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Registered Nurse RN Gold Country Healthcare Center
1 month ago
• Essential Functions*
• Interpersonal, Teamwork & Misc. *
• Communicates unresolved work-related issues productively & effectively solves problems
• Handles confidential information appropriately and is HIPAA compliant
• Friendly and courteous to residents, co-workers etc, and takes ownership in solving problems (taking initiative where appropriate)
• Works well in a team, owning personally assigned work and assisting wherever needed to get the job done
• Follows established policies and guidelines
• Reliable and predictable attendance
• Administrative Functions*
• 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 that all nursing personnel assigned to you 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.
• Meet with your assigned nursing staff, 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 this facility.
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual.
• Make written and oral reports/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 are in compliance with their respective job descriptions.
• Participate in the development, maintenance, and implementation of the facility's 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 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.
• Complete accident/incident reports as necessary.
• Write resident charge slips and forward to the Business Office.
• Maintain the Daily Census Report and submit to the Business Office as required.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. , as necessary.
• Charting and Documentation*
• Complete and file required recordkeeping 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, cardex, medication cards, treatment/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/incident reports. Submit to Director as required.
• Chart all reports of accidents/incidents involving residents. Follow established procedures.
• Record new/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.
• 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 Functions*
• Prepare and administer medications as ordered by the physician.
• Verify the identity of the resident before administering the medication/treatment.
• Ensure that prescribed medication for one resident is not administered to another.
• 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.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
• Ensure that narcotic records are accurate for your shift.
• Notify the Nurse Supervisor 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*
• 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 that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Nurse Supervisor.
• Ensure that all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program.
• Ensure that 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 that department personnel, residents, and visitors follow the department's established policies and procedures at all times.
• 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.
