Job Summary

This position requires that the individual functions to meet resident needs through assessment, planning intervention, and continually evaluates the quality of care being delivered to all residents on his/her assigned unit.  Must work closely with all members of the interdisciplinary health team to identify, suggest change, carry out interventions and evaluate progress.  Completes treatments as prescribed by attending physician – monitors progress/lack of progress.  Will maintain the standards of nursing practice in all aspects of job.

Responsible for the administration of oral medications, subcutaneous intramuscular injections, and intravenous accurately, and be able to detect side effects, correlate disease progress, and report to Nurse Manager or Supervisor any problems or symptoms observed in resident.  Assist with the supervision of nursing assistants, and training of new licensed and non-licensed nursing personnel.  Participates in education programs that update and maintain professional knowledge and skills, as they relate to area of practice and resident care conferences.

Qualifications

Graduate of an accredited program in the field of nursing; preferably have a Bachelor of Science Degree in Nursing or working towards achievement of same.  Be licensed in the State of Pennsylvania as a Registered Nurse or Licensed Practical Nurse.  Have at least one year of recent clinical experience and experience in administration of/educations in a medical-surgical area.  Attends in-service and continuing education programs and maintains the professional knowledge and skills necessary to competently carry out responsibilities of job.

Responsibilities, Duties and Tasks

Assessment

• Assesses the number level of nursing personnel which are required to provide care, and forwards recommendations to the Nurse Manager.

• Assess the quality of care being delivered on assigned unit – identifies problems and institutes corrective measures – reports observations/problems to the Nurse Manager.

• Assesses the health status of residents on assigned unit as outlined in the nursing standards.  Accomplishes this through daily rounds; seeing all residents at the time of admission.

• Assesses the needs of residents at the time of admission and continually thereafter.

• Collects data from the resident, family and significant others, members of the health care team – utilizes and incorporates this information into a plan of care for the resident.

• Assesses resident and collects data using the following techniques, and documents assessments on clinical record.

  • Interview

  • Observation

  • Inspection

  • Auscultation

  • Palpation

Planning

• Is a member of facility’s committee and assists in the review and revision of nursing policies and procedures under the supervision of the Director of Nursing.

• Collaborates with supervisory personnel in the process of problem identification and solution, communicates changes in resident’s condition to Nurse Manager.

• Contributes to and participates in the development of a nursing care plan for each resident which reflects resident’s problems and needs, and establishes appropriate interventions which are required to achieve optimal health for each resident.  Regularly evaluates plan of care, making necessary changes.

• Provides nursing assistants with daily assignments, break schedules, and special assignments.

Implementation

• Participates actively in implementing planned change which contributes to the improvement of the quality of nursing care.

• Holds self and staff accountable for the quality of care being delivered to resident on assigned unit.

• Assists, under the supervision of Nurse Manager or Supervisor, with the orientation and training of new employees, both on the professional and non-professional level.

• Acts quickly and appropriately in emergency situations – manages self, residents, and employees safely and efficiently.

• Implements and provides on-going monitoring of facility’s programs

  • Wound Care

  • Nap Program

  • Repositioning Program

  • Dining Room Service

  • Restraint Utilization and Reduction

  • Weight Monitoring Program

  • Lounge and Leisure Program

  • Behavior Management Program

• Attends in-service education programs, and when assigned is responsible for conducting an in-service program under the supervision and direction of the Director of Nursing.

• Reports to unit promptly and attends reports. Communicates with staff regarding schedule and activities for the day.

• Participates in and facilitates planned change among his/her nursing staff.

• Is active participant in facility’s Quality Assurance Program.

• Responsible to communicate with families/responsible party, changes in resident’s condition, progress and needs. Refers complaints and special problems to Nurse Manager.

• Follows facility’s dress code.

• Is rarely late for or absent from work.

Charge Duties

• Participates in the development of a comprehensive nursing care plan for each resident on his/her assigned unit.  Care plan will be individualized and will thoroughly address resident’s needs and problems.

• Records pertinent information on Shift Report Sheets – patients on T.P.R. and I & O, admissions, discharges and transfers, doctor’s visits and calls – changes in orders, changes in resident’s condition.

