Registered Nurse Night Shift - Berkshire Nursing and Rehabilitation Center

TITLE: REGISTERED NURSE

REPORTS TO: NURSING SUPERVISOR

POSITION SUMMARY:

The purpose of your job as a Registered Nurse is to perform a variety of care practices under the direction of the Nurse Supervisor of the unit/shift. This includes, but not limited to taking charge of a unit and administering medication as ordered. You are also responsible for documentation/care planning in the EMR.

JOB FUNCTION:

Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position.

QUALIFICATIONS:

1. Currently licensed by the State of New York.

2. Mentally and physically capable of performing job duties.

3. Possesses leadership and supervisory qualities.

4. Possesses assessment skills that enable the recognition of condition changes in the resident.

5. Ability to coordinate all functions in the operation of a resident unit through effective team nursing assignments.

6. Maintain meaningful and accurate documentation of services provided.

7. Prior computer skills in (Excel, Word, and Microsoft Office) a plus.

PERSONAL APPEARANCE:

1. Required uniform is to be worn.

2. Wear clean, well-fitting uniform with name tag and title.

3. Shoes must be clean, white rubber soled, and nursing regulation.

4. Makeup must be in good taste and moderate in amount.

5. Hair, hands, fingernails must be neat, well-kept and clean.

6. Jewelry should be restricted to simple ring and wristwatch.

7. Proper, acceptable, personal hygiene must be maintained at all times.

RESPONSIBILITIES:

1. Count and sign for controlled drugs with the nurse going on/off duty. Report any discrepancies to the supervisor immediately. Do not pre-sign for the end of your shift and do not pre-pour medications.

2. Receive report via EMR and nurse going off duty. Be sure you have the keys. Be present for the Charge Nurse’s report to the CNA’s.

3. Establish priorities of care, assess unstable patients and make provisions for appropriate care in coordination with the Supervisor of the shift.

4. Visits each resident at least twice during work shift to make sure that appropriate care is being rendered. Makes corrections as necessary.

5. Supervises and directs the total nursing activities on the assigned unit during your tour of duty, including, but not limited to, assignment of nursing staff and patient care.

6. Assists the nursing personnel in performing procedures as necessary.

7. Evaluates emergencies, consults with Supervisor and determines emergency measures to be used.

8. Notifies the patient’s/ resident’s physician, as well as the resident’s legal guardian and Social Worker, of any changes in patient’s condition, sustained injury or transfers to another facility, as outlined with our established policies.

9. Makes necessary rounds with attending physician, as necessary.

10. Processes Physician’s orders and assures that all orders are carried out. Assures that all diagnostic studies, including specimen collection are completed in a timely manner.

11. Ensures that each resident’s rights to fair and equitable treatment, confidentiality, self-determination, individuality, privacy, property and civil rights, including the right to wage a complaint, is followed by all nursing personnel.

12. Develops and maintains a good working rapport with interdepartmental personnel, as well as other departments within he facility, to assure the nursing services and activities can be adequately maintained to meet the needs of the residents/patients.

13. Adheres to established infection control procedures and isolation techniques in accordance with established policy and procedure. Utilize universal precautions (body substance isolation) and wash hands before and after caring for each resident to prevent cross contamination and spread of infection.

14. Meets with nursing personnel, as needed to assist in identifying and correcting problem area and/or the improvement of services. Involves the resident’s/patient’s family in planning objectives and goals for resident.

15. Assures that the unit/shift area is maintained in a clean and safe manner for resident comfort and convenience.

16. Participates in in-service education through on-the-job training and orientation programs for newly assigned departmental personnel. Makes recommendations concerning training needs.

17. Reviews patient/family complaints and takes corrective action or refers complaints to appropriate person.

18. Completes accident/incident reports and notifies appropriate person at time of occurrence.

19. Assumes responsibility for coordination of the total care for the 7.5 hour period of all patients on assigned unit

20. Check temperature of the medication refrigerator as well as expiration dates on medications in the refrigerator (temperatures should range between 3 and 46 degrees). Never store food items or specimens in medication refrigerator

21. Sign for medications delivered by vendor pharmacy.

22. Observes, records and reports to head nurse or supervisor, as indicated, all pertinent changes in medical condition and/or incidents which involve residents, staff or visitors.

