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RN Team Leader
3 months ago
Waterville Residential -
Job Summary:
Assists in planning and implementing the nursing care of residents within the skilled nursing setting with the supervision of a Registered Nurse. Responsible for ensuring continuity of care of the residents between shifts by providing direct care as well as supervising the care given by CNAs and supportive staff members. Participates in resident and family teaching. Maintains role as resident advocate with a focus on the facilitys mission.
DUTIES AND RESPONSIBILITIES:
Documentation : Documents accurately per policy on residents in a change in condition or on 24 hr report, on an ordered documentation log such as behavior, pain, sleep, functionally mobility, stop and watch, medicare look back as well as required admission, lateral transfer, or discharge documentation.
Change in Condition : Observes for changes in the residents condition and suggests nursing needs. Obtains vital signs, lung sounds and other needed clinical data, notifies on duty facility supervisor and medical via acute log on any new changes in condition with also having appropriate documentation in resident record so that appropriate action can be taken.
Pain Management : Ability to adequately monitor, treat and report resident pain whether physical or emotional, verbal or nonverbal. Demonstrates knowledge of symptoms of pain and depression. Utilizes appropriate pain management techniques checks for available prns and administers appropriately as well as monitors for and documents/reports effectiveness. Reinforces education with resident and family regarding pain management. Ensures the quality of life for residents by advocating and assisting them to remain free from pain.
Medication Administration:
Administers medications safely and per policy, follows the seven (7) medication rights and reduces the potential for medication errors. Demonstrates competency in medication administration per regulations. Utilizes prn medication when needed.
Documentation 2 : Meets current skilled nursing documentation standards and policies.
Time Management Skills : Notes and carries out physicians orders in a timely manner. Completes shift work of med pass, treatments and documentation in timely manor. Demonstrates adequate organizational skills to complete job duties.
Communication Skills : Gives a thorough report to oncoming shift by documenting appropriately in resident record and documenting on 24 hr report. Communicates resident or family concerns to Inter Disciplinary Team.
Follow Through : Follows up on information given by shift report, resident or family regarding resident concerns. Notifies physician of changes in residents condition and follows through until appropriate action is taken.
Care Plan Compliance : Implements plan of care of the resident based on assessments and goals established by the interdisciplinary care team. Ensure care plans are followed.
Customer Service:
Treats residents and their families with respect and dignity. Identifies and addresses psychosocial, cultural, ethnic and religious/spiritual needs of residents and their families. Demonstrates good customer service skills with internal and external staff as well as any outside services that may be associated with resident care or facility. Represents facility in a professional manor.
End of Life Care:
Ensures residents at end of life or on hospice services are kept clean, dry and comfortable. Provides frequent checks for comfort and reports to supervisor or medical any sx of discomfort such as labored breathing, moaning or groaning, facial grimacing or restlessness. Administers pain management meds appropriately, timely and as ordered, obtains increases in pain management orders as needed by continuous observation of resident comfort level and communicating with medical team when need for med increases are observed in a timely manner. Oral care: uses mouth swabs throughout shift for residents no longer taking anything by mouth, uses a&d to lips for moisture. Comforts and gives extra support to residents and family. Treats resident and family with compassion and respect. Provides postmortem care as needed, notifies supervisor and medical of deceased resident and documents appropriately, contacts family, funeral home or medical examiner per supervisor direction enters release of body MD order and emails team time of death and when resident body has left the building.
Resident Dining : Assists in a positive dining experience for the residents. Uses proper hand hygiene when handling food. Provides nursing supervision during mealtime in designated or assigned resident dining areas as well as overseeing that resident nourishment pass is complete.
Infection Control : Is competent in: use of PPE (mask, gloves, gown, goggles), sharps safety (sharps boxes, where they are and what they are used for), Respiratory hygiene and cough etiquette, assists in the cleaning and disinfecting of environment surfaces and shared objects on units. Is competent with sterile and aseptic technique for appropriate nursing procedures. Disinfects equipment between use of residents such as stethoscope, BG machines, BP cuffs, pulse oximeters.
Infection Control : Maintains all isolation precautions as ordered. Ensures red stop sign is present, isolation carts are stocked, isolation garbage or linen bins are emptied every shift. Understands droplet, contact, airborne and universal precautions.
Call Bells:
Answers residents call lights in a timely manner, anticipates residents needs and makes rounds on unit. Does not use that is not my job approach, demonstrates the willingness to assist all residents and staff in need when requested.
Assistive Devices:
Ensures residents have their assistive devices and they are clean and in good working order as care planned such as: dentures, glasses, contact lenses, hearing aids and prosthetic devices, walker, wheelchair ect. Reports and broken or missing items to social work and supervisor.
Transportation of Residents : Assists in transporting residents to and from meals, therapy, activities inside appointments as needed or requested. Uses leg rests when transporting residents for safety.
Accidents and Incident Reporting:
Reports to supervisor all incidents or injuries such as: skin tears, bruises, falls, choking, resident wandering in nonresident areas, confused resident attempting to leave facility, resident attempts or threats of suicide to hurt self or others, resident to resident verbal or physical aggression and any other incidents observed or heard of that could potentially cause harm to a resident.
