Administer medications, perform ordered treatments, monitor medical conditions and document.
To deliver nursing care and provide active treatment to the intellectually disabled and/or developmental delayed individuals requiring long-term or rehabilitative care.
1. Works under the direct supervision of the Director of Nursing and/or Assistant Director of Nursing using the state-specific Nurse Practice Act, IHS Standards, Policies and Procedures, and nursing judgement.
2. Delivers nursing care to clients requiring long-term or rehabilitative care.
3. Collects client data, makes observations, and reports pertinent information related to the care of the client.
4. According to state-specific regulations, implements the client plan of care, which includes active treatment and evaluates the client response.
5. In accordance with state-specific regulations, directs and supervises care given by other personnel in selected situations.
6. Maintains knowledge of necessary documentation requirements.
7. Maintains knowledge of equipment set-up and maintenance.
8. Maintains confidentiality and client rights, regarding all client/personnel information.
9. Provides client/family/responsible party education as directed.
10. Conducts self in a professional manner in compliance with unit and facility policies.
11. Works rotating shifts, holidays and weekends as scheduled.
12. Initiates emergency support measures (i.e., CPR, protects clients from injury).
13. Performs other duties as deemed necessary and appropriate, or as may be directed by the Director of Nursing and/or Administrator.
1. Participates in the identification of staff educational needs.
2. Serves as a preceptor, as delegated, for new staff.
3. Maintains patient/resident care supplies, equipment and environment.
4. Participates in the development of unit objectives.
5. Provides input in the formulation and evaluation of standards of care.
The Licensed Vocational Nurse is at moderate to high risk for exposure to blood and body fluids or other potentially infectious materials.
SUPERVISION RECEIVED
Receives administrative supervision from the Director of Nursing and/or Administrator. May receive functional supervision from the Director of Nursing and/or Assistant Director of Nursing.
SUPERVISION EXERCISED
According to state-specific regulations, exercises functional supervision in specific situations over facility personnel.
MINIMUM QUALIFICATIONS
1. Graduation from a basic educational program in practical (vocational) nursing.
2. Current license to practice profession in state.
3. A minimum of one (1) year nursing experience in a long-term or acute care setting preferred.
MINIMUM PERFORMANCE STANDARDS
Performance in the following areas is acceptable when:
DATA COLLECTION
1. Admission and routine client observations/transfer notes are complete and accurately reflect the client’s status.
2. Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.
3. Nursing history is present in the medical record for all clients.
4. Changes in client’s physical/psychological condition (i.e., changes in lab data, vital signs, mental status), are reported appropriately.
PLANNING OF CARE
Contributions to the formulation/review of nursing care plans are made as needed.
1. Pertinent nursing problems are identified.
2. Goals are stated.
3. Appropriate nursing orders are suggested.
EVALUATION OF CARE
1. Observations related to the effectiveness of nursing interventions, medications, etc. are reported as appropriate and documented in the progress notes.
2. Care plans:
a. Evaluation of care plan is noted monthly or as indicated.
b. Contributions to care plan revision are made as indicated by the client’s status.
GENERAL CLIENT CARE
1. Client is approached in a kind, gentle and friendly manner. Respect for the client’s dignity and privacy is consistently provided.
2. Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
3. Independence by the client in activities of daily living is encouraged to the fullest extent possible.
4. Treatments are completed as indicated.
5. Make rounds every two- (2) hours of your unit to assist in the hydration needs of clients deemed by the Interdisciplinary Team as high-risk to dehydration and constipation.
6. Ensure clients who are at risk for pressure sores are repositioned at the time intervals documented on Client Repositioning form which is located in the clients' closet. Initial Repositioning Form to verify client has been repositioned. Wheelchair clients should be placed on floor mats in the activity area.
7. Make periodic/random checks to assure that prescribed and/or preventive treatments (i.e. facility’s preventive foot-care program) are being properly administered by designated personnel and evaluate the client’s physical and emotional status.
8. Safety concerns are identified and appropriate actions are taken to maintain a safe environment.
a. Siderails and height of bed are adjusted.
b. Restraints, when used, are maintained and documented properly.
c. Rooms are neat and orderly.
