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LVN/RN Charge Nurse
3 months ago
Job Location
Coronado at Stone Oak - San Antonio, TX
Description
Diversity, Equity, and Inclusion are at the heart of Cantex. We are committed to a culture that respects our differences and values the contributions of all people.
Please visit for more information on this location.
Job Summary:
The overall purpose of the Nurse Manager position is to participate in and oversee the provision of patient care as prescribed by the attending physician, consistent with accepted standards of practice. This position is responsible to provide care directly to the Patient and/or supervise the direction of care to ensure the highest practical care is provided to the Patient.
Qualifications
Qualifications:
- Graduation from an accredited Nursing School and a current and valid LVN/LPN license in the applicable State
- Minimum of one-year supervisory experience in a long-term or health care setting is preferred.
- Ability to read, write, and speak the English language.
- Monitor/Review the following daily for accuracy, completion, required documentation and appropriate intervention:
- Telephone Orders
- Medication Administration Record
- PRN Medication Administration Record
- IV Medication Administration Record
- Treatment Record
- G-Tube Record
- Diabetic Record
- Anticoagulant Monitoring Form
- Weekly Skin Assessment Form
- Patient Daily Record
- Flow Record
- Behavior Monitoring Sheets
- Narcotic Control Sheets
- Monthly Summaries that are due
- Lab, X-ray, etc. reports received
- Glucometer Control Log
- Refrigerator temperature Logs
- Make rounds on all Patients at a minimum of every 4 hours and as needed. Communicate any findings/concerns to the charge nurse for intervention.
- Review the 24-hour report book for information regarding the last 24 hours; assessing Patients with a recent change in condition. Any change in a Patients condition requires assessment, notification, documentation, and intervention.
- Review incident reports and follow up for proper documentation of nursing assessment, intervention and notification to the responsible party and physician.
- Review the medical record on every Patient discharged for accuracy; follow up, proper documentation and intervention. If transferred to home or to another Facility, reviews the Post Discharge Plan of Care for completion.
- Check appropriate documentation on patients regarding:
- 24-hour follow-up on room changes.
- 72-hour documentation on admissions and re-admissions.
- Review medical records on follow up to determine problems, assessments, interventions, documentation, and notification of responsible party and physician in a timely manner (see DON Manual for detailed instructions on follow up documentation).
- Distribute the monthly MDS/care plan calendar to appropriate members of the Interdisciplinary team by the 15th of each month.
- Complete MDS assessments, RAPs if applicable, Care Plans and TILE assessments due for completion.
- Attend weekly care plan meetings with the Interdisciplinary team, Patient and Responsible party.
- Attend the weekly TILE and Medicare meetings with appropriate Interdisciplinary team members.
- Enter physician orders daily into the clinical software system.
- Print physicians orders and check for accuracy by 25th of each month and place orders in patient medical records by midnight on first day of the following month.
- Complete recommendations from the Consultant Pharmacists Report within 72 hours of exit interview.
- Complete recommendations from the Dietary Consultant Report within 72 hours of exit interview.
- Verify emergency box to evidence completion of charge slips for medications.
- Enter weights into the clinical software system per RCMS # 2.
- Print the monthly Weight Change Alert reports and updated Weight Change Log per RCMS #2.
- Confirm Skin Site Identification Forms (RCMS Form 1-6) and the Communication Form (RCMS Form 7-3) are available at the nursing station(s) and in the shower room(s).
- Weekly, update and distribute the Daily Care Guides.
- Has reviewed Cantex Continuing Care Networks Clinical Policies and Procedures for Abuse Prevention and knows the employees responsibility to enforce it.
- Attends weekly in-services, understands, complies, and enforces Patient Care Management Systems.
- Responsible for assuring patient/resident safety.
- Performs other duties and tasks as assigned.
