LPN - Southern Oaks Care Center

Primary Purpose of this Position

The primary purpose of this position is to provide direct nursing care to the residents while supervising the nursing activities for the assigned shift.

Duties and Responsibilities

Administrative Functions

• Ensure the facility meets the minimum staffing levels for nurses and nurse aides; complete required posting of nursing staff data as required.
• Ensure that each resident who experiences a significant change in status is assessed using the Resident Assessment Instrument (RAI) process.
• Ensure that all resident rooms, common areas, treatment areas and nurse’s stations are maintained in a clean, safe and sanitary manner.
• Assist to develop a dementia care program involving an interdisciplinary approach with a holistic focus on the needs of the resident living with dementia.
• Verify resident census accuracy and report new admissions, discharges, leaves of absence and bed-holds per facility policies; document census as established for billing and clinical purposes.
• Assist with safe and orderly resident transfers and discharges in accordance with facility policies.
• Coordinate pre-certifications and recertifications in accordance with facility policies for Medicare Advantage and commercial insurance payers.
• Interpret the department’s policies and procedures to personnel, residents, visitors and government agencies as required.
• Participate in developing, maintaining and updating written facility policies and procedures that govern the day-to-day functions of the nursing services department.
• Participate in facility surveys (inspections) made by authorized government agencies as requested.
• Audit nursing documentation in the clinical record for appropriate and relevant entries.
• Attend and contribute in facility “triple check” process for reviewing coding for accuracy.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
• Periodically review the department’s policies and procedures manuals, job descriptions, etc., and make recommendations for revisions to the Director of Nursing.
• Coordinate the completion of resident billable charge sheets in accordance with billing policies.

Duties and Responsibilities

Committee Functions

• Prepare reports as requested.
• Attend various committee meetings of the facility (i.e., infection prevention and control, policy advisory, pharmaceutical, quality assurance and performance improvement(QAPI), etc.) as required.
• Participate in developing the agenda for committee meetings as necessary.
• Participate in regularly scheduled reviews of the discharge plans.

Nursing Care Functions

• Provide licensed nursing care to residents that is consistent with the written plans of care.
• Communicate with primary care physician and members of the comprehensive care planning team regarding the status of residents; follow up on critical labs, order requests and physician notifications.
• Arrange for an interpreter or translation services in accordance with facility policies for those with limited English proficiency(LEP).
• Obtain orders to provide essential care to the resident consistent with the resident’s mental and physical status upon admission to the facility.
• Ensure that all residents are treated with dignity, respect and consideration and have the right to exercise their choice and self-determination.
• Ensure that residents receive culturally competent trauma-informed care in accordance with professional standards of practice.
• Evaluate residents’ response to care.
• Coordinate nursing care to accommodate resident’s person-centered plan of care including sleep schedule, social activity and participation in other resident-directed activity; minimize interruption of activities as possible.
• Ensure that residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience that are not required to treat the residents’ medical symptoms.
• Assist in coordinating nursing services with other resident services to ensure the continuity of the residents’ plan of care.
• Identify the learning needs of residents and families and provide individualized and comprehensive resident/family education.
• Educate residents and families on the risk and benefits of a treatment or choice when consent is needed.
• Monitor residents for patterns of decreased social interaction or signs of distress.
• Implement individualized approaches to dementia care including meaningful activities addressing the resident’s customary routines, interest preferences and choices.

Duties and Responsibilities

• Carry out restorative and rehabilitative programs including restorative nursing, activities of daily living (ADLs)teaching, bowel and bladder retraining and education for self-help as appropriate.
• Provide pain management for residents in accordance with established pain management protocols.
• Complete accident/incident reports as necessary.
• Assist the interdisciplinary team (IDT)with establishing nutrition, hydration and body weight parameters for residents; help facilitate the responsibilities of the food and nutrition services department.
• Keep the Director of Nursing informed of the status of residents and other related matters through written/oral reports; document reportable events and notifications in accordance with facility policies.
• Cooperate with and coordinate social and activity programs with nursing services schedules.
• Periodically review the resident’s written discharge plan; participate in updating the resident’s written discharge plan as required.
• Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident including regular re-evaluation to identify changes that require modifications.
• Make periodic checks to ensure that Certified Nursing Assistants(CNAs)are properly administering prescribed treatments and to evaluate the resident’s physical, psychosocial and emotional status.
• Report problem areas to the Director of Nursing; assist in developing and implementing corrective action.
• Arrange for diagnostic and therapeutic services as ordered by the physician and in accordance with established facility procedures.
• Provide information to the QAPI Committee as requested.
• Coordinate transfer or discharge of residents including arranging transportation, compiling the discharge summary, reconciling medication and reviewing upcoming appointments with resident in a language understood by the resident with the goal of a safe discharge.
• Ensure that discharged residents are escorted to the pick-up area.

