Position Description:

A licensed professional nurse under the supervision of a Registered Nurse who provides nursing care and services to residents in a long-term care setting.

General Duties and Responsibilities:

GENERAL

1. Provides nursing care as prescribed by the physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures
2. Administers professional services and provides care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being. Provides clinical data and observations to contribute to the nursing plan of care

CLINICAL

1. Admits, transfers, and discharges residents in accordance with policy and procedure.
2. Orient new residents/families as necessary.
3. Gives/receives nursing reports upon beginning and ending of assigned shift. Reviews daily patient report and assignments with Nursing Assistants upon the beginning of an assigned shift.
4. Assures that the unit area is maintained in a clean and safe manner for resident comfort and convenience.
5. Conducts daily resident rounds to observe the resident's physical and emotional status.
6. Collects clinical data and reports significant clinical findings according to policy.
7. Performs manual and technical skills according to the scope of practice under the direction of a Registered Nurse.
8. Records care information accurately, in a timely manner, and concisely. Completes all required documentation, including resident observations, interventions, and patient response(s) in the medical record in accordance with policy.
9. Assists in developing, reviewing, revising, and updating resident Plans of Care as indicated.
10. Contributes to the evaluation of the patient's progress towards specific goals and the adjustment of the nursing plan of care as necessary.
11. Receives and transcribes orders accurately from attending/alternate physician.
12. Assists in making rounds with the attending physician, as necessary.
13. Prepares/administers medications as ordered by the physician and within the legal scope of practice.
14. Completes medical treatments as indicated and ordered by the physician.
15. Evaluates response and reports adverse reactions to medication or treatments in accordance with the policy.
16. Ensures that narcotic and controlled drugs are secure, inventory counts are accurate, and narcotic register documentation is timely and accurate
17. Orders prescribed medications, supplies, and equipment as established by the facility's policies and procedures.
18. Requests and arranges for diagnostic and therapeutic services as ordered by the physician.
19. Notifies the attending/alternate physician, as well as the resident's legal guardian/representative, when the resident becomes critically ill, injured, etc., or has a significant change in condition as outlined within established policies.
20. Notifies the attending/alternate physician of resident incidents/unusual occurrences. Completes Accident/Incident Report forms as indicated and documents relevant information in the resident's medical record as outlined in established policies and procedures. Initiate investigation of accidents and unusual occurrences.
21. Informs RN Supervisor or RN in charge of the facility of significant changes in resident condition, unusual occurrences, incidents, or accidents as indicated and per facility policy and procedure.
22. Attend various facility meetings (care conferences, stand-up meetings, staff meetings, Medicare meetings, discharge plan meetings, etc.) as required.
23. Reports allegations of abuse or unusual occurrences per State and Federal Regulations and facility policy. Assists with gathering information relevant to the event.
24. Initiates emergency procedures (including basic CPR) and provides emergency patient treatments.
25. Participates in the facility's infection control program for monitoring communicable and/or infectious disease among residents and staff.
26. Participates in procedures for reporting hazardous conditions or equipment.
27. Assists in the orientation of newly assigned personnel as requested.
28. Assumes Charge responsibility following the orientation period as requested.
29. Performs other position-related duties as assigned.
30. Supervise CNAs

SUPERVISION

1. Make resident rounds to ensure appropriate care is being rendered, identifying and making corrections as necessary.
2. Meet with nursing personnel to assist in identifying and correcting problem areas and/or the improvement of resident care.
3. Assist the Charge Nurse in revision and distribution of nursing assignments as needed.
4. Assist in the supervision and direction of nursing personnel.
5. Participate in disciplinary action and evaluation of nursing personnel.

ADDITIONAL DUTIES

1. Participate in the facility's quality assurance (QA) program as requested or needed. Assist in correcting findings and deficiencies from the Department of Health Services, Consultants, and the Quality Assurance Team as directed by the Director of Nursing
2. Ensures the protection of health information as required by the Health Insurance Portability and Accountability Act (HIPAA).
3. Participates in the facility's Infection Control Program for monitoring communicable and/or infectious disease among residents and staff.
4. Participate in procedures for reporting hazardous conditions or equipment.
5. Orient new staff members upon request.
6. Attend various facility meetings (care conferences, stand-up meetings, staff meetings, Medicare meetings, discharge plan meetings, etc.) as required.
7. Attends in-services and educational classes to maintain nursing skills competency and current knowledge of the standard of care and effective practices.
8. Assumes Charge responsibility following the orientation period as requested.
9. Performs other position-related duties as assigned.

Qualifications:

• Graduate of an accredited school of nursing or an approved LVN program
• Current nursing licensure in good standing with the State licensing board
• Strong communication and organizational skills
• Ability to provide quality patient care under applicable standards, policies, and procedures
• Ability to identify and report problems, use initiative, and good judgment to reach quality decisions
• Comprehensive knowledge of applicable nursing principles and practices to ensure quality of care standards for residents are met
• Possess the willingness to work with professional and non-professional personnel. Proficiency in the English language, including the ability to speak, read, write, and comprehend the language with minimal to no difficulty
• Valid BLS certification