Description

JOB SUMMARY: Provides nursing care to a group of patients for a designated time frame. Routinely leads team of care providers. May assume charge responsibility for unit when assigned. Has principal responsibility for delivery and supervision of resident care throughout the nursing process of assessment, planning, implementation and evaluation according to the regulatory standards for the Nursing Home. Supervises direct patient care personnel. Prepares and maintains records and reports as required. May provides direct and indirect care on a routine basis. OSHA Bloodborne Pathogens Class I.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Responsible for the delivery and supervision of resident care.

• During the shift, assumes responsibility for the total nursing care of residents/families.
• Recognizes significant changes in the condition of the resident/patients and takes necessary action.
• Ensures that the individual nursing care plans are followed to meet the resident’s needs.
• Ensures that drugs and medications are procured, inventoried, prepared, administered and charted according to policy and procedure.
• Administers and supervises prescribed treatments.
• Makes rounds with physicians and records visits in medical record.
• Provides care appropriate for the geriatric patients served based on demonstrated knowledge of the principles of growth and development over the life span.
• Assess and interprets data to identify patient requirements related to their age specific needs and provides care needed as stipulated in departmental policy.
• Provides service direct to patients while maintaining a positive patient relations atmosphere

Provides supervision, assistance and support duties as needed.

• Supervises direct patient care personnel
• Monitors the serving of prescribed diets and nourishments and reports persistent unresolved problems to the physician and the DON.
• Ensures the preparation of accident/incident reports and follows through with recommendations and required procedures.
• Ensures that all patient care is documented according to policy.
• Assists in maintaining a clean, safe environment for residents, detecting and correcting situations that have a high probability of causing accidents or injuries to residents/patients. 
• Recognizes when a situation cannot be handled and requests help from proper personnel when necessary.
• Participates in the Interdisciplinary Care Plan meetings.
• Receives verbal or telephone orders from physician. 
• Ensures continuing promotion of resident/patient physical and emotional health by assisting and teaching them.

Maintains accurate and timely records according to hospital policy.

• Documents ongoing assessments in medical record
• Accurately documents on each shift the nursing patient care activities and the patient’s response to interventions. 
• Documents teaching completed with patient and family response.
• Documents interdisciplinary recommendations for plan of care.
• Completes all appropriate transfer and discharge forms.
• Transcribes and/or cosigns physician/provider order accurately.

Requirements

• Education – Graduate of an accredited School of Professional Nursing
• Job Related skills –  
• Demonstrated effective oral and written communication skills
• License, Registry or Certification – 
• Registered Nurse currently licensed in the State of Texas.  
• Current BLS certification 
• Prior Work Experience -  
• One year nursing experience in long term care or related field..  
• Technical Training – Computer skills required.
• Physical and Mental Requirements -  
• Position requires extended periods of walking and standing. 
• Repeated bending, stooping and reaching, lifting up to 50 pounds.
• Transferring and lifting or supporting patients who may experience sudden weakness or inability to stand.
• The ability to comprehend and follow written or verbal instructions and directions and to instruct employees. 

OTHER SIGNIFICANT REQUIREMENTS

• Follows aseptic procedures and procedures for using precautions when involved in direct patient contact or handling potential infectious materials.
• Interacts with patients, family members, Medical Staff members and department managers on a continuous basis.
• Maintains HIPAA required and all other confidentiality while working with confidential matters on a daily basis.
• Follows MCHD Policies and Procedures and safety guidelines.
• Performs other duties as assigned by the department management staff.
• Performs essential job functions with or without reasonable accommodations.