The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by licensed practical nurses and nursing assistants.
JOB DUTIES & RESPONSIBILITIES:
· Organize and assign all jobs to be done on tour of duty so that workload is evenly distributed among nursing personnel on the basis of staff qualifications, size and physical layout of the facility.
· Periodically review department policies, procedures and job descriptions and make recommendations for revisions.
· Implement established policies and procedures.
· Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
· Meet with your assigned nursing staff and support personnel to plan appropriate services, programs and activities for your shift.
· Cooperate with other resident services when coordinating nursing services to ensure that the resident’s individual care plans are being followed.
· Participate in the development, maintenance, and implementation of the facility’s quality assurance program.
· Request conferences with the Director of Nursing as needed to discuss resident, personnel and facility related business.
· Participate in facility surveys made by authorized regulatory agencies as requested.
· Periodically review the resident’s written discharge plan and participate in updating that plan as required.
· Admit, transfer and discharge residents as required.
· Place and receive, personally, all calls to and from physicians.
· Assist in updating the resident care plans as instructed by the MDS/Care Plan Coordinator and/or Director of Nursing.
· 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 the care.
· Document status of each resident on the chart at least weekly, more often if significant change occurs or as directed. Follow up with monthly and quarterly summaries as instructed.
· Make rounds with physician, as directed, and record visits in resident’s chart.
· Transcribe, accurately and promptly, all physician’s orders.
· Direct documentation and make weekly detailed evaluation of all resident documentation so that chart reflects progress and condition of resident at all times.
· Approve and sign charts when observations are made.
· Insure that all medications and treatments are charted and signed following administration of the medication/treatment, by the administering person.
· Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc. to the ADON or DON.
· Complete accurate accident/incident reports as necessary.
· Fill out and complete transfer forms in accordance with established procedures.
· Prepare and administer medications as ordered by physician.
· Verify the identity of the resident before administering the medication/treatment.
· Ensure that prescribed medication for one resident is not administered to another.
· Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hand to meet the nursing needs of the residents.
· Order prescribed medications, supplies, and equipment as necessary and in accordance with established policies.
· Ensure that narcotic records are accurate for your shift.
· Notify the ADON or DON of all drug and narcotic discrepancies noted on your shift.
· Prepare, administer and record all parenteral, intramuscular, sub-cutaneous injections.
· Administer I.V. fluid therapy in accordance with policy and procedure.
· Administer or supervise all treatments prescribed by physician.
· Dispose of drugs and narcotics as required and in accordance with established procedures.