RN/LPN

PRINCIPAL DUTIES AND RESPONSIBILITIES:

1. Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long term care facility.
2. Ensure that the written policies and procedures that govern the day-to-day functions of the nursing service department are followed by all nursing personnel assigned to you.
3. Cooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.
4. Ensure that all nursing service personnel are following their respective job descriptions.
5. Participate in and report all reportable incidents in compliance with the facility’s State-mandated Risk Management Plan.
6. Participate in State and Federal survey inspections made by authorized government agencies.
7. Make written or oral reports and/or recommendations concerning the activities of your shift as required.
8. Periodically review the department’s policies, procedure manuals, job descriptions, etc., and make recommendations for revisions.
9. Meet with your assigned nursing staff and support personnel in planning the shift's services, programs, and activities.
10. Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.
11. Admit, transfer, and discharge residents as required.
12. Complete accident and/or incident reports as necessary.

CHARTING AND DOCUMENTATION:

1. Chart all accidents and/or incidents involving the resident. Follow established procedures.
2. Have the attending physician review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
3. Chart progress notes in an informative and descriptive manner that reflects the care provided to the resident as well as the resident’s response to that care.
4. Complete and file required recordkeeping forms/charts “observations and events” upon the resident’s admission, transfer, and/or discharge.
5. Receive and record telephone orders from physicians. Enter the orders into Matrix and print a hard copy for the physician to sign. Orders must include a diagnosis.
6. Print a new MAR/TAR sheet with the new order on it and place it in the MAR/TAR. Discontinue old orders by hand and date them.
7. Record new and/or changed diet orders and notify the Dietary Department of the change by printing them a copy of the order and delivering it to them.
8. Document in the progress notes that the resident has new orders.
9. Report all discrepancies noted concerning physicians' orders, diet change, charting errors, etc., to the Director of Nursing.
10. Perform routine charting duties as required in accordance with our established Charting and Documentation Policies and Procedures.
11. Ensure the date and time for all entries made in the resident’s medical record are correct.
12. Fill out and complete resident transfer forms in accordance with the established procedure.

DRUG ADMINISTRATION FUNCTIONS:

1. Prepare and administer medications as ordered by the physician.
2. Ensure that the prescribed medication for one resident is not administered to another.
3. Verify the identity of the resident before administering the medication and/or treatment.
4. Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
5. Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hand to meet the nursing needs of the residents.
6. Ensure that narcotic records are accurate for your shift.
7. Dispose of drugs and narcotics in accordance with established procedures.
8. Notify the Director of Nursing of all drug and narcotic discrepancies noted on your shift.
9. Notify the physician of any medication that is unavailable to administer and document the notification.

PERSONNEL FUNCTIONS:

1. Find alternate staff to substitute when assigned personnel fail to report to work.
2. Develop work assignments and/or assist in completing and performing such tasks.
3. Make frequent rounds of the unit to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards.  Report problem areas to the Director of Nursing.
4. Log absentee call-ins including signs and symptoms of illness.
5. Review complaints and grievances made or filed by your assigned personnel.  Make appropriate reports to the Director of Nursing as required or as necessary.
6. Ensure that disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
7. Develop and maintain a good working rapport with interdepartmental personnel, as well as other departments within the facility to assure that nursing services and activities can be adequately maintained to meet the needs of the residents.
8. Assure that department personnel, residents, and visitors follow the department's established policies and procedures at all times. Coach staff as needed and report to DON.
9. Create and maintain an atmosphere of personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.
10. Meet with your shift’s nursing personnel on a regularly scheduled basis to assist in identifying and correcting problem areas and/or the improvement of services.
11. Give and/or receive the nursing report upon reporting in and ending shift duty hours.
12. Provide leadership to nursing personnel assigned to your shift.
13. Support and participate in the home’s quality assurance and QAPI program.
14. Participate on committees as assigned.
15. Complete records and reports as needed.
16. Adhere to professional codes of ethics.

NURSING CARE FUNCTIONS:

1. Inform nursing personnel of new admissions, their expected time of arrival, room assignment, etc.
2. Ensure that rooms are ready for new admissions.
3. Provide direct, hands-on nursing care as necessary.
4. Make rounds with physicians as necessary.
5. Implement and maintain established nursing objectives and standards.
6. Make independent decisions concerning nursing care.
7. Notify the resident’s physician and family when the resident is involved in an accident or incident.
8. Make periodic checks to assure that prescribed treatments are being properly administered by nursing assistants and to evaluate the resident’s physical and emotional status.
9. Administer professional services such as injections, catheterization, tube feedings, administering medications, suction, oxygen administration, blood sugar tests, breathing treatments, applying and changing dressings/bandages, packs, colostomy, drainage bags, care of the dead/dying, etc., as required.
10. Participate in the orientation of new residents/family members to the facility.
11. Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with established procedures.
12. Admit, transfer, and discharge residents as necessary.
13. Inspect the nursing service areas daily to ensure that they are maintained in a clean and safe manner.
14. Consult with the resident’s physician in providing the resident’s care, treatment, and rehabilitation as necessary.
15. Notify the resident’s physician, next of kin, and DON when there is a change in the resident’s condition.
16. Work with the facility’s consultants and implement those changes recommended by them.
17. Enter laboratory and radiology tests as ordered into Matrix, print a hard copy, and take to patient registration. Document the new orders in the progress notes.
18. Take and record TPR’S, blood pressures, and neurological checks as necessary and document.
19. Inform family members of the death of a resident.
20. Ensure established post mortem procedures are followed.

