Lead Registered Nurse

2 weeks ago

Manchester, Michigan, United States AristaCare at Whiting Full time
Full Time 3pm - 11pm

The primary responsibility of this position is to deliver direct nursing care to residents while overseeing the daily nursing operations carried out by nursing assistants. This oversight must align with current federal, state, and local standards, guidelines, and regulations governing our facility, as directed by the Director of Nursing Services or Nurse Supervisor, to ensure the highest quality of care is consistently provided.

Key Responsibilities

  • Oversee the daily activities of nursing assistants in compliance with the established rules and regulations of the long-term care facility.
  • Ensure adherence to the facility's written policies and procedures by all nursing personnel under your supervision.
  • Regularly review and recommend updates to the department's policies, procedure manuals, and job descriptions.
  • Collaborate with nursing staff and support personnel to plan services, programs, and activities for each shift.
  • Maintain the Nursing Service Procedures Manual to ensure it accurately reflects daily nursing practices.
  • Ensure compliance with the Nursing Service Procedures Manual among all nursing staff.
  • Prepare written and oral reports regarding your shift's activities as required.
  • Work in conjunction with other resident services to coordinate nursing care and maintain a comprehensive care regimen for residents.
  • Ensure all nursing personnel fulfill their job responsibilities as outlined in their respective job descriptions.
  • Engage in the development and implementation of the facility's quality assurance program for the nursing department.
  • Participate in facility inspections conducted by authorized government agencies as requested.
  • Review and update residents' discharge plans as necessary.
  • Assist in planning nursing services related to residents' discharge plans as needed.
  • Clarify departmental policies and procedures for staff, residents, visitors, and regulatory agencies as necessary.
  • Manage the admission, transfer, and discharge processes for residents as required.
  • Complete necessary accident and incident reports.
  • Prepare resident charge slips and submit them to the Business Office.
  • Maintain and submit the Daily Census Report to the Business Office as required.
  • Perform administrative tasks such as completing medical forms, reports, evaluations, and charting as necessary.

Documentation and Charting

  • Complete and file all required recordkeeping forms and charts upon residents' admission, transfer, or discharge.
  • Encourage attending physicians to review and sign treatment plans, orders, and progress notes in accordance with established policies.
  • Receive and document telephone orders from physicians on the Physicians' Order Form.
  • Transcribe physician orders into resident charts, medication cards, and treatment plans as required.
  • Document nurses' notes in a clear and descriptive manner that reflects the care provided and the residents' responses.
  • Complete accident and incident reports and submit them to the Director as required.
  • Document all incidents involving residents following established procedures.
  • Record new or changed diet orders and communicate this information to the Dietary Department.
  • Report any discrepancies in physician orders, diet changes, or charting errors to the Nurse Supervisor.
  • Complete transfer forms in accordance with established procedures.
  • Ensure proper documentation of unauthorized discharges is recorded in the resident's medical record as per established procedures.
  • Perform routine charting duties in accordance with established policies and procedures.
  • Sign and date all entries made in the resident's medical record.

Medication Administration Responsibilities

  • Prepare and administer medications as prescribed by the physician.
  • Verify the identity of residents prior to administering medications or treatments.
  • Ensure that medications prescribed for one resident are not given to another.
  • Maintain an adequate supply of medications, supplies, and equipment to meet residents' nursing needs, reporting shortages to the Nurse Supervisor.
  • Order necessary medications, supplies, and equipment in accordance with established policies.
  • Ensure accuracy in narcotic records for your shift.
  • Notify the Nurse Supervisor of any discrepancies in drugs and narcotics observed during your shift.
  • Review medication cards for completeness and accuracy in transcription of physician orders.
  • Notify attending physicians of automatic stop orders prior to the last dosage being administered.
  • Dispose of drugs and narcotics as required and in accordance with established procedures.

Qualifications

Must possess, at a minimum, a Nursing Degree from an accredited college or university.

License: Registered Nurse

Experience Requirements

  • Minimum of one year of supervisory experience in a hospital, long-term care facility, or related healthcare environment.
  • Training in rehabilitative and restorative nursing practices is required.

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