Registered Nurse

Job Description

• Assess each resident; collect and document the resident’s current health status and medical history. Complete and/or review the Admission Data Record. Make accurate and ongoing assessments of the resident’s status and respond appropriately.
• Plan/Implement: Set priorities for nursing action in a logical sequence according to the resident’s needs and formulate a plan of care by the appropriate selection of Nurse Practice Standards. The Plan of Care is initiated on resident admission based on all aspects of the initial assessment. Plan includes physiological, psychosocial, and environmental factors.
• Evaluate: Perform ongoing assessments and revise plan of care based on new data and resident’s condition. .
• Documentation: Document accurate and ongoing assessments of resident status. Document resident care which reflects nursing intervention, resident response to care provided, resident needs, problems, capabilities, limitations and progress toward goals.
• Communicate with physicians regarding resident needs, the nursing assessments, and recommendations as needed. Collaborate with other nurses and nursing department staff to ensure the resident’s well being.
• Perform direct patient care utilizing established procedures, policies and standards.
• Administer medications, IV’s, treatments and procedures in accordance with physician’s orders.
• Observe and document resident’s response to medications and treatments.
• Ensure proper disposal of all drugs and medications.
• Ensure adequate levels of medication, supplies and equipment is available at all time. Report needs to the Director of Nursing.
• Handle emergency situations in a prompt, precise and professional manner.
• Maintain the comfort, privacy, and dignity of each resident in the delivery of services.
• Interact with residents in a manner that displays warmth and promotes a caring environment.
• Comprehensive understanding and adherence to all aspects of residents’ rights, including the right to be free of restraints and free of abuse.
• Promptly report to the charge nurse or administrative staff all incidents or evidence of resident abuse or violation of residents’ rights.
• Assure residents have call lights at hand and answer resident’s call lights promptly and courteously.
• Assist with orienting residents and their families to the nursing facility upon admission.
• Receive the nursing report upon reporting for duty each shift. Give the nursing report to relief personnel before departing at the end of each shift.
• Observe and report the presence of pressure areas and skin breakdown to the Charge Nurse.
• Promptly report injuries of an unknown source, including skin tears to the Charge Nurse.
• Communicate and interact effectively, courteously, and tactfully with residents, visitors, family members, peers, and supervisors.
• Thoroughly wash hands before and after performing any service for the resident.
• Make rounds frequently and check each resident routinely to ensure his/her nursing care needs are being met.
• Respond to inquiries or requests from residents and family members in a prompt and courteous manner.
• Promote positive public relations with residents, family members and guests.
• Maintain the confidentiality of all resident care information.Develop and implement nursing care plans and assessments.

• Inform the Charge Nurse of any changes in the resident’s conditions so that appropriate changes (if necessary) can be made to the care plan.
• Ensure all nursing notes convey specific care provided and the resident’s response or lack of response to the care provided.
• Perform all nursing services in accordance with the individualized care plan.
• Honor the resident’s refusal of treatment request. Document and promptly report such requests to the Charge Nurse.
• Assist in developing preliminary and comprehensive assessments of the nursing needs of each resident.
• Assist in developing a written plan of care that identifies the nursing needs of the resident and the goals to be accomplished for each nursing need identified.
• Ensure that all nursing personnel are aware of the care plans and that care plans are used in providing daily nursing services to the residents.
• Review nurses notes and monitor residents to ensure the care plans are being followed and that residents’ needs are being met.
• Review and revise care plans and assessments as necessary.

• Practice careful, efficient, and no-waste use of supplies and linens in accordance with established policies and procedures.
• Perform all job responsibilities in accordance with prescribed safety and infection control procedures including thorough hand washing, use of disposable gloves where indicated, and proper disposal of soiled materials.
• Actively participate in fire, safety and disaster preparedness drills
• Maintain safe working conditions and practices and follow established safety regulations in the use of equipment and supplies.Timely and accurately record nursing notes in an informative and description manner.

• Record all entries on notes, charts, etc. in an informative and descriptive manner.
• Use only authorized abbreviations established by the facility when recording information.
• Properly document all care, responses to care, vitals, changes in condition, etc. in accordance with established policies and procedures.Perform “Charge Nurse” duties as assigned.

• Assess residents and analyze information to develop appropriate interventions to prevent decline. Record signs of change in condition.
• Notify appropriate staff per facility protocol to evaluate weight loss, decline in ambulation, development of skin breakdown, etc.
• Observe conditions which indicate possible need for restorative nursing programs and notify appropriate staff of the need for evaluation.
• Inform the physician of changes in assessment as appropriate.
• Administer medications and treatments to residents. Place orders for medication.
• Respond to emergencies; assess the condition of the resident; decide on type of medical attention; call appropriate ambulance service if needed.
• Admit, transfer, or discharge residents as necessary.
• Notify family when resident is transferred or admitted to the hospital.
• Maintain resident clinical files; keep charts updated; document appropriately.
• Documentation requirements include, but are not limited to, the following: Changes in medical and physical condition; Responses to antibiotic therapy; Report of weight loss/gain and response to change; Complete, accurate, and timely physician’s information; Changes in specialized diets; and Report of pressure ulcer condition and response to treatment. * Maintain current knowledge of patient conditions/information through the maintenance of accurate lists. The list must be shift specific. This knowledge includes, but is not limited to: Resident skin conditions; Diet and supplements; Special equipment needs; continence and protection used; Weight gain/loss; Side rail use and reason for use; Residents at high risk for skin breakdown requiring more frequent positioning.
• Maintain accountability for controlled substances; Inventory medications at the beginning and end of each shift; notify Director of Nursing of discrepancies.
• Communicate status of residents to incoming personnel according to established procedures.
• Shift report to the certified nursing assistants must include, but are not limited to, the following: Changes in resident condition; Report of new admissions; Residents scheduled for appointments and rehabilitation; Assigned baths and restorative instructions; Changes in specialized diets; Individualized patient instruction. Give special attention to CNA’s who are new to their assignments. * Transcribe, clarify and implement physician’s orders.
• Supervise the certified nursing assistants and determine work procedures, prepare work schedules, expedite workflow, evaluate, and counsel as appropriate.
• Insure that certified nursing assistants and other supervised personnel adhere to standard job requirements.
• Review the missing treatments report prior to the end of each shift. Take appropriate corrective action to ensure missing treatments are given and documented; and that any treatments not given are properly documented including reason.
• Review punch detail reports for department staff. Promptly research and submit missed punch forms, PTO requests, etc. as needed to correct daily punches. Sign all punch detail reports, missed punch forms, and PTO requests to authorize payment.
• Monitor department staff to ensure they are following established safety and infection control policies and procedures.
• Monitor department staff’s adherence to Employee Handbook policies and procedures. Provide appropriate counseling and discipline as needed.