S.P.J.S.T SKILLED NURSING AND REHABILITATION
JOB DESCRIPTION
TITLE: LICENSED PRACTICAL NURSE (VOCATIONAL)
LPN/LVN
DEPARTMENT: Nursing
REPORT TO: Director of Nursing
WAGE: Hourly
WORK HOURS: Rotation shifts, holidays, and weekends as scheduled.
MINIMUM QUALIFICATIONS:
-
Supports the facility.
-
Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the privacy, dignity, and well-being of all residents in a safe, secure environment.
- Agrees to comply with Code of Conduct.
- Graduation from a basic education program in practical (vocational) nursing.
-
A minimum of 1 year of nursing experience in a long-term or acute care setting preferred.
-
Must have a current license to practice profession in state.
-
Must have a reliable source of transportation.
-
Must have a valid driver’s license and automobile insurance.
-
Must be able to read, write, and speak the English language.
- TFER (Texas Food Established Rules) food handler certificate must be obtained within 90 days upon hire.
-
Must be able to transfer residents and assist in emergency evacuations.
-
Able to interact with residents, family members, staff, visitors, government agencies/personnel, etc., under all conditions/circumstances.
-
Able to relate and work with the disabled, ill, elderly, emotionally upset, and at times, hostile people within the facility.
-
Able to effectively communicate with the management staff, medical staff, nursing staff, and other unit supervisors.
RESPONSIBILITIES:
-
Works under direct supervision in accordance with the state-specific Nurse Practice Act, facility Policies and Procedures, and nursing judgement.
-
Delivers nursing care to patients/residents requiring long-term or rehabilitative care.
-
Collects patient/resident data, make observations, and reports pertinent information related to the care of the patient/resident.
-
According to state-specific regulations, implements the patient/resident plan of care and evaluates the patient/resident response.
-
In accordance with state-specific regulations, direct and supervises care given by other nursing personnel in selected situations.
-
Maintains knowledge of necessary documentation requirements.
-
Maintains knowledge of equipment set-up, maintenance, and use, i.e., monitors, infusion devices, drain devices, etc.
-
Maintains confidentiality and patient/resident rights, regarding all patient/resident/personnel information.
-
Provides patients/residents/family/caregiver education as directed.
-
Conducts self in a professional manner in compliance with unit and facility policies.
-
Initiates emergency support measures (i.e., CPR, protects patients/residents from injury).
-
Data Collection:
-
Admission and routine patient/resident observations/transfer notes are completed and accurately reflect the patient’s/resident’s status.
- Documentation of observations in complete and reflects knowledge of unit documentation policies and procedures.
-
Nursing history is present in the medical record for all patient/residents.
-
Changes in a patient’s/resident’s physical/psychological condition (i.e., changes in lab data, vital signs, mental status), are reported appropriately.
-
Planning of Care: Contributions to the formula/review of nursing care plans are made as appropriate, under the direct supervision or delegation of an RN.
-
Pertinent nursing problems are identified.
-
Goals are stated.
-
Appropriate nursing orders are recommended.
-
Evaluation of Care
-
Observations related to the effectiveness of nursing interventions, medications, etc. are reported as appropriate and documented in the progress note.
-
Care Plans:
-
Evaluation of care plan is noted monthly or as indicated.
-
Contributes to care plan revision are made as indicated by the patient’s/resident’s status.
-
General Patient/Resident Care
-
Patient/Resident is approached in a kind, gentle, and friendly manner. Respect for the patient’s/resident’s dignity and privacy is consistently provided.
-
Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
-
Independence by the patient/resident in activities of daily living is fully encouraged.
-
Treatments are completed as indicated.
-
Safety concerns are identified, and appropriate actions are taken to maintain and assure patient safety including but not limited to:
-
Guard rails and height of bed are adjusted.
-
Patient/Resident call light and equipment is within reach.
-
Restraint, when used, are maintained properly.
-
Rooms are neat and orderly.
-
Patient/Resident identification bands and allergy bands (if applicable) are present.
-
Functional assignments are completed.
-
Emergency Situations are recognized, and appropriate action is instituted.
-
All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguisher, etc.)
-
Patient/Resident Education /Discharge Planning
-
Patient /resident/Family teaching is conducted according to the nursing care plan.
-
Explanations are given to the patient/resident prior to intervention.
-
Discharge/death summaries are complete and accurate.
-
Transfer forms are complete and accurate.
-
Active participation in patient/resident care management is evident.
-
Adherence to Facility Procedures
-
Facility Policy and Procedures Manual or reference materials are utilized as needed.
-
Procedures are performed according to the method outlined in the procedure manual.
-
Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
-
Safety guidelines established by the facility (i.e., proper needle disposal) are followed.
-
Documentation
- The patient’s/resident’s full name and room number are presented on all chart forms. Allergies are noted on the chart cover.
-
Only approved abbreviations are utilized.
-
Vital signs are properly and timely recorded.
-
I&O summaries are recorded and added correctly.
-
Progress notes are timed, dated, and signed with full signatures and title.
-
Unit Flow sheets are completed properly (i.e., wound care records, treatment record, weight sheets, etc.).
-
Medication Administration/Parenteral Therapy Record
-
Adheres to state-specific Nurse Practice Act for administration of medication and parental therapy.
-
Dates that medications are started or discontinued are documented.
-
Medications are charted correctly with name, dose, route, site, time, and initials, of nursing administering.
-
Pulse and blood pressure are obtained and recorded when appropriate.
-
Medications not given are circled, reason noted, and physician notified if applicable.
