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 CNAs/GNAs and other nursing personnel. To monitor the performance of CNAs/GNAs, nursing and non-licensed personnel, provide education and counseling, perform disciplinary action as necessary, and complete performance evaluations. 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 that the highest degree of quality care is maintained at all times.
Delegation of Authority
As Licensed Practical Nurse/Registered Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.
Job Function
Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is an essential function of the position.
Duties and Responsibilities
Administrative Functions
- Direct the day-to-day functions of the CNAs/GNAs or other nursing personnel in accordance with current rules, regulations, and guidelines that govern the long-term care Facility.
- Ensure that all assigned nursing personnel including CNAs/GNAs comply with the written policies and procedures established by this Facility.
- Periodically review the department’s policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.
- Provide discipline and evaluations of assigned CNAs/GNAs and other nursing personnel in accordance with current rules, regulations, and guidelines that govern the Facility.
- Issue verbal and written disciplinary warnings to assigned CNAs/GNAs and other nursing personnel for violations of current rules, regulations, and guidelines of the Facility.
- Meet with your assigned nursing personnel, including CNAs/GNAs, as well as support personnel, in planning the shifts’ services, programs, and activities.
- Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in the Facility.
- Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual.
- Make written and oral reports or recommendations concerning the activities of your shift, as required.
- Cooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.
- Ensure that all nursing service personnel comply with their respective job descriptions.
- Participate in the maintenance and implementation of the Facility’s quality assurance program for the nursing service department.
- Participate in Facility surveys or inspections made by authorized government agencies, as may be requested.
- Periodically review the resident’s written discharge plan. Participate in the updating of the 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 and incident reports, as necessary.
- Write resident charge slips and forward to the Business Office.
- Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
Charting and Documentation
- Complete and file required recordkeeping forms or 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, cardex, medication cards, treatment or 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 resident’s response to the care.
- Fill out and complete accident and incident reports. Submit to Director of Nursing, as required.
- Chart all reports of accidents and incidents involving residents. Follow established procedures.
- Record new and changed diet orders. Forward information to the Food Services Department.
- Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Nurse Supervisor and/or Unit Manger.
- Fill out and complete transfer forms in accordance with established procedures.
- Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident’s 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 made in the resident’s medical record.
Drug Administration Function
- Prepare and administer medications as ordered by the physician.
- Verify the identity of the resident before administering the medication and treatment.
- Ensure that prescribed medication for one resident is not administered to another resident.
- Ensure that 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 and/or Unit Manager.
- Order prescribed medications, supplies, and equipment, as necessary, in accordance with established policies.
- Ensure that narcotic counts are accurate before and after every shift.
- Notify the Nurse Supervisor and/or Unit Manager of all drug and narcotic discrepancies noted on your shift.
- Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, and adherence 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.
Personnel Functions
- Inform the Nurse Supervisor and/or Unit Manager of staffing needs when assigned personnel fail to report to work. Recommend overtime for assigned CNAs/GNAs and other nursing personnel to the Nurse Supervisor or Unit Manager to insure residents’ needs are met.
- Report absentee call-ins to the Nurse Supervisor and/or Unit Manager.
- Provide feedback and recommendations for probationary and annual employee performance evaluations for CNAs/GNAs and other nursing personnel. Prepare probationary and annual employee performance evaluations for CNAs/GNAs and other nursing personnel. Meet with CNAs/GNAs and other nursing personnel to review performance.
- Develop work assignments and/or assist in completing and performing such assignments. Reassign assigned CNAs/GNAs and other nursing personnel based upon skills and qualifications.
- Provide leadership, education, counseling, and discipline, when appropriate, to assigned CNAs/GNAs and other nursing personnel.
- Make daily rounds of your unit/shift to ensure that assigned CNAs/GNAs and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards. Make changes to assignments based upon resident needs and availability of skilled staff.
- Evaluate daily performance of assigned CNAs/GNAs and other nursing personnel. Document any disciplinary issues and report problem areas or disciplinary actions to the Nurse Supervisor and/or Unit Manager.
- Meet with your assigned CNAs/GNAs and other nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services. Assign personnel accordingly to insure quality resident care while allowing personnel to improve in areas where they may be deficient, with appropriate supervision.
- Ensure that CNAs/GNAs, department personnel, residents, and visitors follow the department’s established policies and procedures at all times.
