REPORTS TO: Director of Nursing
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 be required by the Director of Nursing to maintain the highest degree of quality care at all times.
Essential Job Functions
This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents. Therefore, the following list of duties is not all-inclusive:
Charting and Documentation
- 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 complies with the procedures set forth 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 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 the 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 reflect 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.
- 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.
Medication Administrative Functions
Nursing Care Functions
- Prepare and administer medication as ordered by the physician.
- Responsible for IV medication/fluid administration.
- 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 the 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.
- Perform physical assessment through observation, inspection, palpitation, percussion, and auscultation.
- Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.
- Promptly respond to call lights and 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 CNAs 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 CNAs are aware of the resident care plans. Verify that the CNAs refer to the resident’s care plan prior to administering daily care to the resident.
- Attend in-service education programs in order to meet facility educational requirements.
- Be familiar with Standard Precautions, Exposure Control Plan, Fire Drill & Evacuation Procedures and know how to use the information.
- Maintain confidentiality of resident and facility records/information.
- Protect residents from neglect, mistreatment, and abuse.
- Protect the personal property of the residents of the facility.
- Others as directed by the supervisor or administrator.
- Registered Nurse with a current state license.
- Excellent technical, assessment and documentation skills.
- Good Leadership qualities.
- Organized and detailed in work performance.
- Good communication skills with excellent self-discipline and patience.
- Genuine caring for and interest in elderly and disabled people in a nursing facility.
- Comply with the Residents Rights and Facility Policies and Procedures.
- Perform work tasks within the physical demand requirements as outlined below.
- Perform Essential Duties as outlined above.
- Subject to frustrations in meeting work demands due to frequent interruptions.
- Fast-paced, required to make decisions quickly
- Involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
- May work beyond normal duty hours, on weekends, and in other positions temporarily, when necessary.
- Subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
- 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
Physical and Sensory Requirements
- Assist in the evacuation of residents during emergency situations
- Meet the general health requirements set forth by the policies of this facility, which may include a medical and physical examination.
1-2 hours per 8-hour work shift. Alternates frequently to walking.
5-7 hours per 8-hour work shift. Alternates frequently to standing and occasionally to sitting.
1-3 hours per 8-hour work shift. Alternating frequently to walking and occasionally to sitting.
Key: Rarely = ≤ 5% Occasionally = 0% - 33%; Frequently = 33% - 66%; Constantly = 66% - 100%
*(Rarely – would most likely occur in emergency situations only)
Resident charts, books, supplies, and equipment
Supplies and equipment
Equipment, boxes of supplies
Transfer of resident, ambulation of residents, and equipment
Transferring of residents
Resident charts, books, supplies, and equipment
Supplies and equipment
Equipment, boxes of supplies
Fine Manipulation: Continuously
Exposure Determination Information:
Numbers 1 through 3 indicates the risk potential of your exposure to blood or body fluids. Established procedures identify the appropriate personal protective equipment that you should use when performing tasks. The following numbers indicate your risk potential:
It is highly likely that while performing functions of this job, there will be tasks that will require you to be exposed to blood or body fluids.
This job does not normally involve contact with blood and/or body fluids but while performing the tasks associated with this job, it may be necessary for you to perform a task that involves exposure to blood or body fluids.
This job does not typically involve exposure to blood or bodily fluids. However, if the employee is trained in first aid/CPR, this may entail some exposure risk.
The position of Registered Nurse has an exposure determination of.
EMPLOYMENT AT WILL: It is the express policy and intent of this facility that the employment relationship is one created and governed by the continuing will of both parties. I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause by either party, unless provided otherwise by a written agreement signed by the President of this company.
NONDISCRIMINATORY STATEMENT: This facility does not discriminate on the basis of race, religion, national origin, color, creed, sex, age, disability, marital or veteran status with regard to employment.