Purpose of Your Job Position
Must have active Florida RN/LPN license
The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with the Florida Nurse Practice Act current federal, state & local standards, guidelines, and regulations that govern our facility, and as may be directed by the Director of Nursing or Nurse Supervisor/Unit Manager to ensure that the highest degree of quality care is maintained at all times.
Delegation of Authority
As a Floor Nurse, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.
Job Functions
Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.
Duties and Responsibilities
Administrative Functions
Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulation, and guidelines that govern the long-term care facility.
Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual.
Participate and cooperate in facility surveys (inspections) by local, state and federal governmental agencies.
Admit, transfer, and discharge residents in accordance with facility protocols, as required.
Make written and oral reports/recommendations concerning the activities of your shift as required.
Cooperate with other resident services/departments when coordinating nursing services to ensure that the resident's total regimen of care is maintained.
Participate in facility surveys (inspections) made by authorized government agencies as may be required
Periodically review the resident's written discharge plan. Participate in updating the resident's written discharge plan as required.
Assist in planning the nursing service portion of the resident's discharge plan as necessary.
Complete accident/incident reports as necessary. Submit to the Director of Nursing or designee.
Charting and Documentation
Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge.
Receive telephone orders from physicians and record in the EMR system.
Transcribe physician's orders to resident’s EMR, card-ex, medication cards, treatment care plans in electronic format or paper as required.
Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.
Chart all reports of accidents/incidents involving residents. Follow established procedures.
Record new/changed diet orders. Forward information to the Dietary Department.
Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor/Unit Manager.
Fill out and complete transfer forms in accordance with established procedures.
Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident's medical record in accordance with established procedures
Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
Drug Administration Functions
Prepare and administer medications as ordered by the physician in accordance with federal, state and local laws and regulations and facility policy.
Verify the identity of the resident before administering the medication/treatment. Ensure that prescribed medication for one resident is not administered to another.
Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report need to the Nurse Supervisor/Unit Manager.
Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
Ensure that narcotics are handled in accordance with federal, state and local laws and facility policies. Ensure that narcotic’s records are accurate for you shift.
Notify the Nurse Supervisor/Unit Manager of all drug and narcotic discrepancies noted on your shift.
Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies.
Notify the attending physician of automatic stop orders prior to the last dosage being administered.
Dispose of drugs and narcotics as required, and in accordance with established procedures.
Personnel Functions
Participate in employee performance evaluations, determining your shift's staffing requirements, and making recommendations to the Nurse Supervisor/Unit Manager concerning employee dismissals, transfers, etc.
Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work.
Report absentee call-ins to the Nurse Supervisor/Unit Manager.
Develop work assignments, and/or assist in completing and performing such assignments.
Monitor Nursing Assistants to ensure that care and services are being provided to residents in accordance with the resident’s plan of care.
Report problem areas to the Nurse Supervisor/Unit Manager.
Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the residents.
Create and maintain an atmosphere of warmth, personal interest and positive emphasis as well as a calm environment throughout the unit and shift.
Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the Nurse Supervisor/Unit Manager as required or as may be necessary. Follow facility's established procedures.
Receive/give the nursing report upon reporting in and ending shift duty hours.
Report occupational exposures to blood, body fluid, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures governing accident and incidents.
Nursing Care Functions
Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc.
Ensure that rooms are ready for new admissions.
Greet newly admitted residents upon admission and escort them lo their rooms as necessary.
For LPNs, observe and document the status of each patient upon admission and throughout the patient's course of treatment. Report concerns to the Registered Nurse for assessment.
For RNs, assess and document the status of each patient upon admission and throughout the patient’s course of treatment
Participate in the orientation of new residents/family members to the facility.
Make rounds with physicians as necessary.
Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.
Consult with the resident's physicians in providing the resident's care, treatment, rehabilitation, etc., as necessary.
Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary.
Implement and maintain established nursing objectives and standards.
Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status.
Ensure that direct nursing care is provided in accordance with the resident’s plan of care and wishes.
Notify the resident's attending physician when the resident is involved in an accident or incident.
Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition.
Carry out restorative and rehabilitative programs, to include self-help and care.
Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, range of motion exercises, and care for the dead/dying, etc., as required.
Use restraints only when prescribed and in accordance with established policies and procedures.
Obtain sputum, urine and other specimens for Jab tests as ordered.
Take and record TPRs, blood pressures, etc., as necessary.
Monitor seriously ill residents as necessary.
Check food brought into the facility by the resident's family/visitors to ensure that it is within the resident's dietary allowances.
Report problem areas to the Nurse Supervisor/Unit Manager and Dietary Supervisor.
Promptly respond to call bells.
Promptly and courteously respond to requests for assistance from residents, staff, resident family members and visitors
Ensure that residents who are unable to call for help are checked frequently.
Meet with residents, and/or family members, as necessary.
Report problems to the Nurse Supervisor/Unit Manager.
Admit, transfer and discharge residents as necessary.
Assist in arranging transportation of discharged residents as necessary.
Ensure that discharged residents are escorted to the pick-up area.
Inform family members of the death of the resident.
Call funeral homes when requested by the family.
Ensure that established post-mortem procedures are followed.
Act in compliance with established regulatory and professional standards and guidelines.
