Qualifications:
- Graduation from an accredited Nursing School and a current and valid LVN/LPN license in the applicable State
- Minimum of one-year supervisory experience in a long-term or health care setting is preferred.
- Ability to read, write, and speak the English language.
Must have SNF (Skilled Nursing Facility) ExperienceÂ
Essential Functions:
- Monitor/Review the following daily for accuracy, completion, required documentation and appropriate intervention:
- Telephone Orders
- Medication Administration Record
- PRN Medication Administration Record
- IV Medication Administration Record
- Treatment Record
- G-Tube Record
- Diabetic Record
- Anticoagulant Monitoring Form
- Weekly Skin Assessment Form
- Patient Daily Record
- Flow Record
- Behavior Monitoring Sheets
- Narcotic Control Sheets
- Monthly Summaries that are due
- Lab, X-ray, etc. reports received
- Glucometer Control Log
- Refrigerator temperature Logs
- Make rounds on all Patients at a minimum of every 4 hours and as needed. Communicate any findings/concerns to the charge nurse for intervention.
- Review the 24-hour report book for information regarding the last 24 hours; assessing Patients with a recent change in condition. Any change in a Patients condition requires assessment, notification, documentation, and intervention.
- Review incident reports and follow up for proper documentation of nursing assessment, intervention and notification to the responsible party and physician.
- Review the medical record on every Patient discharged for accuracy; follow up, proper documentation and intervention. If transferred to home or to another Facility, reviews the Post Discharge Plan of Care for completion.
- Check appropriate documentation on patients regarding:
- 24-hour follow-up on room changes.
- 72-hour documentation on admissions and re-admissions.
- Review medical records on follow up to determine problems, assessments, interventions, documentation, and notification of responsible party and physician in a timely manner (see DON Manual for detailed instructions on follow up documentation).
- Distribute the monthly MDS/care plan calendar to appropriate members of the Interdisciplinary team by the 15th of each month.
- Complete MDS assessments, RAPs if applicable, Care Plans and TILE assessments due for completion.
- Attend weekly care plan meetings with the Interdisciplinary team, Patient and Responsible party.
- Attend the weekly TILE and Medicare meetings with appropriate Interdisciplinary team members.
- Enter physician orders daily into the clinical software system.
- Print physicians orders and check for accuracy by 25th of each month and place orders in patient medical records by midnight on first day of the following month.
- Complete recommendations from the Consultant Pharmacists Report within 72 hours of exit interview.
- Complete recommendations from the Dietary Consultant Report within 72 hours of exit interview.
- Verify emergency box to evidence completion of charge slips for medications.
- Enter weights into the clinical software system per RCMS # 2.
- Print the monthly Weight Change Alert reports and updated Weight Change Log per RCMS #2.
- Confirm Skin Site Identification Forms (RCMS Form 1-6) and the Communication Form (RCMS Form 7-3) are available at the nursing station(s) and in the shower room(s).
- Weekly, update and distribute the Daily Care Guides.
- Has reviewed Cantex Continuing Care Networks Clinical Policies and Procedures for Abuse Prevention and knows the employees responsibility to enforce it.
- Attends weekly in-services, understands, complies, and enforces Patient Care Management Systems.
- Responsible for assuring patient/resident safety.
- Performs other duties and tasks as assigned.
#HP
We are an Equal opportunity employer; We offer an excellent benefit plan to include 401K with match, CEU reimbursement, vacation, sick, holidays, medical, dental, and supplemental insurance Plans as well as a Highly competitive compensation package.