RN - Randolph Gardens Nursing and Rehabilitation

JOB DESCRIPTION

Position:                     Registered Nurse

Department:               Nursing          

Reports to:                 Director of Nursing   

Summary:

Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern our facility, and as may also be required by the Director of Nursing to maintain the highest degree of quality care at all times.

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:

• Meet physical and sensory requirements stated below, and be able to work in the described environment.
• Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and/or improve the work environment.

• Direct the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the long-term care industry.
• Confirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
• Meet with your assigned nursing staff, as well as support personnel, in planning the shift’s services, programs and activities.
• Verify that all nursing personnel comply with the procedures set forth the in the Nursing Policies and Procedures Manual.
• Make written and oral reports/recommendations concerning the activities of your shift, as required.
• Cooperate with other resident services when coordinating nursing services and be certain that the resident’s total regimen of care is maintained.
• Verify that all nursing service personnel are in compliance with their respective job descriptions.
• Participate in the development, maintenance, and implementation of the facility’s quality assurance program for the nursing department.
• Participate in surveys (inspections) made by authorized government agencies.
• Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan, as required.
• Assist in planning the nursing portion of the resident’s discharge plan, as necessary.
• Admit, transfer, and discharge residents, as required.
• Complete accident/incident reports, as necessary.

• Complete and file required forms/charts upon resident’s admission, transfer, and/or discharge.
• Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
• Receive telephone orders from physicians and record on the Physicians’ Order Form.
• Transcribe physician’s orders to resident charts, cardex, medication cards, and treatment/care plans, as required.
• Chart nurses’ notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident’s response to care.

• Record new/changed diet orders.  Forward information to the Dietary Department.
• Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Nurse Supervisor, Unit Manager, or ADON/DON.
• Fill out and complete transfer forms in accordance with established procedures.
• Enter appropriate documentation concerning unauthorized discharges in the resident’s medical record in accordance with established procedures.
• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
• Sign and date all entries made in the resident’s medical record.
• Write nurses’ notes to reflect that the care plan is being followed when administering nursing care or treatment.
• Prepare and administer medication as ordered by the physician.
• Verify the identity of the resident before administering the medication/treatment.
• Verify that prescribed medication for one resident is not administered to another.
• 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.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with established procedures.
• Verify that narcotic records are accurate for your shift.
• Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
• Review medication cards for completeness of information, accuracy in the transcription of the physician’s order and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage being administered.

Immediately notify the Nurse Supervisor and attending physician of any medication administration errors.

• Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.
• Promptly respond to call lights and assist with other resident needs.
• Make rounds with physicians, as necessary.
• Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.
• Review the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.
• Make periodic checks to confirm that prescribed treatments are being properly administered by CNA’s and to evaluate the resident’s physical and emotional status.
• Notify the resident’s attending physician when the resident is involved in an accident or incident.
• Notify the resident’s attending physician and responsible party when there is a change in the resident’s condition.
• Administer professional services such as: 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.
• Monitor seriously ill residents, as necessary.
• Review care plans daily to confirm that appropriate care is being rendered.

Confirm that CNA’s are aware of the resident care plans.  Verify that the CNA’S refer to the resident’s care plan prior to administering daily care to the resident.

Other special projects and duties, as assigned.

Job Requirements:

• Registered Nurse or Licensed Practical/Vocational 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.

I understand this job description and its requirements, and that I am expected to complete all duties as instructed and assigned. I also understand that the job functions may be altered from time to time, and that Management has the right to modify this job description at any time, without advance notice to me, except as required by law.

I further understand this description identifies the essential and primary duties and responsibilities of the job, and that it is not intended to detail or contain each and every duty inherent in this job.

By your signature below, you acknowledge your understanding that your employment is at will, and that nothing in this job description is intended to constitute a contract of employment, express or implied.

I will immediately notify my supervisor if, currently or at some time in the future, I need an accommodation and/or if I am no longer able to perform any of my job duties, with or without accommodation.

                                                                                                            _______________________________________

Print Name

Employee Signature                                                                               Date

Supervisor Signature                                                                              Date