Assesses and determines the health status and level of care of all new admissions.
Ensures the accurate and timely completion of all MDS Assessments including PPS Medicare, quarterly, annual, significant change.
Communicates level of care for new resident to all disciplines.
Coordinates interdisciplinary participation in completing the Minimum Data Set (MDS) for each new admission to facility according to regulatory time frames. Ensures completeness and thoroughness of documentation as mandated by federal, state and medical standards.
Maintains an accurate schedule of all MDS assessments to include the proper reference dates throughout the resident’s stay.
Responsible for the data entry function to assure accurate data entry and electronic submission of MDS assessments.
Verifies electronic submissions of MDS, performs corrections when necessary and maintains appropriate records.
Coordinates interdisciplinary participation in completing the MDS for each resident according to regulatory time frames. Ensures completeness and thoroughness of documentation as mandated by federal and state standards.
Schedules and conducts resident care conferences in compliance with state and federal regulations and ensures completion of all MDS reviews prior to resident care conference.
Assists disciplines in formulating and revising care plans. Ensures that resident’s present/potential problems are identified and prioritized; realistic goals are established and nursing intervention is appropriate.
Evaluates resident care plans for comprehensiveness and individuality.
Assesses the achievement or lack of achievement of desired outcomes. Ensures that resident’s care plan is reassessed and revised appropriately.
Responsible for all level of care changes within the facility. Notifies all departments when a level of care change has been made.
Generates appropriate forms to complete level of acuity and changes. Transmits forms to the appropriate agency for processing as required by state law.
Assists and participates in the development, organization and implementation of the philosophy, objectives, policies, procedures and standards of nursing care in accordance with the goals of the Care Center Facility care and the individual center.
Confers with the Director of Nursing/Assistant Director of Nursing in assessing the quality of nursing care being delivered and recognizes the need of improving or changing nursing practices.
Makes daily rounds to evaluate patient care, the progress of individual employees, monitor nursing practices, and assist Human Resources with nursing and educational needs.
Remains cognizant of legal aspects of nursing practice, as well as government regulations; demonstrates this in teaching, supervision, and evaluation of patient care.
Performs rehabilitation assessments upon all new admission and for existing patients throughout the center on quarterly basis and as needed.
Performs or oversees functional evaluations on admission, quarterly and/or as clinically indicated. Consults with nurses in making recommendations for restorative plan of care. Works with nurses in developing restorative plan of care.
Oversees that all restorative nursing measures are reflected on the care plan as an approach to the focus or need for which that are being completed.
Works closely with the therapy department. Sees that specific recommendations, when discharged from therapy are carried through.
Reviews weekly documentation completed for residents receiving restorative services. Ensures that all proper ADL documentation has been completed for patients.
Oversees incontinent management programs.
Attends care planning conferences and makes recommendations. Reports progress of restorative nursing measures.
Attends Interdisciplinary/QAPI meeting as indicated to provide feedback and identify any residents for evaluation of restorative service needs.
Coordinates with Human Resources and Director of Nursing to orient new staff relative to roles, responsibilities, principles and practices of restorative nursing.
Coordinates with Director of Nursing and Therapy to provide ongoing education/evaluation of direct care staff relative to roles, responsibilities, principles and practices of restorative nursing.
Actively participates in physical restraint reduction and fall management programs.
Sets up documentation flow sheets for daily documentation of restorative nursing measures for each resident on the program in coordination with medical records.
Performs or supervises the performance of restorative nursing staff.
Serves as a liaison with all therapists: physical, occupational, and speech.
Participates in patient care planning and CMI meetings.
Serve in the role of Medicare Services Coordinator (MDS Coordinator) as needed.
Puts patients first; ensures that patients and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals’ needs and rights
Other duties as assigned.
