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Lead Registered Nurse

2 months ago

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

The primary objective of this position is to deliver direct nursing care to residents while overseeing the daily nursing operations conducted 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 maintained.

Key Responsibilities

  • Oversee the daily activities of nursing assistants in compliance with the current regulations and guidelines governing long-term care facilities.
  • Ensure adherence to the facility's established policies and procedures by all nursing personnel under your supervision.
  • Regularly review and suggest revisions to departmental policies, procedure manuals, and job descriptions.
  • Collaborate with assigned 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 service personnel.
  • Prepare written and oral reports regarding shift activities as required.
  • Coordinate nursing services with other resident services to maintain a comprehensive care regimen for residents.
  • Ensure all nursing staff comply with their designated job descriptions.
  • Contribute to 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 resident discharge plans as necessary.
  • Assist in planning nursing services related to resident discharge as needed.
  • Clarify departmental policies and procedures for personnel, residents, visitors, and regulatory agencies as required.
  • Manage the admission, transfer, and discharge processes for residents.
  • 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 necessary recordkeeping forms upon resident admission, transfer, and discharge.
  • Encourage attending physicians to review and sign treatment plans, orders, and progress notes as per established policies.
  • Record telephone orders from physicians on the Physicians' Order Form.
  • Transcribe physician orders to resident charts, medication cards, and treatment plans as required.
  • Document nurses' notes in a detailed manner that reflects the care provided and the resident's response.
  • Complete accident and incident reports and submit them to the Director as required.
  • Document all incidents involving residents and follow established procedures.
  • Record any new or changed diet orders and communicate this information to the Dietary Department.
  • Report discrepancies regarding physician orders, diet changes, or charting errors to the Nurse Supervisor.
  • Complete transfer forms in accordance with established procedures.
  • Ensure documentation of unauthorized discharges is entered in the resident's medical record as per established procedures.
  • Perform routine charting duties in line 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 medication administration.
  • 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 to the Nurse Supervisor as necessary.
  • Order prescribed medications and supplies as needed, following 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 accordance with 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 a Nursing Degree from an accredited institution.

License: Registered Nurse

Experience Requirements

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