Maple Grove Rehab and Care Center is currently recruiting for a Full Time RN.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Utilize the nursing process by demonstrating appropriate assessment, planning, implementation, and evaluation of the resident’s care.
- Assess each resident; collect and document the resident’s current health status and medical history. Complete and/or review the Admission Data Record. Make accurate and ongoing assessments of the resident’s status and respond appropriately.
- Plan/Implement: Set priorities for nursing action in a logical sequence according to the resident’s needs and formulate a plan of care by the appropriate selection of Nurse Practice Standards. The Plan of Care is initiated on resident admission based on all aspects of the initial assessment. Plan includes physiological, psychosocial, and environmental factors.
- Evaluate: Perform ongoing assessments and revise plan of care based on new data and resident’s condition. .
- Documentation: Document accurate and ongoing assessments of resident status. Document resident care which reflects nursing intervention, resident response to care provided, resident needs, problems, capabilities, limitations and progress toward goals.
- Communicate with physicians regarding resident needs, the nursing assessments, and recommendations as needed. Collaborate with other nurses and nursing department staff to ensure the resident’s well being.
Perform direct patient care utilizing established procedures, policies and standards.
- Administer medications, IV’s, treatments and procedures in accordance with physician’s orders.
- Observe and document resident’s response to medications and treatments.
- Ensure proper disposal of all drugs and medications.
- Ensure adequate levels of medication, supplies and equipment is available at all time. Report needs to the Director of Nursing.
- Handle emergency situations in a prompt, precise and professional manner.
- Maintain the comfort, privacy, and dignity of each resident in the delivery of services.
- Interact with residents in a manner that displays warmth and promotes a caring environment.
- Comprehensive understanding and adherence to all aspects of residents’ rights, including the right to be free of restraints and free of abuse.
- Promptly report to the charge nurse or administrative staff all incidents or evidence of resident abuse or violation of residents’ rights.
- Assure residents have call lights at hand and answer resident’s call lights promptly and courteously.
- Assist with orienting residents and their families to the nursing facility upon admission.
- Receive the nursing report upon reporting for duty each shift. Give the nursing report to relief personnel before departing at the end of each shift.
- Observe and report the presence of pressure areas and skin breakdown to the Charge Nurse.
- Promptly report injuries of an unknown source, including skin tears to the Charge Nurse.
- Communicate and interact effectively, courteously, and tactfully with residents, visitors, family members, peers, and supervisors.
- Thoroughly wash hands before and after performing any service for the resident.
- Make rounds frequently and check each resident routinely to ensure his/her nursing care needs are being met.
- Respond to inquiries or requests from residents and family members in a prompt and courteous manner.
- Promote positive public relations with residents, family members and guests.
- Maintain the confidentiality of all resident care information.*
Develop and implement nursing care plans and assessments.
Inform the Charge Nurse of any changes in the resident’s conditions so that appropriate changes (if necessary) can be made to the care plan.
- Ensure all nursing notes convey specific care provided and the resident’s response or lack of response to the care provided.
- Perform all nursing services in accordance with the individualized care plan.
- Honor the resident’s refusal of treatment request. Document and promptly report such requests to the Charge Nurse.
- Assist in developing preliminary and comprehensive assessments of the nursing needs of each resident.
- Assist in developing a written plan of care that identifies the nursing needs of the resident and the goals to be accomplished for each nursing need identified.
- Ensure that all nursing personnel are aware of the care plans and that care plans are used in providing daily nursing services to the residents. * Review nurses notes and monitor residents to ensure the care plans are being followed and that residents’ needs are being met.
- Review and revise care plans and assessments as necessary.
Performs duties in a safe manner in accordance with established policies and procedures.
- Practice careful, efficient, and no-waste use of supplies and linens in accordance with established policies and procedures.
- Perform all job responsibilities in accordance with prescribed safety and infection control procedures including thorough hand washing, use of disposable gloves where indicated, and proper disposal of soiled materials.
- Actively participate in fire, safety and disaster preparedness drills
- Maintain safe working conditions and practices and follow established safety regulations in the use of equipment and supplies.Timely and accurately record nursing notes in an informative and description manner.
- Record all entries on notes, charts, etc. in an informative and descriptive manner.
- Use only authorized abbreviations established by the facility when recording information.
- Properly document all care, responses to care, vitals, changes in condition, etc. in accordance with established policies and procedures.
Job Type: Full-time