Registered Nurse (RN)

Highlights

Job Description

The purpose of this position is to render professional nursing care to residents; to follow facility policies and procedures to implement treatment orders; to assess resident treatment needs and take appropriate action; to maintain residents’ medical records; and to participate in supervision of care provided to residents. Essential Functions: Attend work as scheduled and follow company’s call-off procedures Follow established standards of nursing practices in accordance with National Standards of Practice and the State Practice Act to implement facility policies and procedures. Obtain report from nurse being relieved and record sufficient information to implement appropriate follow-up action as necessary relating to the residents’ treatment needs. Obtain report from nurse being relieved and record sufficient information related to medication administration to implement accurate changes to medication orders. Conduct resident rounds as assigned and report problems to the Nursing Supervisor or Director of Nursing Service, and take necessary follow-up action. Administer medications to residents in an accurate, timely manner. Monitor residents for effectiveness of drug therapy and occurrence of adverse effects. Document resident care related to medication administration, related monitoring, effectiveness of drug therapy and occurrence of adverse effects. Notify physician, when necessary, of changes in residents’ conditions, weight, medication errors, medication not available, abnormal laboratory/X-ray results and any other unusual observations. Document physician notification and follow up action(s) per facility policy. Complete all documentation related to the resident’s medication administration. Follow comprehensive care plans related to medication administration based on each resident’s needs and his/her comprehensive assessment as assigned. Identify safety hazards and initiate corrective action. Assume responsibility for compliance with federal, State and local regulations within the assigned unit. Verify accuracy of narcotic count, check emergency kit and exchange keys. Order, receive and store medications accurately and appropriately. Identify special nursing problems and emergency situations quickly and initiate immediate “life-saving” measures in the absence of a physician. Participate in facility educational programs including, but not limited to, orientation, in-service and nursing education. Provide clinical supervision to nurses and CNAs. Monitor for completion of assigned duties. Attend staff meetings as required. Attend all scheduled inservices as assigned. Instruct nursing assistants in proper, preventative safety measures and use of adaptive equipment to meet residents’ needs. Use and supervise the use of equipment and supplies efficiently and in a cost-effective manner. Compile information for facility committees as instructed. Administer treatments according to the physician’s order and accurately record treatments administered and weekly progress notes. Be responsible for the safety of residents under his/her supervision. Document resident care provided and resident’s response or lack of response to treatment provided. Assess and report changes in resident’s condition including development of decubitus to physician, Charge Nurse, Nursing Supervisor, Director of Nursing Service and take follow-up action as necessary. Assess each resident’s skin condition weekly, and as necessary, including stage, size (measurements), sites, depth, color, drainage and odor of each condition. Assist with admission/transfer and discharge of residents as necessary and as assigned by the Director of Nursing Service. Complete admission/transfer and discharge documentation. Perform basic nursing skills. Obtain physicians’ orders and any revisions for treatments as necessary. Assess resident needs and initiate development of individualized care plans. Review and update resident care plans as necessary and as assigned. Provide direct resident care, in addition to treatment, as necessary. Give daily instruction to Nursing Assistants regarding care related to treatment. Assume Quality Assurance duties as assigned. Provide Charge Nurse coming on duty with concise, accurate report. Consistently work cooperatively with residents, nursing personnel, physicians, families, consultant personnel, community agencies and ancillary personnel. Keep the resident and family informed about nursing care provided. Listen to resident, family or physician complaints and initiate corrective action and report special problems to his/her supervisor. Render immediate assistance to any resident in need. Follow facility Residents’ Rights policies. Comply with facility policies and procedures against discrimination and sexual harassment. Protect the privacy of resident Protected Health Information. Protect the confidentiality and security of all resident and facility information.