The primary purpose of your position is to provide direct nursing care to the residents and to supervise the day to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure the highest degree of quality care is maintained at all times.
DUTIES AND RESPONSIBILITIES
Direct the day to day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
Ensure all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
Periodically review the departments’ policies, procedures manuals, job descriptions, etc. Make recommendations for revisions.
Meet with your assigned nursing staff, as well as support personnel, in planning the shift services, programs and activities.
Ensure all nursing service personnel comply with procedures set forth in the Nursing Service Procedures Manual.
Make written and oral reports/recommendations concerning the activities of your shifts as required.
Cooperate with other resident services when coordinating nursing services to ensure the residents’ total regimen of care is maintained.
Ensure all nursing service personnel are in compliance with their respective job descriptions.
Participate in the development, maintenance and implementation of the facilities quality assurance program for the nursing service department.
Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
Periodically review the resident’s written discharge plan. Participate in the updating of resident’s written discharge plan as required.
Assist in planning the nursing services portion of the resident’s discharge plan as necessary.
Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.
Admit, transfer, and discharge residents as required.
Complete accident/incident reports as necessary.
Maintain the Daily Census Report and submit to Business Office as required.
Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
Other duties may be assigned as needed.
CHARTING AND DOCUMENTATION
Complete and file required record keeping forms/charts upon the resident’s admission, transfer, and/or discharge.
Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
Receive telephone orders from physicians and record on the Physicians’ Order Form.
Transcribe physician’s orders to resident charts, carded, medications cards/care plans, as required.
Chart nurses’ notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents response to the care.
Fill out and complete accident/incident reports. Submit to director as required.
Chart all reports of accidents/incidents involving residents. Follow established procedures.
Report new/changed diet orders. Forward information to the Dietary Department.
Report all discrepancies noted concerning physicians’ orders, diet change, charting errors, etc., to the Nurse Supervisor.
Fill out and complete transfer forms in accordance with established procedures.
Ensure the appropriate documentation concerning unauthorized discharges is entered in the residents’ medical record in accordance with established procedures.
Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
Sign and date all entries in the residents’ medical record.
DRUG ADMINISTRATION FUNCTIONS
Prepare and administer medications as ordered by the physician.
Verify the identity of the resident before administering the medication/treatment.
Ensure prescribed medication for one resident is not administered to another.
Ensure an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the Nurse Supervisor.
Order prescribed mediations, supplies, and equipment as necessary, and in accordance with established policies.
Ensure narcotic records are accurate for your shift.
Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
Review MARs for completeness of information, accuracy in the transcription of the physician’s order, and to adhere to stop order policies.
Notify the attending physician of automatic stop orders prior to the last dosage being administered.
Dispose of drugs and narcotics as required, and in accordance with established procedures.
Participate in employee performance evaluations, determining your shift’s staffing requirements, and making recommendations to the Nurse Supervisor concerning employee dismissals, transfers, etc.
Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work.
Report absentee call-ins to the Nurse Supervisor.
Review and evaluate your department’s work force and make recommendations to the Nurse Supervisor.
Develop work assignments and/or assist in completing and performing such assignments.
Provide leadership to nursing personnel assigned to your unit/shift.
Make daily rounds of your unit/shift to ensure nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Nurse Supervisor.
Ensure all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program.
Ensure all nurse aide trainees are under the direct supervision of a licensed nurse.
Meet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services.
Ensure department personnel, residents, and visitors follow the departments’ established policies and procedures at all times.
Develop and maintain a good working rapport with interdepartmental personnel, as well as other departments within the facility to ensure nursing services and activities 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.
Review complaints and grievances made or filled by your assigned personnel.
Make appropriate reports to the Nurse Supervisor as required or as may be necessary. Follow established procedures.
Ensure departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
Receive/give the nursing report upon reporting in and ending shift duty hours.
Report occupational exposure to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility’s policy and procedures governing accidents and incidents.
NURSING CARE FUNCTIONS
Inform nursing personnel of new admissions, their admissions, their expected arrival, room assignment, etc.
Ensure rooms are ready for new admissions.
Greet newly admitted residents upon admission. Escort them to their room as necessary.
Report missing/illegible labels and MSDS to the Safety Officer or designated person.
EQUIPMENT AND SUPPLIES
Notify the Nurse Supervisor of the equipment and supply needs of your unit/shift.
Ensure an adequate stock level of medications, medical supplies, equipment, etc., is maintained on your unit/shift at all times to meet the needs of the residents.
Participate in the development and implementation of the procedures for the safe operation of all nursing service equipment.
Ensure only trained and authorized personnel operate your unit/shifts’ equipment.
Ensure all personnel operate nursing equipment in a safe manner.
Monitor nursing procedures to ensure nursing services supplies are used in a efficient manner to avoid waste.
Ensure appropriate MSDS are on file for hazardous chemicals used in the nursing service department.
CARE PLAN AND ASSESSMENT FUNCTIONS
Review care plans daily to ensure appropriate care is being rendered.
Inform the Nurse Supervisor of any changes that need to be made on the care plan.
Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.
Ensure your assigned Certified Nursing Assistants (CNAs) are aware of the resident care plans. Ensure the CNAs refer to the residents’ care plan prior to administering daily care to the resident.
Assist the Resident Assessment Care/Plan Coordinator in planning, scheduling, and revising the MSDS, including the implementation of RAPs and Triggers.
Ensure all nursing care is provided in privacy and nursing services personnel knock before entering the residents’ room.
Ensure all nursing service personnel are knowledgeable of the Residents’ Responsibilities and Rights including the right to refuse treatment.
Review complaints and grievances made by the resident and make a written/oral report to the Nurse Supervisor indicating what action(s) were taken to resolve the complaint or grievance. Follow the facility’s established procedures.
Maintain a written record of the residents’ complaints and grievances which indicate the action taken to resolve the complaint and the current status of the complaint.
Report and investigate all allegations of resident abuse and/or misappropriate of the resident property.
Ensure nursing staff personnel honor the residents’ refusal of treatment request. Ensure such requests are in accordance with the facility’s policies governing advance directives.
Provide data to the Quality Assurance and Assessment Committee as requested.
Must be capable to execute all terms and conditions set forth in the Employee Handbook including, but not limited to:
Works in a safety conscious manner which insures safe work practices are used in order not to pose a risk to others in the workplace.
Complies with company policies and procedures, local, state and federal regulations.
Adheres to policy on Drug Free Workplace.
Maintain a dependable attendance record and adheres to standards of cleanliness, grooming, hygiene, and dress code.
Must possess, as a minimum, a Nursing Degree from an accredited college or university, or be a graduated of an approved LPN/RN Program.
Supervises and assist CNAs.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Must be able to make responsible decisions regarding the residents’ daily and medical needs.
Must have a valid Georgia LPN or RN License.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations under the ADA may be made to enable individuals with disabilities to perform the essential functions.
Must be able to push, pull, move and/or lift at least 50 pounds to a height of 6 feet and be able to push, pull, move and carry such weight a minimum distance of 20 feet.
The work environment characteristics described here are a representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.