CHARGE NURSE
DEPARTMENT: NURSING
POSITION: CHARGE NURSE
SUPERVISOR: DIRECTOR OF NURSING
POSITION SUMMARY:
Under the supervision of the Director of Nursing, the Provides nursing care to residents as prescribed by the Physician and in accordance with standards of nursing Practices and regulations; and supervises the Certified Nursing Assistant (CNA) staff in the delivery of direct resident care.
ESSENTIAL POSITION FUNCTIONS:
- Prepare and review medical records and nurse's notes, and assess residents to evaluate their physical and emotional status; monitor resident activity and provide nursing care according to the physician's orders, care plans, established standards and facility policies. Coordinate and assist prepare for new admissions, transfers, and discharge of residents. Transcribe physicians' telephone orders. Communicate with residents, family members, other interdisciplinary team members and management regarding resident status.
- Prepare and administer medications as ordered by the physician in accordance with nursing standards and facility policies. Sign, date and perform all charting and record keeping in accordance with established policies and procedures
- Supervise and direct the CNA staff in the delivery of resident care and monitor their performance schedule CNA job assignments, set priorities, assist, coach and counsel as necessary
- Understand, comply with, and promote all rules regarding residents' rights
- Assist and participate in developing and implementing a written care plan for each individual resident that addresses the needs of the resident
- Participate in in-service training; assist in implementing orientation programs and job skills training maintain professional competence
- Monitor environment and care practices of nursing personnel to ensure compliance with established safely, fire, disaster, infection control and all other departmental policies and procedures; ensure cleanliness and safety of work and treatment areas
NURSING GUIDELINE
Shift Report
- Verify that all staff coming on duty are present for report
- Report the condition of each resident
- List and report any elevated temperatures or abnormal vital signs and the last time
- Report the last dose of any PRN medication administered and effectiveness
- Report any condition change or follow-up on any condition change of any resident
- Report use of oxygen during past shift, duration used and effectiveness
- Report incidents, status of residents, orders to be followed
- Report all equipment failure or supplies needed
- Report on status of staffing for following shift(s)
- Report status of "ALL CALLS TO PHYSICIANS"
- When last call was placed
- Report on all medication not administered as ordered and reason
- Report all residents out on pass
- Report all physician order changes
Nursing Routine
- Get on coming report/perform walking rounds
- Find out who your aids are assigned to and which residents are to receive showers on your shift
- Vitals on all MC, ABT, change in condition, ect.
- 6-2 and 2-10 meals, charting, treatment, BS
- 10-6: test glucometer, check temperature on refrigerators, replace g-tube syringes/face masks for neb treatment, make sure that carts are stock
- End of shift treatments, BS, ect.
- Charting follow-ups and any other changes
- Give report with walking rounds, count meds and go home
a. *** DO NOT GO HOME WITH KEYS ***
THIS is an example of time management. Make a plan. We all know that things come up and time management is the key to keeping you on track.
Remember nurses it is your responsibility to keep your CNAs on task. Including: making sure residents are being showered, shaved, turned, etc. Make sure that CNAs are on their hall, if they are either on lunch, break, getting supplies, or helping out after they have finished their own work.
**Make sure call lights are being answered at a timely manner
