Essential Job Functions Duties and Responsibilities
Plan, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long term care facility.
Develop, maintain, update and communicate and enforce facility and state specific written policies and procedures that govern the daily functions of the nursing service department including the safety program.
Maintain a current reference of written nursing material that will assist the nursing service department in meeting the day to day needs of the resident.
Communicate service schedules with other services to ensure the continuity of the resident’s total regimen of care.
Develop, implement and maintain an ongoing Continuous Quality Improvement and Quality Assurance program for the nursing services department.
Recommend to the Executive Director the equipment needs of the department.
Participate with the Executive Director to prepare and plan the department’s budget.
Nursing Care Functions
Conduct the daily nursing functions 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 including the safety program.
Admit, transfer, and discharge residents with documentation regarding care and service provided.
Participate in the orientation of new residents/family members to the facility.
Make rounds with health care provider.
Utilize nursing personnel qualifications according to the resident’s care plan, wishes, and health care provider orders.
Complete daily clinical and environmental rounds to evaluate resident care being provided and report significant events.
Meet and resolve issues with residents and/or family members. Report significant issues to the supervisor.
Participate in facility surveys (inspections) as requested by management.
May be responsible for clinical programs as directed, e.g. dementia, wound care, quality assurance, infection control, admissions.
Complete an initial assessment and develop interim care plan.
Update, review, and transcribe the care plan that identifies the goals, problems, approaches, and revisions based on nursing needs and new health care provider orders.
Communicate with health care provider to review treatment plans, complete orders, progress notes, etc., in accordance with established policies.
Review the resident’s medical record for specific treatments, medication orders, diets, labs etc., as for implementation and follow up.
Requisition and arrange for diagnostic and therapeutic services, as ordered by the health care provider, and in accordance with our established procedures.
Communicate the department’s policies and procedures to personnel, residents, and visitors.
Communicate with written (24 hour report) and oral reports/recommendations concerning any changes in resident condition and other activities of your shift to nursing management.
Fill out and complete accident/incidents involving residents or staff and submit to Director of Nursing.
Complete and file assessments and all other medical record documentation as required to provide care services.
Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the supervisor.
Complete clinically accurate documentation according to policy.
Review the resident medical documentation and progress notes from the interdisciplinary team to determine if the care plan is being followed. Report any concerns to your supervisor.
Inform nursing personnel of new admissions and the resident’s care needs. Ensure that rooms are ready for new admissions. Greet newly admitted residents upon admission.
Notify the resident’s attending health care practitioner and family when there is a change in the resident’s condition.
Meet with your assigned support personnel (Housekeeping, Dining Services, Nursing Assistants, etc.) to plan the shift’s services, programs, and activities and monitor tasks are completed as directed.
Coordinate services with other members of the disciplinary team (Housekeeping, Dining Services, Nursing, etc.) to ensure that the resident’s total regimen of care is maintained.
Assist in arranging transportation for residents and other third party services.
Medication Administration Functions
Prepare and administer medications ordered by the health care provider.
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 supervisor.
Review medication administration record for completeness of information, accuracy in the transcription of the health care provider’s order. Report concerns to your supervisor.
Dispose of drugs and narcotics as required, and in accordance with established procedures.
Determine and adjust the staffing needs of the department necessary to meet the total nursing needs of the residents.
Assist in the recruitment and selection of personnel.
Develop work assignments, schedule duty hours, and assist and supervise staff to ensure that all personnel are performing their work assignments in accordance with acceptable standards.
Assist in staff development. Formally and informally monitor performance of personnel and ensure adjustments/corrections are made by using coaching, counseling, and discipline methods.
Work with the Executive Director to resolve staff performance issues including those that may lead to termination.
Complete timely performance evaluations.
Review complaints and grievances, complete investigations, and work with the Executive Director for a plan of action and resolution..
Participate in developing, conducting, and scheduling of timely in-service and orientation training classes that meet state and federal requirements.
Safety and Sanitation
Supply and make available protective equipment for staff.
Maintain nursing service work areas (i.e., nurses’ stations, medicine preparation rooms, etc.), resident rooms, and treatment areas in a clean and sanitary manner.
Recommend to the Director of Nursing the equipment and supply needs of the nursing department. Ensure that a stock level of medications, medical supplies, equipment, etc., is maintained on the premise at all times to adequately meet the needs of the residents.
Obtain and maintain material safety data sheets (MSDSs) for hazardous chemicals in the department. Ensure that containers of hazardous chemicals in the department are properly labeled and stored. Ensure that all personnel are trained to use labels and MSDSs to recognize hazards and to follow appropriate protective measures.
Required Knowledge, Skills and Abilities
Must possess the ability to make independent decisions, follow instructions, and accept constructive criticism.
Must be able to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
Must be able to work with ill, disabled, and elderly people within the facility.
Must be able to speak, write and understand English in a manner that is sufficient for effective communication with supervisors, employees, residents, and families.
Education and Experience
Must have, as a minimum, 1 year of experience in nursing.
Prefer two years experience in a long-term care facility.
Must have experience in supervision and principles, practice of teaching, etc.
Must possess skills in leadership and communication.
Must possess creativity, integrity, and initiative.
Must be able to provide critical thinking skills to address clinical issues.
Must possess a current, unencumbered, active license to practice as an RN in this state.
All employees are expected to create an atmosphere of warmth, personal interest and positive emphasis as well as a calm environment. This community is committed to providing courteous, responsive, quality service to our residents by fostering a respectful, positive, and welcoming environment for all. Developing and maintaining a good working rapport with all staff is critical to the functioning of the facility.