Quality LPN Medical Records
4 weeks ago
Job Title: LICENSED PRACTICAL NURSE
Under the direction of the RN Nursing supervisor, Unit manager, DNS or ADNS the Licensed Practical Nurse delivers efficient and effective nursing care while achieving positive clinical outcomes and patient family satisfaction. He/she operates within the scope of practice defined by the state nurse practice act and delegates aspects of patient care to C.N.A.'s consistent with their scope of practice.
Requirements:
• Current license by the State of MA Board of Nursing, as a Licensed Practical Nurse.
• 2+ years' experience in Long-term care, as a Licensed Practical Nurse is a must.
• Previous experience with memory care and dementia care is preferred.
• Med Pass experience.
• Ability to lead and motivate subordinates (CNAs and Nurse Aides).
• Ability to perform a variety of duties characterized by frequent change, as work schedule will change on a daily basis.
• Able to work intimately with residents, physicians, and staff.
• Capable of working to prescribe nursing standards.
• Good interpersonal and communication skills and work well with a team.
Responsibilities:
• The Licensed Practical Nurse will be responsible for daily med-pass and nursing general responsibilities of a specific unit.
• Performs nursing techniques for the comfort and well-being of the residents; checks residents daily to determine status; ensures residents reach the highest attainable level of functioning.
• Observes, records, and reports changes in residents’ condition to supervisor and attending physician.
• The Licensed Practical Nurse maintains residents’ medical record by way of documentation, as required by DPH and facility policy.
• Assists in the Continuous Quality Improvement Program and ensures follow-up occurs.
• Reports accurately to oncoming shift Charge Licensed Practical Nurses regarding a change in resident status and follow-up needs.
• Coaches, counsels, and disciplines C.N.A.’s as needed; ensures personnel policies are followed.
• Participates in the care planning process and ensures the Nursing component is implemented.
• Ensures the rights of residents are respected; coordinates with other departments and ensures residents are taken to activities, etc.
• Assists physicians during their rounds.
• Administers prescribed medications, orally or by injection; provides treatments using therapeutic equipment; ensures proper handling and storage of medications and controlled substances.
• Observes residents’ reactions to medication and treatment.
• Assists in planning, supervising and instructing C.N.A.’s; assigns daily work assignments to ensure positive outcomes for residents.
• Implements and maintains policies are utilized.
• Ensures that safe work practices are utilized.
• Ensure proper infection control techniques are utilized.
• Provides input for CNA performance evaluations.
• Recommends staffing, equipment, and supply needs to D.O.N.
• The Licensed Practical Nurse is responsible for capturing charges for supplies issued to residents on that unit.
QUALIFICATIONS AND SKILLS:
• Graduate of accredited school of Nursing
• Valid Nursing licensure in Massachusetts
• Valid CPR certification
• At least 1 year of Licensed Practical Nursing experience (preferred)
• Computer skills are highly valuable, but actual knowledge of our EMR will be taught during the orientation process.
Safety & Health Requirements:
• Identifies safety hazards and emergency situations and reports appropriately.
• Follows facility fire, safety and evacuation plans.
• Functions effectively in emergency situations.
• Follows facility procedures related to control of equipment and supplies within the unit. Assures that work/assignment areas are clean, equipment and supplies are stored before leaving care area on breaks and at end of shift.
• Observes infection control procedures including hand washing and isolation procedures.
• Assumes responsibility for the safety of residents under his/her supervision, including resident alarms being on and intact when ordered for resident.
• Performs resident alarm checks when assigned per facility protocol.
• Observes all facility safety policies and procedures.
• Utilizes proper body mechanics for self and residents including use of gait belts and other equipment.
• Transports residents in required equipment safely to other departments or activities.
• Maintains residents' units - bedside table, bureau, closets, and personal care items in a clean and orderly fashion.
• Knows and uses universal precautions.
Individual Growth Requirements:
• Participates in facility education programs as assigned.
• Attends all classes as assigned and completes assignments.
• Comes to work in a clean neat uniform and consistently presents a professional appearance in accordance with department dress code.
• Comes to work as scheduled and consistently demonstrates dependability and punctuality.
• Accepts assigned duties in a cooperative manner.
• Assists others when own work is completed.
• Effectively organizes varying workloads.
Documentation Requirements:
• Documents incidents and/or unusual problems according to established facility procedures. i.e. personal injuries within 24 hours; residents' incidents immediately.
• Documents in the nursing assistant notes the care and treatment provided to the resident and the resident's response or lack of response to care provided.
• Documents positioning and restraint usage on designated flow sheets.
General Requirements:
• Follows established performance standards and performs duties according to nursing service policies and procedures.
• Assumes accountability for compliance with federal, state and local regulations within the unit assigned and within his/her span of control.
• Listens tolerantly and patiently to resident and family complaints and report problems to Charge Nurse.
• Follows Resident's Rights policies at all times including confidentiality, privacy and dignity.
• Consistently works cooperatively with residents, charge nurses, staff nurses, restorative assistants, other nursing assistants, physicians, families, consultant personnel, ancillary service providers and administration.
• Performs other related duties as directed by licensed nursing personnel.
• Accepts assignments to specific areas of nursing home at the discretion of management.
NON-ESSENTIAL FUNCTIONS:
• Assists new employees in following established facility policies and procedures.
• Participates in resident care conferences and other facility meetings as assigned.
• Reviews care plans and performs nursing care as outlined.
• Follows facility procedures for admission, discharge, and transfer of residents.
• Performs post mortem care according to facility policy and procedure.
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