- Resolve personnel disputes and issues within the unit and reassign or remove personnel, if necessary, to insure patient safety.
- Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the Facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the residents.
- Review complaints and grievances made or filed by your assigned CNAs/GNAs or other nursing personnel. Make appropriate reports to the Nurse Supervisor and/or Unit Manager as required or as may be necessary. Follow Facility’s established procedures.
- Receive/provide the nursing report upon reporting in and ending shift duty hours.
- Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the Facility’s policies and procedures governing accidents and incidents.
Nursing Care Functions
- Inform nursing personnel including assigned CNAs/GNAs of new admissions, their expected time of arrival, room assignment, etc.
- Ensure that rooms are ready for new admissions.
- Greet newly admitted residents upon admission. Escort them to their rooms, as necessary.
- Participate in the orientation of new residents and family members to the Facility.
- Make rounds with physicians, as necessary.
- Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.
- Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.
- Review the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.
- Maintain established nursing objectives and standards.
- Make periodic checks to ensure that certified nursing assistants, CNAs/GNAs, and/or other nursing personnel are properly administering prescribed treatments and to evaluate the resident’s physical and emotional status.
- Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, CNA/GNA, and/or a nurse aide trainee qualified to perform the procedure.
- Cooperate with and coordinate social and activity programs with nursing service schedules.
- Notify the resident’s attending physician when the resident is involved in an accident or incident.
- Notify the resident’s attending physician and next-of-kin when there is a change in the resident’s condition.
- Carry out restorative and rehabilitative programs to include self-help and care.
- Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.
- Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings and bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead and dying, etc., as required.
- Use restraints when necessary and in accordance with established policies and procedures and applicable state laws and guidelines.
- Use an Automated External Defibrillator, as required.
- Obtain sputum, urine, blood, and other specimens for lab tests, as ordered
- Take and record TPRs, blood pressures, etc., as necessary.
- Perform Cardiopulmonary resuscitation (CPR), as necessary.
- Monitor seriously ill residents as necessary.
- Check foods brought into the Facility by the resident’s family or visitors to ensure that it is within the resident’s dietary allowances. Report problem areas to the Nurse Supervisor and/or Unit Manager and Dietary Supervisor.
- Ensure that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.
- Ensure that residents who are unable to call for help are checked frequently.
- Meet with residents, and/or family members, as necessary. Report problem areas to the Nurse Supervisor and/or Unit Manager.
- Admit, transfer and discharge residents, as necessary.
- Assist in arranging transportation for discharged residents, as necessary.
- Ensure that discharged residents are escorted to the pick-up area.
- Inform family members of the death of the resident.
- Call funeral homes when requested by the family. Ensure that established post- mortem procedures are followed.
Staff Development
- Participate in planning, conducting, and scheduling in-service training classes for CNAs/GNAs and any other nursing personnel that provide instructions on “how to do the job,” and ensure a well-educated nursing service department.
- Implement and maintain an effective orientation program that orients the new employee, including CNAs/GNA assigned to your shift, its policies, and procedures, and to his/her job position and duties.
- Assist in standardizing the methods in which work will be accomplished.
- Assist in training department personnel in identifying tasks that involve potential exposure to blood or body fluids.
- Assist the Director in planning clinical supervision for nurse aide trainees.
- Attend and participate in outside training programs, as requested.
- Attend and participate in annual Facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.).
- Attend and participate in advance directive in-service training programs for the staff and community.
- Attend and participate in continuing education programs designed to keep you abreast of changes in your profession, as well as to maintain your license on a current status.
Safety and Sanitation
- Ensure that all personnel performing tasks that involve potential exposure to blood or body fluids participate in appropriate in-service training programs prior to performing such tasks.
- Ensure that adequate supplies of personal protective equipment are on hand and are readily available to personnel who perform procedures that involve exposure to blood or body fluids.
- Ensure that your assigned work areas (i.e., nurses’ stations, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner.
- Ensure that your unit’s resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner.
- Ensure that assigned CNAs/GNAs and other nursing personnel follow established hand washing and hand hygiene technique in the administering of nursing care procedures.
- Ensure that assigned CNAs/GNAs and other nursing personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner.
- Participate in the implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel.
- Ensure that assigned CNAs/GNAs and other nursing personnel follow established infection control procedures when isolation precautions become necessary.