• Maintains an accurate clinical record for each resident to include complete documentation in nurse’s notes, renewal of physician’s orders and progress note, not exceeding an every 30 – day interval, monthly summaries per schedule.

• Completes re-caps and notifies attending physician five days before orders are to be renewed (7:00a.m. to 3:30p.m. shift.)

• Responsible for completing prescribed treatments (if Treatment Nurse not able to complete) and necessary Medicare documentation on a daily basis.

• Prior to 1st of the month, checks medication charts for accuracy – compares chart with most recent physician’s orders.

• Ensure that resident’s rights and dignity are maintained by enhancing staff awareness and nursing rounds.

Medication Duties

• Administers and records medication as prescribed by physician, and in accordance with facility policy and procedure

  • Detect side effects – withholds medications as indicated and documents in resident’s clinical record.

  • Takes and records pulses and BPs of residents receiving cardiovascular medicine.

• Administers medication to residents on assigned unit in a timely fashion (Department of Health mandates a timely interval of one hour before to one hour after prescribed time.)

• Periodically evaluates expiration of drugs in the medication cart.  Removes discontinued drugs, drugs of discharged patients from unit and returns them to pharmacy.

• Counts narcotic/control drugs on assigned unit with on-coming shift Charge/Medication Nurse.  Reports any discrepancies to Director of Nursing immediately.

• Checks and stocks emergency kit.

• Keeps medication preparation room neat and tidy.

• Maintains accurate and updated Medication Administration Records.

• Ensures that medicine containers are properly labeled with the required information (as defined by Pennsylvania Department of Health.)

Evaluation

• Evaluates nursing care administered by self and others on assigned unit, and evaluates ability to identify and solve problems.

• Contributes to the performance evaluation of nursing personnel on assigned unit, both professional and non-professional.

• Makes recommendation to Director of Nursing regarding the orientation policies and procedures for licensed personnel.

• Participates in evaluation of in-service and continuing education programs.

• Frequently evaluates progress or lack of progress, as it relates to previously established long-term/short-term goals, and makes necessary revisions in plan of care for each resident.

• Evaluates medication administration policies and procedures, and recommends revisions to improve techniques.

• Assists in the evaluation process of medication errors, and makes suggestions for revisions in procedure that insure accuracy and minimizes errors.
  

Charge Nurse Responsibilities

• Count narcotics, if count not right notify your immediate supervisor right away.

• Walking rounds

• Shift to shift report, be specific on new admission, re-admission; their diet, DXs, etc.

• Check crash cart, call supply department for refill as needed.

• Make sure enough supplies for emergencies; full O2 tanks with regulators, suction machine working properly.

• Make sure that for admission and transfer, rooms are ready with appropriate supplies.

• Make sure that on admission, weight, vital signs, observations, care plans, and nurse's notes are done. If there are any wounds, make sure to get order for wound care.

• All residents are ready for appointments, discharge, therapy, LOAs, etc.

• Weekly skin assessment, psych notes, quarterly observations, nurse’s note on every resident on 24 hour report sheet.

• All residents are served meals on time.

• Check for labs and consults, and address abnormal labs and follow up on consults.

•  Keep your med cart neat and clean, re-order medication on time. (72 hours in advance.) ABSOLUTELY NO FOOD OR DRINKS ON THE MED CART.

• Insulin must be kept in the refrigerator.  Vials must be dated when they are opened; discard after 28 days.

• Tube feeding bottles and tubes must be dated, initialed, and timed. Feeding pumps are to be kept clean/

• No tubing on the floor; O2 tubing, and nebulizer tubing needs to be in a plastic bag with resident's name and room number.

• Take off orders.

• Help other nurses who are behind in their work.

• Communicate with UMs for any decline/improvement in resident's condition.

•  SUPERVISE CNAs - meals are served on time, no breaks until all trays served and collected, turning residents, baths are given, beds are made and all residents are out of bed, weights, vital signs in timely manner, rooms are kept neat and clean, POC documentation and ADL sheets are done, Foley bags are emptied, call lights are answered promptly.