Registered Nurse

General Purpose:Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. 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 to maintain the highest degree of quality care at all times.Essential Job Functions:This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents. Therefore, the following list of duties is not all-inclusive:Administrative FunctionsDirect the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the long-term care industryConfirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facilityMeet with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs and activitiesVerify that all nursing personnel comply with the procedures set forth the in the Nursing Policies and Procedures ManualMake written and oral reports/recommendations concerning the activities of your shift, as requiredCooperate with other resident services when coordinating nursing services be certain that the resident's total regimen of care is maintainedVerify that all nursing service personnel are in compliance with their respective job descriptionsParticipate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing departmentParticipate in surveys (inspections) made by authorized government agenciesPeriodically review the resident's written discharge plan. Participate in the updating of the resident's written discharge plan, as requiredAssist in planning the nursing portion of the resident's discharge plan, as necessaryAdmit, transfer, and discharge residents, as requiredComplete accident/incident reports, as necessaryCharting and DocumentationComplete and file required forms/charts upon resident's admission, transfer, and/or dischargeEncourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policiesReceive telephone orders from physicians and record on the Physicians' Order FormTranscribe physician's orders to resident charts, cardex, medication cards, and treatment/care plans, as requiredChart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to careRecord new/changed diet orders. Forward information to the Dietary DepartmentReport all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse SupervisorFill out and complete transfer forms in accordance with established proceduresEnter appropriate documentation concerning unauthorized discharges in the resident's medical record in accordance with established proceduresPerform routine charting duties as required and in accordance with established charting and documentation policies and proceduresSign and date all entries made in the resident's medical recordWrite nurses' notes to reflect that the care plan is being followed when administering nursing care or treatmentMedication Administrative FunctionsPrepare and administer medication as ordered by the physicianResponsible for IV medication/fluid administrationVerify the identity of the resident before administering the medication/treatmentVerify that prescribed medication for one resident is not administered to anotherVerify that 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 SupervisorOrder prescribed medications, supplies, and equipment as necessary, and in accordance with established proceduresVerify that narcotic records are accurate for your shiftNotify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shiftReview medication cards for completeness of information, accuracy in the transcription of the physician's order and adherence to stop order policiesNotify the attending physician of automatic stop orders prior to the last dosage being administeredImmediately notify the Nurse Supervisor and attending physician of any medication administration errorsNursing Care FunctionsPerform physical assessment through observation, inspection, palpitation, percussion and auscultationDeliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practicesPromptly respond to call lights and other resident needsMake rounds with physicians, as necessaryConsult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessaryReview the resident's chart for specific treatments, medication orders, diets, etc., as necessaryMake periodic checks to confirm that prescribed treatments are being properly administered by CNAs and to evaluate the resident's physical and emotional statusNotify the resident's attending physician when the resident is involved in an accident or incidentNotify the resident's attending physician and responsible party when there is a change in the resident's conditionAdminister professional services such as: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as requiredMonitor seriously ill residents, as necessaryReview care plans daily to confirm that appropriate care is being renderedConfirm that CNAs are aware of the resident care plans. Verify that the CNAs refer to the resident's care plan prior to administering daily care to the residentOther DutiesAttend in-service education programs in order to meet facility educational requirementsBe familiar with Standard Precautions, Exposure Control Plan, Fire Drill and Evacuation Procedures and know how to use the informationMaintain confidentiality of resident and facility records/informationProtect residents from neglect, mistreatment, and abuseProtect the personal property of the residents of the facilityOthers as directed by the supervisor or administratorMinimum Qualifications:Registered Nurse with current state licenseExcellent technical, assessment and documentation skillsGood Leadership qualitiesOrganized and detailed in work performanceGood communication skills with excellent self-discipline and patienceGenuine caring for and interest in elderly and disabled people in a nursing facilityComply with the Residents Rights and Facility Policies and ProceduresPerform work tasks within the physical demand requirements as outlined belowPerform Essential Duties as outlined above