Summary:
Provide direct nursing care to the residents and provide oversight of the day-to-day nursing activities performed by Certified Nursing Assistants. Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern facility.
Environment:
Work will be performed primarily indoors at one of our long-term healthcare facilities, throughout all areas, including in resident rooms, and on carpeted and/or tiled floors. Work will be performed there routinely around other co-workers, healthcare staff, residents, and guests. Due to the nature of facility’s business, worker may be exposed to occasional slippery floors, object on floors, chemicals, sharp objects, hazardous materials, and waste (including human), blood borne pathogens, and communicable diseases, as well as high-stress medical and/or life-threatening situations.
Essential Duties & Responsibilities:
1. Meet physical and sensory requirements stated below and be able to work in the described environment.
2. Identify and participate in process improvement initiatives that improve the patient centered experience, enhance workflow, and/or improve the work environment.
3. Direct the day-to-day functions of the Certified Nursing Assistants and or Patient Care Assistants in accordance with rules, regulations, and guidelines that govern the long-term care industry.
4. Ensure nursing personnel assigned to you comply with the written policies and procedures established by this facility.
5. Obtain clinical guidance from the Director of Nursing/designated RN as appropriate related to resident care.
6. Meet with your assigned nursing staff, as well as support personnel, in planning the shift’s services, programs and activities.
7. Make written and oral reports/recommendations concerning the activities of your shift, as required.
8. Cooperate with other resident services when coordinating nursing services and be certain that the resident’s total regimen of care is maintained.
9. Participate in the development, maintenance, and implementation of the facility’s quality assurance program for the nursing department.
10. Participate in surveys (inspections) made by authorized government agencies.
11. Participate in the updating of the resident’s written discharge plan, as required.
12. Assist in planning the nursing portion of the resident’s discharge plan, as necessary.
13. Admit, transfer, and discharge residents, as required.
14. Complete accident/incident reports, as necessary.
15. Complete and file required forms/charts upon resident’s admission, transfer, and/or discharge.
16. Work with physicians and physician extenders to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
17. Receive telephone orders from physicians and electronically document and forward new orders to other departments as needed.
18. Effectively use EHR process to transcribe physician’s orders to resident EHR, eMAR and eTAR and care plans, as required.
19. Document in EHR in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident’s response to care following established facility charting and documentation policies.
20. Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Nurse Supervisor, Unit Manager, or ADON/DON.
21. Fill out and complete transfer forms in accordance with established procedures.
22. Prepare and administer medication as ordered by the physician in accordance with facility policy and procedures and in accordance with Standards of Practice.
23. Verify that adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the Nurse Supervisor.
24. Order prescribed medications, supplies, and equipment as necessary, and in accordance with established procedures.
25. Verify that narcotic records are accurate for your shift.
26. Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
27. Notify the attending physician of automatic stop orders prior to the last dosage being administered.
28. Immediately notify the Nurse Supervisor and attending physician of any medication administration errors.
29. Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.
30. Respond to call lights and assist with other resident needs.
31. Make rounds with physicians, as necessary.
32. Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.
33. Review the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.
34. Make periodic rounds to confirm that care and services are being properly administered CNA’s and PCAs and to evaluate the resident’s physical and emotional status.
35. Notify the resident’s attending physician when the resident is involved in an accident or incident.
36. Notify the resident’s attending physician and responsible party when there is a change in the resident’s condition.
37. Administer professional services such as but not limited to catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required in accordance with Professional and Regulatory Standards.
38. Monitor seriously ill residents, as necessary.
39. Review care plans to confirm that appropriate care is being rendered.
40. Confirm that CNAs are aware of the resident care plans, PCC Point of Care and Kardex.
41. Other duties, as assigned.
Job Requirements:
- Licensed Practical or Registered Nurse with current state license.
- Must have a current/active CPR certification.
- Excellent technical, assessment and documentation skills.
- Effective verbal and written English communication skills.
- Demonstrated intermediate to advanced skills in Microsoft Word, Excel, Power Point and Outlook, Internet, and Intranet navigation.
- Highest level of professionalism with the ability to maintain confidentiality.
- Ability to communicate at all levels of organization and work well within a team environment in support of company objectives.
- Customer service oriented with the ability to work well under pressure.
- Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
- Strong analytical and problem-solving skills.
- Ability to work with minimal supervision, take initiative and make independent decisions.
- Ability to deal with new tasks without the benefit of written procedures.
- Approachable, flexible, and adaptable to change.
- Function independently, and have flexibility, personal integrity, and the ability to work effectively with employees and vendors.
Physical and Sensory Requirements:
- Moderate physical activity:
- Push, pull, move, and/or lift a minimum of fifty (50) pounds to a minimum height of three (3) feet and be able to push, pull, move, and/or carry such weight a minimum distance of fifty (50) feet.
- Standing and/or walking for more than four (4) hours per day.
- Bending and/or stooping for more than one (1) hour at a time.
- Sitting for more than one (1) hour at a time.
- Requires writing and/or computer work with repetitive typing and concentrating on computer screen and/or documents for more than two (2) hours at a time.
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