Abuse Reporting : Understands and follows the policy on abuse reporting, reports any questionable signs or observations of abuse whether verbal, physical, emotional, sexual of resident to resident, staff to resident, or visitor to resident. Reports any and all resident accusations or suspicion to immediate supervisor and removes resident from any potential harm.
Skin Care and Skin Protocol:
Follows skin protocol policy. Participates in providing proper skin care keeps residents skin clean, dry and intact. Uses moisturizers on dry skin and barrier creams on incontinent residents as instructed. Follows pressure prevention care plans ensures turning and positioning, bed to chair schedules, incontinence rounds, heel booties, floats heels are completed as instructed per care plan. Observes for and reports any skin issues or concerns immediately to supervisor, medical and in shift huddles.
Supervision and Leadership Skills:
Demonstrates adequate supervision of certified nursing assistants. Ensures POC documentation and quality resident care is provided on assigned residents. Functions as a leader for the CNAs; delegates in a manner that contributes to the excellence of the nursing unit to which LPN is assigned.
Clinical Competencies:
Demonstrates competence in technical and manual skills according to scope of practice for LPNs. Stays current with completing annual nursing competencies in Employee Education. Demonstrates daily competence and follows regulatory guidelines in nursing clinical skills such as wound care, foley care, respiratory treatments, vital signs, lung sounds, bowel sounds, apical heart rate and safe medication administration.
Residents Preferences and Choices:
Functions as a resident advocate by protecting the residents rights and honors residents preferences and choices.
Participates in Performance Improvement Plans : Demonstrates creativity in solving problems and looking at situations in new and innovative ways. Works with management in problem solving unit, facility or resident issues. Participates in accident incident review.
Promotes Positive Environment : Interacts with residents, families, co-workers, managers and other departmental staff in a kind, knowledgeable, professional and friendly manner. Demonstrates good customer service skills. Promotes a positive environment for residents and staff. Supports and maintains a culture of safety and quality for residents and staff.
Medication Storage Safety : Demonstrates competency in proper med storage keeps med cart locked and clean up to regulatory standards, follows policy with the handling of narcotics medications, shift narcotic count and narcotic lock boxes, med room and med refrigerator.
Professionalism:
Demonstrates ability to remain calm and professional in emergency and/or stressful situations and gives everyone a feeling of confidence that station is under control. Acts as a role model to others.
Educates/Supports:
Participates in orientation of new staff and assists in performance evaluations when needed. Plays a role in staff development provides on going education and support to staff.
Stop and Watch : Has knowledge of stop and watch, attends shift huddles, responds to and reports on any resident change in conditions.
RN Assessments: Demonstrates competency in providing RN assessments when ever requested or needed in the facility such as responding to falls, PICC lines, Nephrostomy, IVs or any other RN only duties that may occur.
Demonstrates competent RN documentation in residents record on all RN duties or skills provided in facility such as accident incident reports, PICC lines, infusions given, IV monitoring, Nephrostomey flushes or any other assigned RN skills provided.
Manages Medical Orders:
Confirms and transcribes all new medical orders on assigned unit prior to end of shift. Demonstrates ability to accurately transcribe/confirm/enter all orders: lab and diagnostic orders, therapy orders, outside and inside appointments, dietary orders, admission, discharge orders, sending resident to hospital, release of body orders. Checks orders pending nursing confirmation through out shift and at end of shift to ensure no delay in care takes place. Calls pharmacy when medications are needed or missing, faxes long orders when indicated in PCC that do not go through electronically such as sliding scale insulins or other treatment orders.
Immunizations:
Demonstrates competence in administering and accurately documenting immunizations, signing EMAR and Immunization tab in resident record. Assists facility to stay in compliance with CDC recommended guidelines on immunizations, ensures the safety and wellbeing of residents.
Professional Requirements:
Adheres to dress code, wears name badge, appearance is professional, neat and clean.
Completes annual education requirements.
Maintains regulatory requirements and active NYS certification.
Maintains resident confidentiality at all times.
Reports to work on time and as scheduled, completes work within designated time.
Wears identification while on duty, uses computerized punch time system correctly.
Completes education/in-services in a timely fashion. Monthly and annually and as requested.
Attends annual review and department inservices, as scheduled.
Attends staff meetings such as shift huddles/reports.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) and QAPI activities.
Complies with all organizational policies regarding ethical business practices.
Communicates the mission, ethics and goals of the facility.
Makes eye contact, smiles and greets others by name
Make an effort to get to know team members, residents and their families.
Learn about and deliver on the needs of the residents
Do what you say you will do
Follow up in a timely manner
Take time to listen to and understand others
Recognize and share successes of our Life in Balance culture in action
Be willing to help others
Reach out and ask for help when needed
Speak positively about our care center and the people who live & work here
Bring positivity and fun to the work environment
Accept and learn from mistakes
Be flexible and adaptive to changes in the work environment
Seek to find solutions to problems
Take responsibility for the quality of your work
Seek out information you need to be your best
Share your knowledge and expertise to help others
Be knowledgable and enthusiastic about our care center and what we do
Communicate and work together across departments
Regulatory Requirements:
Graduate of an accredited Nursing program.
Current Licensed Registered Nurse in State of New York.
Current CPR certification.
Skills:
Basic computer knowledge.
Physical Demands:
For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising resident care.
