Registered Nurse (RN)
Provides skilled nursing care and services to residents. Supervises staff as assigned in the day-to-day delivery of resident care. Such supervision must be in accordance with state and federal regulations and as may be required by the Director of Nursing or Designee to ensure the highest degree of quality care is maintained.
Qualifications:
• Must have and maintain throughout employment an unencumbered Registered Nurse licensure issued by the State Board of Nursing.
• Must be knowledgeable of nursing and medical practices and procedures, as well as state and federal regulations specific to nursing home operation and licensure.
• Must have valid CPR certification and maintain active CPR certification throughout employment.
• Must be able to make independent decisions when circumstances warrant such actions.
• Must possess leadership and supervisory ability and the willingness to work harmoniously with residents, families, vendors, visitors, government agencies, facility staff, hospital personnel, hospice representatives, and the general public.
• Must have excellent follow-through.
• Must possess the ability to plan, organize, develop, implement and interpret programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality individualized care.
• Must be able to lift 60-70lbs frequently.
• Must be able to stand and/or walk throughout the scheduled shift.
• Must comply with attendance policy and established nursing staff schedules, be flexible, and make necessary accommodations for the needs of residents and families.
• Must have knowledge of computer systems, systems applications, and other office equipment.
• Must be able to read, write and follow written and oral directions as a level necessary to accomplish the job.
• Must be able to meet all local health regulations, and pass pre/post-employment physical exam if required. This requirement also includes drug screening, criminal background investigation, and reference inquiry.
• Must have the ability to promote positive interpersonal relationships through the use of tactful, direct and sensitive interaction. Must be able to communicate verbally in a positive and professional manner.
• Must be able to relate positively and favorably to residents, families, co-workers, and to work cooperatively with others.
• Must attend in-service/education programs as required to learn new procedures and develop skills to meet regulatory compliance.
• Must agree not to disclose resident protected health information and report suspected or known violations of such to the Administrator.
Duties and Responsibilities:
1) Operate and supervise within the prescribed scope of practice for a Registered Nurse in the state.
2) Give and receive shift report.
3) Meet with your assigned nursing staff as well as support personnel, in planning the shifts services, progress, and activities as needed.
4) Admit, transfer, and discharge residents as required. Initiate and complete all required documentation, forms, inter-department communication, etc. per facility policy.
5) Ensure rooms are clean, prepped and ready for new admissions.
6) Perform administrative duties as assigned (such as: various medical forms, reports, evaluations, studies, training, etc.).
7) Assist and remind physicians and their extenders to complete required documentation, review treatment plans, care plans, sign documents, etc. Accompany on rounds as needed.
8) Contact physicians, nurse practitioners, and physician assistants as needed to report resident change of condition, convey lab/x-ray reports, emergencies, resident/family concerns, incidents/accidents, etc. and document new/changed orders and communication outcomes per facility policy.
9) Inform residents, resident representatives, and/or family members of resident change of condition, emergencies, incidents/accidents, new/changed etc. and document new/changed orders and communication outcomes per facility policy.
10) Review individualized plans of care (problems, goals, and interventions/approaches) for the residents to include: overall health, fall risk/positioning devices, restorative nursing programs, elopement risk, behaviors, skin conditions, discharge plans, therapy services, restraints, psychotropic medication usage, etc.
11) Administer medications and treatments as prescribed by the physician, nurse practitioner, or physician’s assistant. Document administration timely.
12) Order/Re-order prescribed medications, supplies, and equipment per facility policy.
13) Dispose of medications and narcotics in accordance with facility policy and state and/or federal regulations.
14) Administer specialized skilled services per physician or extender orders to include (but not limited to):
• Urinary catheterization, catheter removal, intermittent catheterization, catheter irrigation, urine specimen collection, etc.
• Tracheostomy care, suctioning, sputum specimen collection, monitoring, ostomy care, etc.
• G-tube/J-tube/PEG tube care, feedings, flushes, medication administration, ostomy care, etc.
• Wound/Skin care, preventative measures, advanced dressings, wound irrigation, wound packing, wound vacs, suture/staple removal, etc.
