Job Summary:
Provide nursing care in accordance with facility and nursing service policy and procedure while collaboratively and efficiently establishing a workplace with attention to quality standards.
Responsibilities:
• Recognize significant changes in conditions of residents.
• Administer medications according to procedure and be aware of pharmacological and therapeutic effect.
• Chart medications and treatments according to procedures.
• Record nursing information on resident’s care plans and clinical records, including nursing notes, MARs, treatment record, and transcription of physician orders.
• Observe, report and record resident react.
• Assess new onset symptoms, reactions, and/or change in resident’s condition, while efficiently, based upon urgency, communicate to the physician in accordance local, state and federal standards of care.
• Observe, report and record resident reaction to drugs, tests, treatments, and therapeutic measures.
• Participate in formal and informal staff development in-service programs, workshops, institutes and conferences.
• Inform Nursing Supervisor/Unit Manager of departmental activities and condition of each resident.
• Assume responsibility for assigned residents by conducting regular wellness rounds during the assigned shift.
• Report incidents of reported resident abuse immediately.
• Report all unusual occurrences (incidents/accidents) that occur during the shift.
• Supervision of CNAs who give direct resident care on the shift.
• Ensure rehabilitative procedures are performed and carried out as outlined in the plan of care.
• Record monthly resident’s assessment, quarterly assessment, or other needed documentation as assigned by Director of Nursing or designee. Â
