Certificates, Licenses, Registrations
• Valid license as a Registered Nurse in the state of practice
• Valid CPR certificate
QUALIFICATION REQUIREMENTS:
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.
LANGUAGE SKILLS: Ability to read, analyze, and interpret professional journals, technical procedures, or governmental regulations. Ability to communicate orally and through written reports, and other documents relating to residents, staff and others. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the public.
REASONING ABILITY: Ability to define and solve problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions and deal with several abstract and concrete variables.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
• Assign duties and coordinate nursing service
• Conduct and document a thorough assessment of each patient’s medical status upon admission and throughout the patient’s course of treatment
• Assist in the development and implementation of an individualized treatment plan for each assigned resident
• Complete required documentation in an accurate and timely manner
• Oversee care delivered by Certified Nursing Assistants
• Make frequent rounds to ensure residents are receiving required services
• Maintain confidentiality of records
• Report to supervisory staff of residents’ conditions and any daily changes
• Evaluate nursing activities to ensure resident care, staff relations and efficiency of service
• Observe nursing care and visit residents to ensure that nursing care is carried out as directed and treatment administered in accordance with physician’s instructions
• Direct preparation and maintenance of residents’ clinical records
• Inspect rooms for cleanliness and comfort
• Accompany physician on rounds, and keep informed of special orders concerning residents
• Participate in orientation and training of personnel
• Order, or direct ordering of drugs, solutions, and equipment and maintain records on narcotics
• Chart pertinent information in resident records
• Take and record vital signs
• Has a working knowledge of standards of care established by the profession, regulatory bodies, and state and government and execute policies and procedures to maintain compliance
• Identify safety hazards and emergency situations and initiate corrective action
• Identify resident problems and emergency situations, and initiate immediate “life saving” measures in the absence of a physician
• Follow staffing guidelines and make nursing assignments according to qualifications of staff and characteristics of the resident population
• Participate in relief coverage of nursing units as necessary
• Assume responsibility for compliance with Federal, State and local regulations within the
assigned nursing unit
• Keep the Nursing Supervisor and/or Director of Nursing informed of needed employee coaching
• Administer and document medications and treatments per the physician’s order and accurately record all care provided
• Develop an accurate comprehensive care plan based on each resident’s comprehensive
assessment and update as needed
• Document resident care provided and resident’s response or lack of response to care provided
• Report changes in residents’ conditions to a physician, the Nursing Supervisor and/or Director of Nursing and the responsible party promptly and take follow up action as necessary
• Follow facility admission procedures and communicate resident admission to other
departments, physicians and ancillary providers
• Complete documentation related to the resident’s discharge or transfer
• Participate in resident care meetings as required
• Provide direct resident care and give instruction to Certified Nursing Assistants related to resident care
• Prepare Certified Nursing Assistants’ assignments and explain all pertinent resident care
• Personally obtain continuing education relating to nursing in long- term care or other needs indicated by a specialized resident population
• Attend mandatory meetings, in-services and training sessions as required
• Observe infection control procedures related to the department and the facility
• Protect residents’ rights to assure fair and equitable treatment, self-determination, individual privacy and dignity, as well as property and civil rights
• Attend training and practices procedures related to safety of environment; safety, security, hazardous materials, life safety (R.A.C.E . procedures), medical equipment and utility system (ex: call lights).
• Deal tactfully with personnel, residents, visitors and the general public
• Input care plans on computer, as applicable
• Investigate and resolve complaints, or refer unusual problems to Nursing Supervisor and/or Director of Nursing
• Perform other related duties as assigned by Nursing Supervisor and/or Director of Nursing
• In cases of emergency, will assist residents out of facility