• Colostomy/Urostomy care, bag/wafer changes, skin care, irrigation, etc.
• IV therapy-peripheral catheter insertion and site change, central line care/maintenance/flushing/dressing changes, administration of medications and/or fluids, etc.
15) Coordinate with other departments as needed to ensure resident care is delivered per the individualized plan of care.
16) Direct the day-to-day functions of the nursing assistants in accordance with facility policy and current regulations.
17) Practice standard precautions with all resident care.
18) Meet with resident and/or families often-If a resident or family member expresses any concerns, direct the information to the appropriate person for prompt resolution of the issue. If able to address the concern, do so promptly and follow-up with the resident and/or family to ensure satisfaction.
19) Help with the dining process for all residents as requested.
20) Assist residents with standard ADL’s (Activities of Daily Living) to include: bathing, toileting/bed pan, transfers, bed mobility, turning and repositioning, peri-care, grooming, dressing, changing bed linens, applying/utilizing specialized equipment, etc. per the individualized plan of care.
21) Ensure residents remain clean, have clean dentures in place, hearing aids in or stored appropriately, clean eyeglasses on, prosthetic limbs/devices in place, dressed appropriately, clothes are in good repair, and dressed appropriate to temperature/season.
22) Ensure use of positioning devices, restraints, splints, braces, immobilizers, cushions, etc. are utilized per the individualized plan of care.
23) Obtain vital signs, height, weight, and record in the clinical record per facility policy.
24) Monitor and record resident intake and output per policy.
25) Assist residents to prepare for meals and snacks ensuring proper attire, position, and location. Ensure the proper assistive devices/equipment are available and offered. Document food and fluid consumption per facility policy.
26) Complete facility incident/accident reports as necessary and initiate investigations as requested.
27) Conduct facility investigations in a professional manner with a keen attention to detail. Investigations shall include: interviewing staff, interviewing residents, interviewing visitors, gathering statements (witnesses, staff, physicians, residents, etc.), reviewing video surveillance, gathering relevant data, preparing timelines, determining root cause, recreating events, drawing diagrams, creating charts, and detailed reporting of results with outcomes.
28) Make frequent unit/facility rounds during the scheduled shift.
29) Participate in on-call rotation for the nursing department as assigned.
30) Observe the quality of care and services provided during the shift, ensuring compliance with the facility policies and taking corrective action including, but not limited to employee counseling, performance reviews, staff competency evaluations with return-demonstration, and disciplinary action.
31) Understand and adhere to established facility policies. Interpret the departments policies and procedures to personnel, residents, visitors, and government agencies as required.
32) Assist in recruiting, hiring, and orientation of new staff.
33) Use proper body mechanics when lifting.
34) Maintain security of the premises and direct unauthorized persons to leave as indicated.
35) Adhere to safety policies pertaining to infection control and isolation, personal protective equipment (PPE), gait belts, mechanical lifts, and fire/emergency procedures.
36) Customer Service-Promote and maintain positive relationships with co-workers, residents, visitors, volunteers, vendors, and regulatory representatives.
37) Resident Rights-Understand and promote resident rights. Have positive interactions with residents, families and caregivers. Maintain a professional appearance. Ensure confidentiality of all resident information, compliance with HIPPA regulations and policies, Encourage resident autonomy in decision-making.
38) Documentation-Complete documentation in the individual clinical record per policy. Complete any other documentation as assigned.
39) Other-Complete all other duties as assigned.
Physical and Sensory Requirements: Walking, sitting, standing, reaching, stooping, bending, lifting, grasping, pushing and pulling, and fine-hand coordination. Ability to hear and respond to overhead pages. Ability to communicate with residents, families, personnel, vendors, and consultants. Ability to apply training and in-service education provided. Must present a neat, clean, professional appearance and demonstrate a positive approach with employees and residents.
Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The above statements reflect the general duties considered necessary to perform the principle functions of the job as identified and shall not be considered as a detailed description of all the work requirements that may be inherent in the position. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.