- Ensure that CNAs/GNAs and other nursing follow established procedures in the use and disposal of personal protective equipment.
- Participate in the implementation and maintenance of the procedures for reporting hazardous conditions or equipment.
- Ensure that all personnel wear and/or use safety equipment and supplies when lifting or moving residents.
- Report missing and illegible labels and MSDSs to the safety officer or other designated person.
Equipment and Supply Functions
- Recommend to the Nurse Supervisor the equipment and supply needs of your unit or shift.
- Ensure that an adequate stock level of medications, medical supplies, equipment, etc., is maintained on your unit or 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 that only trained and authorized personnel operate your unit or shift’s equipment.
- Ensure that all personnel, including CNAs/GNAs and other nursing personnel assigned during your shift operate nursing service equipment in a safe manner.
- Monitor nursing procedures to ensure that nursing service supplies are used in an efficient manner to avoid waste.
- Ensure that appropriate MSDSs are on file for hazardous chemicals used in the nursing service department.
Care Plan and Assessment Functions
- · Review care plans daily to ensure that appropriate care is being rendered.
- · Inform the Nurse Supervisor and/or Unit Manager of any changes that need to be made on the care plan.
- · Ensure that your nurses’ notes reflect that the care plan is being followed when administering nursing care or treatment.
- · Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.
- · Ensure that assigned CNAs/GNAs and other nursing personnel are aware of the resident care plans. Ensure that the CNAs/GNAs and other nursing personnel refer to the resident’s care plan prior to administering daily care to the resident.
- · Supervise assigned CNAs/GNAs and other nursing personnel activities included in the care plan. Provide CNAs/GNAs and other nursing personnel with direction and counseling necessary to provide services in accordance with the care plan.
- · Assist in planning, scheduling, and revising the MDS, including the implementation of RAPs and Triggers.
Resident Rights
- Ensure that all nursing service personnel including assigned CNAs/GNAs 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 or 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 resident’s complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint.
- Report and investigate all allegations of resident abuse and/or misappropriation of resident property.
- Ensure that nursing staff personnel including assigned CNAs/GNAs honor the resident’s refusal of treatment request. Ensure that such requests are in accordance with the Facility’s policies governing advance directives.
- Must adhere to all HIPAA requirements.
- Provide data to the Quality Assurance & Assessment Committee as requested.
Working Conditions
- Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.).
- Involved with residents, personnel, visitors, government agencies or personnel, etc., under all conditions and circumstances.
- May be subject to hostile and emotionally upset residents, family members, and visitors.
- Communicate with the medical staff, nursing personnel, and other department directors.
- May be required to work beyond normal working hours, and in other positions temporarily, when necessary.
- May be subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
- Attend and participate in continuing educational programs.
- May be subject to the handling of and exposure to hazardous chemicals.
- Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.
Education
- Must possess, at a minimum, a Nursing Degree from an accredited college or university, or graduate from an approved LPN/LVN/RN program.
Experience
- Not applicable. On-the-job training provided.
Specific Requirements
- Must possess a current, unencumbered, active license to practice as an RN or LPN/LVN in this state.
- Must be able to read, write, speak, and understand the English language.
- Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.
- Must be a supportive team member, contribute to and be an example of teamwork and team concept.
- Must possess the ability to make independent decisions when circumstances warrant such action.
- Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies or personnel, and the general public.
- Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.
- Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
- Must be able to evaluate the performance, initiate disciplinary actions, and prepare and complete performance evaluations for personnel.
- Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures that are necessary for providing quality care.
- Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
- Must be able to relate information concerning a resident’s condition.
- Must possess basic computer knowledge.
Physical and Sensory Requirements
(With or Without a Reasonable Accommodation)
- Must be able to walk, sit, stand, and bend intermittently throughout the workday.
- Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
- Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
- Must meet the general health requirements set forth by the policies of the Facility, which may include a medical and physical examination.
- Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the Facility.
- May be necessary to assist in the evacuation of residents during emergency situations.
- Based on the Occupational Safety and Health Administration's Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders and the American Conference Governmental Industrial Hygienists' Threshold Limit Values for Lifting the Facility has identified that this job may require the lifting of residents, equipment, or other objects. Accordingly, this job may require a minimum of 5 pounds and a maximum of 45 pounds lifting, periodically and or as needed
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