Under direction and general supervision, provides assessment and implementation of direct nursing care to residents in a long-term care facility.
ESSENTIAL JOB FUNCTIONS:
Identifies and documents initial assessments of the resident's needs for immediate nursing action following admission. Assesses nursing needs of the resident in order to detect pertinent changes in the clinical picture and identifies appropriate changes necessary in the care plan; Develops, plans, evaluates, and documents care based on this assessment utilizing MDS form.
Initiates appropriate referrals to other departments, services, and/or outside agencies for resident care.
Gives comprehensive patient/resident care.
Consults with supervisors and others regarding significant changes in resident's condition and relays appropriate information to succeeding shift.
Collaborates with the health care team to complete MDS and care planning in compliance with facility and regulatory agency requirements.
Interprets clinical data and notifies the physician of immediate changes in management that are indicated.
Ensures that medical and emergency equipment/devices including alarms are in operating condition, and are available and functioning.
Participates in wound care rounds.
Assists in the orientation and training of new personnel.
Provides clinical supervision of LPN's, CNA's, and other ancillary staff.
Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards; promotes adherence to Resident Bill of Rights.
OTHER JOB DUTIES:
Attends and participates in required inservice training.