STAFF DEVELOPMENT:

1. Assist in the implementation of an effective orientation program that orients the new employee to your shift and to his/her job position and duties.
2. Attend and participate in continuing education programs designed to keep you abreast of changes in your profession as well as to maintain your license on a current status.
3. Provide instruction to staff as needed.
4. Assist with orientation of new employees.
5. Assist in planning and implementing staff development activities.

SAFETY AND SANITATION:

1. Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies. Coach as needed and report to the DON.
2. Monitor your assigned personnel to ensure that they are following established policies and procedures in the lifting, moving, and transferring of residents by means of mechanical lifts and/or gait belts. Coach as needed and report to the DON.
3. Ensure that your assigned work areas are maintained in a clean and sanitary manner.
4. Ensure that resident rooms are maintained in a clean, safe, and sanitary manner.
5. Ensure that your assigned nursing personnel follow established departmental policies and procedures, including dress codes. Coach as needed and report to the DON.
6. Ensure that your assigned personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner.
7. Participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel.
8. Ensure that your assigned personnel follow established infection control procedures when isolation precautions become necessary.
9. Participate in the development and implementation of the procedures for reporting hazardous conditions and equipment.
10. Ensure that your assigned personnel follow established handwashing techniques in the administering of nursing care procedures. Coach as needed.

EQUIPMENT AND SUPPLY FUNCTIONS:

1. Recommend to the Director of Nursing the equipment and supply needs of the unit.
2. Ensure that a stock level of medications, medical supplies, and equipment is maintained on the unit at all times to meet the needs of the residents.
3. Ensure that only trained and authorized personnel operates the unit’s equipment.
4. Ensure that all personnel operates nursing service equipment in a safe manner.
5. Monitor nursing procedures to ensure that nursing service supplies are used in an efficient manner to avoid waste.

CARE PLAN AND ASSESSMENT FUNCTIONS:

1. Review care plans to ensure that appropriate care is being rendered.
2. Make any changes that need to be made on the care plan, and notify staff verbally and via the communication book.
3. Ensure that your nurses’ notes reflect the care plan is being followed.
4. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.
5. Ensure that your assigned nursing assistants are aware of the resident care plans and that they are used in administering daily care to the resident.

RESIDENTS’ RIGHTS FUNCTIONS:

1. Maintain the confidentiality of all resident care information.
2. Monitor nursing care to assure that all residents are treated fairly, and with kindness, dignity, and respect.
3. Ensure that all nursing care is provided in privacy and that nursing service personnel knock before entering the resident’s room.
4. Review complaints and grievances made by the resident and make a written/oral report to the Director of Nursing.

PUBLIC RELATIONS:

1. Promote a positive image of long term care nursing.
2. Meet with current and prospective residents and their families.
3. Promote positive customer service.
4. Assure problems and complaints involving nursing services are managed and resolved in a timely, appropriate manner.
5. Protect the privacy of residents and employees.
6. Represent the home and nursing services in professional and community activities as requested.
7. Maintain positive working relationships between nursing staff and other departments.

These lists are not exhaustive and may be supplemented as necessary.

HOSPITAL POLICIES AND PROCEDURES:

1. Attend facility and department meetings.
2. Participate in fire and disaster drills.
3. Follow the department dress code.
4. Wear name badge so visible at all times while working.
5. Be to work on time and when scheduled.
6. Dependability.
7. Follow the time clock procedures (clock in and out properly).
8. Follow facility safety policies.
9. Follow infection control policies.
10. Follow facility confidentiality policy.
11. Follow facility HIPAA and Corporate Compliance policy.
12. Through approved workshops and in-services, improve skills and job knowledge.
13. Follow personnel policies as stated in the Employee Handbook.

INTERPERSONAL RELATIONSHIPS:

1. Be aware of and cooperate with the mission of Gove County Medical Center.
2. Maintain good interpersonal relationships with personnel of other departments, public, physicians, patients/residents, and promote positive guest relations.
3. Demonstrate the ability and willingness to provide support to Department Managers, Supervisors, and coworkers in a team-oriented manner.
4. Demonstrate a respectful and caring attitude through verbal and non-verbal behavior.
5. Demonstrate flexibility and willingness to contribute an effort to cross-department boundaries to ensure quality and efficient service.