Registered Nurse/Licensed Practical Nurse (RN/LPN)
JOB DESCRIPTION
Position Description |
RN/LPN |
Reports to |
Director of Nursing |
Status |
Non-Exempt |
Job Summary: Provides direct nursing care to the residents and supervises the day-to-day activities performed by CNA’s in accordance with current Federal, State and local standards-of-care and as required by the DON.
Essential Responsibilities
- Participate in and attend relevant meetings at the facility, including mandatory in-services.
- Supervise the day-to-day functions of the CNA’s and support staff in accordance with current rules, regulations, guidelines and standards of care.
- Complete medical forms, reports, evaluations, studies and charting as necessary. Ensures notes are informative, descriptive, and reflective of the care provided and the resident’s response. Ensure all documentation is completed in timely manner including MAR/TAR in SigmaCare.
- Review the residents’ care plans and update as needed.
- Assist with discharge plans and admissions by completing required paperwork and assessments.
- Participate in the annual licensure survey.
- Make phone contact with physicians, family members, and pharmacy; including receiving and processing new orders promptly and accurately.
- Notify each department promptly of any new orders related to diet change, therapy orders etc.
- Assist in and observe, the dining rooms as feasible. Ensures residents are given choices and any problems with intake or dietary issues are addressed to DON. Ensure dietary regulations are in compliance.
- Assist in checking the MAR/TAR and PO sheets for the following month, bringing new orders forward and checking them for accuracy in SigmaCare.
- Report all discrepancies in medications, diet orders, charting errors etc. to the DON promptly.
- Provide treatments as necessary and appropriate.
- Prepare, order and administer all medications following the policies of the facility and current standards of practice, as well as the 5 Right of Medication Administration. Ensure there is ample stock supply and the narcotic count is correct at the beginning and end of each shift. Checks the MAR and documents appropriately in SigmaCare.
- Make daily rounds and rounds with visiting physicians.
- Communicate with direct care staff the needs of the residents, new admissions, diet changes, rehab/restorative plans and the resident care plan.
- Fill out CNA assignments and ensure CNA charting is completed before the end of their shift.
- Assure an environment for residents that is chemically and physically restraint free.
- Ensure the neighborhood is clean and free of odors, addressing any issues with floor staff and housekeeping as appropriate
- Monitor for changes in the functional or mental ability of each resident. Assist in notifying physician, family, DON and ensure follow-up, notifications and documentation are completed in a timely manner.
- Ensure resident’s records, orders and nurses notes are complete and accurate, meeting IDPH regulations.
- Input all labs, x-rays and isolation orders and ensure results are reported to the physician and family in a timely manner & documentation is maintained. Ensure proper forms have been filled out, and follow-up lab requisitions are completed
- Complete all admissions, transfers, and discharges as needed, following appropriate procedures.
- Monitor, track and evaluate infections in the unit and, along with the In-Service/ Infection Control Nurse, serve as a resource for nursing staff. Ensure follow-up cultures &/or x-rays are completed in the time required for clearance of infections.
- Keep updated on current wounds, ulcers and skin issues on the unit. Provide wound care, ulcer and skin care during your shift. Ensure proper pressure relieving devices are initiated and enforced and monitor that the devices are in place during your shift
- Assist with daily, weekly and monthly weights for the residents on the unit and ensure documentation. Monitor significant weight loss/gain, alerting the physician and family as appropriate.
- Assist with TB, Flu and Pneumonia Vaccines for residents in the neighborhood, including physician orders, administering vaccinations, tracking and documenting in accordance with DON instructions.
- Assess residents for safety appliances as necessary and directed by the DON. Ensure other appliances are assessed for need such as bed bolsters, wander-guard, and sensor alarm pads.
- Attend and participate in committee meetings, including mandatory in-services. Attend weekly nurse meetings to facilitate and gather information related to resident status, and work cooperatively with the care plan team to identify & correct problems.
- Actively participate in IDPH surveys and stay updated on IDPH regulations.
- When resident incident and/or accident occurs, ensure the paperwork is completed I & A & it’s routed according to STV policy. Along with floor staff, initiate interventions and inform DON, physician and family, while maintaining appropriate documentation.
- Protect resident rights and privacy at all times - refer to HIPPA policy.
- Monitor and assist in developing safety measures to provide a safe environment at all times.
- Monitor for infection control issues.
- Act on first aid knowledge in emergencies by providing appropriate & responsible care.
- Always performs lifting using approved methods, with safety in mind, to prevent injury to resident and/or self.
- Responds to call lights &/or residents needs in a timely and appropriate manner.
- Maintains HIPPA protected information and privacy at all times.
- Reports any suspicions of abuse IMMEDIATELY to the Administrator or Designee, along with the Illinois Department of Public Health.
- Reports hazardous conditions and equipment immediately, keeping the resident safe at all times.
- Must reply to Onshift Text or phone messages in a timely manner.
- Other duties as assigned by supervisor.
Non-Essential:
- Greets visitors to the facility.
- Assist with maintaining medical equipment including wheelchairs, walkers, and concentrators.
- Assist with the general operation of the facility with regards to organization of work areas.
- Serve on various committees as requested.
- Files & copies forms as needed.
EDUCATION & SKILLS:
Must be a graduate of an approved LPN/LVN or RN program and must possess a current, unencumbered license to practice as a LPN/LVN or RN in the state of Illinois at the time of hire. Previous experience as a long-term care nurse is preferred. Must be proficient in the use of computer and programs utilized by the facility. Must have the ability to communicate in English both orally and in writing so as to complete required documentation. Must have the ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. CPR certification is required as per guidelines at the healthcare provider level. Must possess the desire to care for residents at the highest level of quality. Continuing education through in-service training is mandatory. Additionally, the ability to take initiative, make independent judgments, and promote teamwork is required to successfully fulfill this job’s responsibilities. Must have sufficient written and verbal communication skills to understand instructions and complete basic charting functions and must maintain confidentiality.
Safety:
- Report all incidents/accidents immediately, to include filling out the proper forms. Also report all unsafe/hazardous conditions/equipment immediately to your supervisor.
- Follow established fire safety policies and procedures.
- Must be trained to use labels and SDSs to recognize hazards and to follow appropriate protective measures
- Follow established hand washing procedures.
- Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood, body fluids, or hazardous chemicals.
- Report occupational exposure to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility’s established policies and procedures governing accidents and incidents. (see SDS manual on these prevention programs.)
- Promote safe practices at all times.
- Ensure that used needles are disposed of properly & isolation precautions are followed per policy.
- Report any safety hazards promptly to the DON or Administrator.
- Monitor all staff to ensure the use of equipment and supplies are within the establish safety regulations.
PHYSICAL/MENTAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is frequently required to talk or hear. The employee is required to stand for long periods of time; walk & move intermittently throughout the day; sit; use hands to finger, handle or feel; reach with hands and arms; and smell. The employee is occasionally required to lift up to 50 pounds and to push or pull up to 50 pounds. Employee is subject to multiple interruptions throughout the day. Specific vision abilities required by this job include close vision, distance vision, depth perception, and ability to adjust focus. Must be able to cope with the mental and emotional stress of the position and work beyond normal working hours, and in other positions temporarily, when necessary. Is subject to call-back during emergency conditions (i.e. severe weather, evacuation, post-disaster, etc.). Exposure to infectious diseases/substances is possible.