Charting and Documentation Functions

• Complete and file required recordkeeping forms/charts upon the resident’s admission, transfer and/or discharge; provide notifications to the ombudsman and responsible party per requirements.
• Document reports of accidents/incidents involving residents; follow established procedures.
• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.

Duties and Responsibilities

• Audit clinical record for appropriate consents and assessments including advance directives, living wills and other documents required for the delivery of person-centered care with respect to rights and choices.
• Record verbal and telephone orders from practitioners on order sheets or in electronic health record (EHR) per facility policies.

Medication Administration Functions

• Review the controlled substance and drug disposal records for accuracy and notify the Director of Nursing and pharmacy of discrepancies.
• Monitor medication administration process and provide appropriate feedback or changes to prevent medication errors.
• Ensure that the medication carts and medication rooms are clean, sanitary and well stocked
• Assess residents for appropriate self-administration of medication in coordination with the IDT.
• Reconcile medication delivery from pharmacy by verifying the medications, quantity and accuracy.
• Collaborate with the IDT to ensure the safe and appropriate use of medications for all residents.
• Administer medications in accordance with physician orders, regulations and facility policies.
• Support the objectives of the infection prevention and control program including antibiotic stewardship.
• Work with the IDT to review unnecessary medications and coordinate gradual dose reductions as appropriate.
• Reconcile resident medications (pre/post-discharge) as part of the discharge process.
• Order prescribed medications, supplies and equipment as necessary and in accordance with established facility policies.

Personnel Functions

• Meet with assigned nursing staff as well as support personnel in planning the shifts’ services, programs and activities and to assist in identifying and correcting problem areas and/or improving delivery of person-centered care and services.
• Assist the Director of Nursing in directing the day-to-day functions of the nursing activities in accordance with current rules, regulations and guidelines that govern the facility.
• Direct the day-to-day functions of the CNAs in accordance with current rules, regulations and guidelines that govern the facility.
• Coordinate with the scheduler to ensure a Registered Nurse (RN) is on duty at least 8 hours a day/7 days a week and a Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN)is on duty 24 hours a day.

Duties and Responsibilities

• Ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity; this includes proper licensure or certification if required.
• Assess residents for conditions which may be aided by assistive or adaptive devices; recommend/request in accordance with facility policies; monitor for proper utilization and application of assistive devices.
• Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.
• Develop positive professional relationships with nursing students, teachers/professors and other visitors.
• Prepare and deliver nursing report at change of shift or in situations requiring a coordinated effort.
• Assist in the grievance process in coordination with the grievance officer; assist residents with filing grievances, investigating allegations and coordinating an appropriate response; respond to resident or family grievances in accordance with facility policies.
• Review complaints and grievances made or filed by your assigned personnel; make appropriate reports to the Charge Nurse/Nurse Supervisor as required or as necessary.

Staff Development Functions

• Collaborate with the Staff Development Coordinator for team member training, skill development and competencies in accordance with facility policies(e.g.,proper hand-washing techniques, proper operation of Hoyer lift or assistive device); educate in a manner or format understood by the team member.
• Assist in training department personnel.
• Assist the Director of Nursing in planning clinical supervision for nurse aide trainees, nursing students and newly hired nurses.
• Attend continuing education program or training as needed to provide competent nursing care; assist with coaching and training with nursing team members in unit/facility.

Safety and Sanitation Functions

• Ensure that all nursing services personnel comply with established departmental policies and procedures.
• Ensure that all personnel wear and/or use safety equipment and supplies (e.g., back brace, mechanical lifts, etc.) when lifting or moving residents in accordance with plan of care and facility policies; order and stock personal protective equipment (PPE)as necessary.
• Ensure that the resident environment remains as free of accent hazards as possible and that each resident receives adequate supervision and assistive devices to prevent accidents.
• Ensure that nursing services personnel follow established infection prevention and control procedures.