-
Appropriate notes are written for medications not given and actions taken.
-
Name and title of nurse administering medication are documented.
-
Patient’s/Resident’s medication record is labeled with full names, room number, date, and allergies.
-
The procedure for administration and counting of narcotics is followed.
-
All parenteral fluids, including additives, are charted with time and date started, time infusion completed, site of infusion, and signature of nurse.
- All parenteral fluids are administered according to the ordered infusion rate.
-
Parenteral intake is accurately recorded on the unit flow sheet or I&O record.
-
Appropriate actions are taken related to identified IV infusion problems (infiltration, phlebitis, poor infusion, etc.).
-
IV sites are monitored, and catheters changed according to unit policy.
-
IV bags and tubing’s are changed according to unit policy.
-
Coordination of Care
-
Tests are scheduled and preps are completed as indicated.
-
Co-workers are informed of changes in patients/resident conditions or of any other changes occurring on the unit.
-
Information is relayed to other members of the health care team (i.e., physicians, respiratory therapy, physical therapy, social services, etc.) and family/responsible party.
-
Unit activities are coordinated (i.e., changing patient’s/resident’s rooms for admissions, coordinating transfer/discharge forms, etc.).
- Leadership
-
Equitable care assignments appropriate to patient/resident needs are made prior to the beginning of the shift.
-
Staffing needs are communicated to the nursing supervisor.
-
Assistance, direction, and education are provided to unit personnel and families.
-
Problems are identified, data are gathered, solutions are suggested, and communication regarding the problem is appropriate.
-
Transcription of all orders is checked.
-
All work areas are neat and clean.
-
Communication
-
Change of shift report is complete, accurate, and concise.
-
Incident reports are completed accurately and in a timely manner.
-
Staff meetings are attended, if on duty, or minutes read and initialed if not on duty.
-
Professionalism
-
Decisions are made that reflect knowledge and good judgement and demonstrate an awareness of patient/resident/family/physician needs.
-
Awareness of their own limitations is evident, and assistance is sought when necessary.
-
The dress code is adhered to.
-
Committee meetings (if assigned) are attended. Reports related to the committee are given during staff meetings.
-
Responsibility is taken for own professional growth. All mandatory and other in-services are attended annually.
- Organizational ability and time management demonstrated.
-
Confidentiality of patient/resident is always respected (i.e., when answering telephone and/or speaking to co-workers).
-
Professional behavior is demonstrated.
-
Human Relations
- A positive working relationship with patients/residents, visitors, and facility staff is demonstrated.
-
Authority is acknowledged and response to the direction of supervisors is appropriate.
-
Time is spent with patient/resident rather than other personnel.
-
Co-workers are readily assisted as needed.
- Cost Awareness
-
Supplies are used appropriately.
-
Charge stickers (or charge system) are utilized appropriately.
-
Minimal supplies are stored in the patient’s/resident’s room.
-
Discharged medications are given to ADOM.
-
Floor-stock medications are charged and re-stocked.
-
Participates in the identification of staff educational needs.
-
Serves as a preceptor, as delegated, for new staff.
-
Maintains patient/resident care supplies, equipment, and environment.
- Participates in the development of unit objectives.
-
Provides input in the formulation and evaluation of standard of care.
-
Supports, cooperates with, and implements specific procedures and programs for:
-
Safety, including precaution and safe work practices, established, fire/safety/disaster plans, risk management, and security report and/or correct unsafe working conditions, equipment repair and maintenance needs.
-
Confidentiality and privacy of all data, including patient/resident, employee, and operation data.
-
Compliance with all regulatory requirements.
-
Compliance with and enforcement of current law and policy to provide a work environment free from harassment and all illegal and discriminatory behavior.
-
Supports and participates in common teamwork:
-
Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction, including appropriate judgement.
-
Uses tactful, appropriate communications in sensitive and emotional situations.
-
Reports complaints, problems and concerns regarding co-workers, management, or residents in accordance with facility policy.
-
Promotes positive public relations with patients, residents, family members, and guests.
-
Completes requirements for in-service training, acceptable attendance, uniform, and dress code including personal hygiene, and other work duties as assigned.
-
May be involved in community/civic health matters/projects.
- Maintains a liaison with residents, their families, support staff, etc. to ensure that the residents’ needs are continually met.
- Other duties as assigned.
WORK ENVIROMENT:
-
Office areas as well as throughout the facility.
-
Able to move intermittently including standing, lifting, bending, stooping, twisting, pushing, and pulling with or without accommodations.
-
May be exposed to infectious waste, diseases, conditions, etc., including exposure to the AIDS and hepatitis B viruses.
JOB DESCRIPTION ACKNOWLEDGEMENT:
I acknowledge and understand that:
Job description does not imply or create a promise of employment, or an employee contact of any kind. My employment is always contingent upon acceptable job performance.
Job description provides a general summary of the position in which I am employed, that the contents of this job description are job requirements, and, at this time, I know of no limitations that would prevent me from performing these functions with or without reasonable accommodations. I further understand that ii is my responsibility to inform my supervisor at any time that I am unable to perform these functions.
This job description is not intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under his/her direction. Job responsibilities, work hours, and work requirements can be changed at any time. I agree to follow the instructions and responsibilities as directed by management.
Acceptable job performance includes completion of the job responsibilities as well as compliance with the policies, procedures, rules, and regulations.
I have read that above position description and fully understand the requirements set forth therein. I hereby accept the position and agree to abide by the requirements set forth.
________________________________ _____________
Employee Printed Name Date
________________________________ _____________
Employee Signature Date