23. Review physician’s orders for any changes and check to see that these changes have been carried over in EMR or other appreciate records.

24. Be aware of residents who are fasting for lab work, etc., making certain that this information is communicated to the staff. Tube feeders that receive insulin will require their coverage following lab work.

25. Assemble supplies for medication administration including fresh water, juice, and applesauce, which must be dated. Supplies will also include hand spray for hand washing in between each resident, souffl cups, medicine cups, drinking cups, straws, spoons, tissues, paper towels, etc.

26. Maintain a system to check all medication labels for incorrect labeling and/or expired dates.

27. Medication that has been discontinued must be removed from the medication cart or other areas and brought to the Nursing office as soon as possible for return to the pharmacy. Expired medication is handled in the same manner. Vaccines and PPD does that have expired or vials that are empty are discarded into the used needle and syringe container.

28. Medication and Treatment carts are to remain closed and locked when not in use and keys are to be carried on your person at all times.

29. Wash your hands before starting out with medication cart.

30. The resident’s arm band and or positive identification of the resident are to be made prior to medication administration. Medications are to be administered individually (one at a time) and then documented in EMR. All rules and protocols for medication administration are to be followed. Never pre-pour medications. Medication is not to be left at bedside. Do not administer medications that are poured by another nurse.

31. PRN medications are documented in EMR. Medication refusals are to be documented in EMR.

32. Hand washing must take place in between each resident receiving medication. Hand washing using soap and water is required in between dispensing ENT medications following glove removal.

33. Discipline subordinate staff when necessary.

34. ENT medications are to be dispensed at separate times from oral medication. Eye drops are to be administered at least five minutes apart. Gloves are to be worn when administering eye medications.

35. No medications are to be left on top of the medication and/or treatment cart or at the bedside at any time.

36. When administering medications via feeding tube, injections or performing finger-sticks, privacy of the resident must be maintained. Take the resident back to his/her room, a private area or use a screen to allow for privacy in common areas.

37. Perform finger-sticks as ordered and provide insulin coverage if ordered and document the results via EMR.

38. Assist in feeding of the residents during meal times.

39. No medications are to be administered during meal times unless they indicated/ordered to be given during meals.

40. The medication room is to be kept locked at all times.

41. Perform all treatments and document via EMR.

42. Medication and Treatment cart are to be left clean and re-stocked at the end of the shift.

43. Soiled dressings are to be discarded in a red plastic bag.

44. Administer tube feeding as per procedure and physician order.

45. Assist with documenting and picking up orders via EMR.

46. Attend in-service classes and staff meetings when scheduled. Assist in the orientation of new nursing personnel.

47. Check emergency drug box as per procedure.

48. Report any medication incidents that are unusual and/or refusals to the supervisor. Assist in filling out any required forms pertaining to this or any accident/incident which may occur.

49. Must know the action/side effects of the medications she/he is dispensing and follow the list of non-crushable medications as per manufacture directions.

50. Perform other nursing functions as designated by your supervisor.

51. During inclement weather or emergencies, staff is to remain on duty until adequate staff has arrived and the Supervisor approves dismissal.

52. Medication is not to be administered without a physician/NP/PA order.

53. Discard any medications that have fallen on the floor. When wasting control drugs, a witness must be present when discarded and both parties must sign the control sheet.

54. All liquid medications are to be shaken adequately and poured at eye level away from the label.

55. Pill crusher is to be cleansed after each use. Use two cups to crush medications.

56. PRN medications that have not been administered for long periods of time; the physician is to be notified for the order to be discontinued.

57. All newly opened vials of injectable medications are to be dated.

58. Allergies are to be entered in EMR.

59. Notify Supervisor immediately upon discovery of missing medications and/or any other discrepancies in dosage.

60. All open vials of injectable medications are to discarded after thirty days.