Overview 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 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 Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. Responsibilities Administrative Functions 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. Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility. Periodically review the department's policies, procedure manuals, job descriptions, etc. Make recommendations for revisions. Meet with your assigned nursing staff, as well as support personnel, in planning the shifts' services, programs, and activities. Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this facility. Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service 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 to ensure that the resident's total regimen of care is maintained. Ensure 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 service department. Participate in facility surveys (inspections) made by authorized government agencies as may be requested. 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 services portion of the resident's discharge plan as necessary. Interpret the department's policies and procedures to personnel, residents, visitors, and government agencies as required. Admit, transfer, and discharge residents as required. Complete accident/incident reports as necessary. Write resident charge slips and forward to the Business Office. Maintain the Daily Census Report and submit to the Business Office as required. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator. Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator. Report any known or suspected unauthorized attempt to access facility's information system. Charting and Documentation Complete and file required recordkeeping 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, treatment/care plans, as required. 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. Fill out and complete accident/incident reports. Submit to Director as required. Chart all reports of accidents/incidents involving residents. Follow established procedures. Record new/changed diet orders. Forward information to the Food Services 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. Ensure that appropriate documentation concerning unauthorized discharges is entered 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. Drug Administration Functions Prepare and administer medications as ordered by the 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 is on hand to meet the nursing needs of the residents. Report needs to the Nurse Supervisor. 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 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. Dispose of drugs and narcotics as required, and in accordance with established procedures. Personnel Functions Participate in employee performance evaluations, determining your shift's staffing requirements, and making recommendations to the Nurse Supervisor concerning employee dismissals, transfers, etc. Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work. Report absentee call-ins to the Nurse Supervisor. Review and evaluate your department's work force and make recommendations to the Nurse Supervisor. Develop work assignments and/or assist in completing and performing such assignments. Provide leadership to nursing personnel assigned to your unit/shift. Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Nurse Supervisor. Ensure that all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program. Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse. Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services. Ensure that department personnel, residents, and visitors follow the department's established policies and procedures at all times. Develop and maintain a good working rapport with inter-departmental personnel to ensure services can be maintained to meet residents' needs. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift. Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the Nurse Supervisor as required. Follow facility procedures. Ensure that departmental disciplinary action is administered fairly and without regard to protected characteristics. Receive/give the nursing report upon reporting in and ending shift duty hours. Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals per policy. Report known or suspected incidents of fraud to the Administrator. Ensure security practices around access to information systems. Nursing Care Functions Inform nursing personnel of new admissions, their expected time of arrival, room assignment, etc. Ensure that rooms are ready for new admissions. Greet newly admitted residents upon admission and escort them to their rooms as necessary. Participate in the orientation of new residents/family members to the facility. Make rounds with physicians as necessary. Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, in accordance with procedures. Consult with the resident's physician in providing care, treatment, rehabilitation, etc., as necessary. Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary. Implement and maintain established nursing objectives and standards. Make periodic checks to ensure prescribed treatments are properly administered by certified nursing assistants and to evaluate the resident's status. Ensure direct nursing care is provided by a licensed nurse, a CNA, or a nurse aide trainee qualified to perform the procedure. Cooperate with and coordinate social and activity programs with nursing service schedules. Notify the attending physician when the resident is involved in an accident or incident, and when there is a change in condition. Carry out restorative and rehabilitative programs, including self-help and care. Inspect nursing service treatment areas daily for cleanliness and safety. Administer professional services such as catheterization, tube feedings, suction, dressings, colostomy care, taking blood, massages, ROM, etc., as required. Use restraints when necessary and in accordance with policies. Obtain specimens for lab tests as ordered; take and record vital signs as necessary. Monitor seriously ill residents as necessary. Check foods brought by family/visitors for dietary compliance; report issues as needed. Ensure direct care aligns with the resident's care plan and wishes and check in residents needing assistance. Meet with residents/family as necessary and report concerns. Admit, transfer, and discharge residents as necessary and assist in arranging transportation for discharge. Escort discharged residents to pickup area; inform families of resident death when applicable and coordinate post-mortem procedures. Staff Development Participate in developing, planning, conducting, and scheduling in-service training classes to educate the nursing service department. Implement and maintain an effective orientation program for new employees on your shift. Assist in standardizing methods to accomplish work and identify tasks with exposure to blood/body fluids. Assist in planning clinical supervision for nurse aide trainees and participate in outside training programs. Attend and participate in facility in-service training programs (e.g., OSHA, HIPAA, Safety, Infection Control, etc.). Attend and participate in continuing education to maintain license and stay updated. Safety and Sanitation Monitor safety practices in use of equipment and supplies; ensure dress codes and policies are followed. Assist in infection control activities and isolation precautions as needed. Ensure PPE availability and proper disposal of hazardous materials. Maintain clean and sanitary work and resident care areas; enforce hand hygiene and safety drills. Contribute to reporting hazardous conditions and safety improvements. Equipment and Supply Functions Recommend equipment and supply needs to the Nurse Supervisor. Maintain adequate stock of medications, supplies, and equipment; ensure safe operation of equipment. Ensure trained personnel operate equipment; monitor for waste and ensure MSDS documentation is on file for hazardous chemicals. Care Plan and Assessment Functions Review care plans daily and inform the Nurse Supervisor of changes. Ensure CNAs are aware of and refer to the resident care plan prior to daily care. Assist in planning, scheduling, and revising the MDS and RAPs/Triggers as needed. Budget and Planning Functions Report suspected or known incidence of fraud related to false billings, cost reports, or kickbacks. Miscellaneous Provide data to the Quality Assurance & Assessment Committee as requested. Supervisory Requirements As LPN / LVN you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Qualifications Education and/or Experience Must possess, as a minimum, a Nursing Degree from an accredited college or university, or be a graduate of an approved LPN/LVN program. Must possess a current, unencumbered, active license to practice as an LPN/LVN in this state. Language Skills Must be able to read, write, speak, and understand the English language. Ability to read technical procedures and policy manuals; ability to present information to managers and employees. Must be able to relate information concerning a resident's condition. Mathematical Skills Ability to apply fractions, percentages, ratios and proportions to practical situations. Reasoning Ability Must demonstrate knowledge to provide care appropriate to age-related needs; be a team player; ability to make independent decisions when warranted. Certificates, Licenses, Registrations Must possess a current, unencumbered, active license to practice as an LPN/LVN in this state. Current CPR certification. Knowledge and experience with PCC preferred. Must maintain all required continuing education/licensing and remain in good standing with the State Board of Nursing. Physical Demands Must be able to move intermittently; speak and write English; cope with mental and emotional stress. Must be able to see/hear or use applicable prosthetics; lift at least 25 pounds to 5 feet, with movement up to 50 feet. May be necessary to assist in evacuation during emergencies. Work Environment Typical office and nursing service areas with potential exposure to hostile or emotionally upset individuals; may require extended hours and call-backs during emergencies. Exposure to infectious waste and chemicals; infection control procedures apply. Additional Information Note: Nothing in this job specification restricts management's right to assign or reassign duties and responsibilities to this job at any time. Critical features may change at any time due to reasonable accommodation or other reasons. This description is not a complete list of all responsibilities, duties, and skills required. #J-18808-Ljbffr