immediately.

Follow established smoking regulations. Report all violations.

Report any communicable or infectious disease to the Director of Nursing Services and/or to the Infection Control Coordinator.

Follow established isolation precautions and procedures, including proper disposal of personal protective equipment.

Demonstrate proper use of equipment and supplies (e.g., gait belt, mechanical lifts, lift pad placement, team lifts, etc.) when lifting or moving residents.

Ensure 2 person lifts at all times for full body (Hoyer) lifts for resident safety.

Report missing/illegible labels and SDSs to your Safety officer or supervisor.

Follow Infection Control policy regarding bagging soiled items on site, proper glove usage, blood spill kit usage, etc.

Safety check rounds – monitor for functioning and present tabs, bed/chair alarms, floor mats, non-slip footwear as indicated on Resident Profile.

Attend annual Fire Safety, Hazardous Communications, SDS and Bloodborne pathogen training and review as necessary.

Respond promptly to any pager alerts, drills, or codes occurring during shift.

Demonstrate ability to operate fire extinguisher, and follow evacuation protocol as trained. (RACE and PASS)

Equipment and Supply Functions

Use only the equipment you have been trained to use following established safety guidelines.

Report defective equipment to the Nurse Supervisor/Charge Nurse.

Inform the Nurse Supervisor/Charge Nurse of your equipment and supply needs.

Follow procedures for completing initiation and discontinuation of resident equipment (alarms, nebulizer, oxygen concentrator) place in supply mailbox.

Follow procedures for supply charge stickers to nurse for tracking. (Vaseline, razors, mouth swabs, etc.)

Care Plan Functions

Review resident profile daily to determine if changes in the resident’s daily care routine have been made on the care plan.

Inform the Nurse Supervisor/Charge Nurse of any changes in the resident’s condition so that appropriate information can be entered on the resident’s care plan.

Ensure that your notes reflect that the care plan is being followed.

Behavioral charting complete – add additional interventions as necessary.

Budget and Planning Functions

Report suspected or known incidence of fraud relative to false billings, kickbacks, etc. to Corp Compliance officer or Administrator.

Attend Annual Corporate Compliance training.

Use only the equipment and supplies necessary to do the job. Do not be wasteful.

Resident Rights

Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information to HIPAA officer.

Ensure that you treat all residents fairly, and with kindness, dignity, and respect.

Ensure that all nursing care is provided in privacy.

Knock before entering the resident’s room.

Report all grievances and complaints made by the resident to the Nurse Supervisor/Charge Nurse.

Report all allegations of resident abuse and/or misappropriation of resident property to Administrator immediately.

Honor the resident’s refusal of treatment request. Report such requests to your supervisor.

Complete and demonstrate understanding of facility Abuse, Resident Right, and HIPAA training annually.

Working Conditions

Works throughout the nursing service area (i.e., treatment 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 nursing personnel and other department personnel.

Works beyond normal working hours, on weekends and holidays, and in other positions temporarily, when necessary.

Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).

Attends and participates in continuing educational programs.

Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, and other air contaminants.

Is subject to exposure to infectious waste, diseases, conditions, etc., including bloodborne and airborne pathogens.

May be subject to the handling of and exposure to hazardous chemicals