9. Client identification bands and allergy bands (if applicable) are present.
10. Functional assignments are completed.
11. Emergency situations are recognized and appropriate action is instituted.
12. All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguisher, etc.).
13. Carryout restorative and rehabilitation programs, to include self-help/self-medication/sex education, and ensure appropriate data collection of programs.
14. Catheters are monitored and changed according to facility policy.
CLIENT EDUCATION/DISCHARGE PLANNING
1. Client/Family teaching is conducted according to the nursing care plan.
2. Explanations are given to the client prior to interventions.
3. Discharge/death summaries are complete and accurate.
4. Transfer forms are complete and accurate.
5. Active participation in client care management is evident.
ADHERENCE TO FACILITY PROCEDURES
1. Facility Standards of Practice Manual or reference materials are utilized as needed.
2. Procedures are performed according to method outlined in procedure manual.
3. Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
4. Safety guidelines established by the facility (i.e., proper needle disposal) are followed.
DOCUMENTATION
1. The client’s full name and room number are present on all chart forms. Allergies are noted on chart cover.
2. Only approved abbreviations are utilized.
3. Vital signs are properly and timely recorded.
4. I&O summaries are recorded and added correctly.
5. Progress notes are timed, dated and signed with full signature and title.
6. Facility flowsheets are completed properly (i.e., wound care records, treatment records, quarterly nursing assessments, etc.).
7. Complete accident/incident reports as necessary. Chart all A/I’s involving the client along with follow-up of each until issue is resolved.
8. Accurately maintain the Daily Shift Census Report and submit to the Business Office as required.
9. Accurately record/transcribe diet orders and forward information to the Dietary Department and Central Records in a timely manner.
10. Ensure MAR’s are kept accurate and current, and that physician orders are transcribed in a fashion that anyone could follow. Initial and date all changes, additions and deletions on the MAR.
MEDICATION ADMINISTRATIONS
1. Adheres to state-specific Nurse Practice Act for administration of medication and parenteral therapy.
2. Dates that medications are started or discontinued are documented.
3. Medications are charted correctly with name, dose, route, site, time, and initials of nurse administering.
4. Pulse and blood pressure are obtained and recorded when appropriate.
5. Medications not given are circled, reason noted and physician notified if applicable.
6. Appropriate notes are written for medications not given and actions taken.
7. Notify the attending physician of automatic stop orders prior to the last dosage being administered.
8. Name and title of nurse administering medications are documented.
9. Client’s medication record is labeled with full name, room number, date, and allergies.
10. The procedure for administration and counting of narcotics is followed.
11. Name, date, and time are documented on medication punch card when card is started (first punch on card).
COORDINATION OF CARE
1. Tests are scheduled and preps are completed as indicated.
2. Co-workers and QMRP’s are informed of changes in client conditions or of any other changes occurring.
3. Information is relayed to other members of the health care team (i.e., Administrator, QMRP’s, physicians, facility consultant’s, social services, etc.) and family/responsible party.
4. Facility activities are coordinated (i.e., changing clients rooms for admissions, coordinating transfer/discharge forms, etc.).
5. Work with Social Service to ensure notification of the clients’ next of kin/legal guardian/responsible party when there is a change in client’s status.
LEADERSHIP
1. Equitable care assignments that are appropriate to client needs are made prior to the beginning of the shift.
2. Inform appropriate personnel of staffing needs, i.e., hospital sitters, and in-house sitters if deemed necessary.
3. Assistance, direction, and education are provided to facility personnel and families.
4. Problems are identified, data are gathered, solutions are suggested, and communication regarding the problem is appropriate.
5. Transcription of all orders is checked.
6. All work areas are neat and clean.
COMMUNICATION
1. Change of shift report is complete, accurate, and concise.
2. Incident Reports are completed accurately and in a timely manner.
3. Staff meetings are attended, if on duty, or minutes read and initialed if not on duty.
PROFESSIONALISM
1. Decisions are made that reflect knowledge and good judgement and demonstrate an awareness of client/family/responsible party/physician needs.
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