Duties and Responsibilities

• Ensure that assigned personnel participate in all Life Safety Code and emergency preparedness and response drills in a safe and professional manner and in accordance with facility policies.
• Monitor nursing staff to ensure adherence with manufacturer’s recommendations and established safety protocols during the use of equipment, supplies or resources.
• Participate in the development, implementation and maintenance of the procedures for reporting hazardous conditions or equipment.

Equipment and Supply Functions

• Maintain list(s) of equipment repairs or needs required for resident care.
• Recommend to the Charge Nurse/Nurse Supervisor the equipment and supply needs of your unit/shift.
• Ensure that appropriate safety data sheets (SDSs)are on file for hazardous chemicals used in the nursing services department.
• Participate in the development and implementation of the procedures for the safe operation of all nursing services equipment.

Miscellaneous Functions

Complete tasks requested by the QAPI Committee within the established timeframes.

Working Conditions

• Works in office areas as well as throughout the nursing services area (i.e., drug rooms, nurses’ stations, resident rooms, etc.).
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
• Is subject to hostile and emotionally upset residents, family members, personnel and visitors.
• Communicates with the medical staff, nursing personnel and other department directors.
• Works beyond normal working hours and on weekends and holidays and in other positions temporarily when necessary.
• Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
• Attends and participates in continuing education programs.
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday as well as to reactions from dust, disinfectants, tobacco smoke and other air contaminants.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• May be subject to the handling of and exposure to hazardous chemicals.
• Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.

Education

Must possess, as a minimum, a nursing degree from an accredited college or university, or be a graduate of an approved Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)program.

Experience

• Must have, as a minimum, one (1) year of experience as a supervisor in a hospital, nursing care facility, or other related health care facility.
• Must have training in rehabilitative and restorative nursing practices.

Specific Requirements

• Must possess a current unencumbered active license to practice as a Registered Nurse(RN)or LPN/LVN in the state.
• Must be able to read, write, speak and understand the English language.
• Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.
• Must be a supportive team member, contribute to and be an example of team work and team concept.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
• Must be knowledgeable of nursing and medical practices and procedures as well as laws, regulations and guidelines that pertain to nursing care facilities.
• Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
• Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures, etc., that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm as well as the willingness to handle difficult residents.
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
• Must be able to relate information concerning a resident’s condition.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements (with or without the aid of mechanical devices)

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write the English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
• Must function independently and have flexibility, personal integrity and the ability to work effectively with residents, personnel, and support agencies.
• Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination.
• Must be able to relate to and work with the ill, disabled, elderly, emotionally upset and, at times, hostile people within the facility.
• Must be able to push, pull, move and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move and/or carry such weight a minimum distance of 50 feet.
• May be necessary to assist in the evacuation of residents during emergency situations.

Job Position Analysis Information

(1) Risk Exposure to Blood/Body Fluids Column:

A check mark entered into this column indicates the risk potential of your exposure to blood or body fluids. Established procedures identify the appropriate personal protective equipment (PPE)that you should use when performing this task.

(2) Essential Functions Column:

A check mark entered into this column indicates that you may be required to performt his task.

(3) Safety Factors Column:

RM = Repetitive Motion:

A “RM” in this column indicates that it will be necessary for you to perform some functions of this task repeatedly. When such tasks are not performed properly injury can result. Established procedures identify the precautions and/or equipment that should be used.

WL = Minimum Weight Lifting Requirement:

A “WL” in this column indicates that it will be necessary for you to perform functions of this task that require some lifting, moving, pushing or pulling. When such tasks are not performed properly injury can result. Established procedures identify the precautions and/or equipment that should be used when performing this task. Minimumweight lifting requirements that you must perform are located in the “Physical and Sensory Requirements” section of this job description.

SB = Prolonged Sitting, Standing and Bending:

A “SB” in this column indicates that some functions of this task require you to sit, stand or bend for an extended period of time. When such tasks are not performed properly injury can result. Established procedures identify the precautions and/or equipment that should be used when performing this task.