DESCRIPTION:
Position Purpose: 7 pm to 7 am
To provide the highest quality of care for residents. Working with doctors, obtaining and administering medications and treatments, maintaining accurate records of treatment and supervising CNA’s.
Essential Functions of Position:
- Supervise functions of nursing unit
- Coordinate effective use of personnel, supplies, equipment and facilities; obtain medications and medical records to provide safe, efficient and therapeutic care to residents
- Contact physicians as necessary and ensure physician interventions are timely and appropriate; ensure appropriate documentation of resident care
- Responsible during the shift for the total nursing care of residents in the assigned unit.
- Assumes responsibility for compliance with Federal, State, Local, and company regulations.
- Explains procedures and treatments and care plan to residents.
- Transcribes physician’s orders to resident charts and care plans as required.
- Charts progress notes in an informative, factual manner that reflects the care administered as well as the resident’s response to care.
- Receives*/gives report from*/to nurse he*/she is relieving/*coming on and records sufficient information and implements appropriate follow-up action as necessary
- Follows established procedures for charting and reporting all reports of incident/accidents for residents
- Conducts frequent rounds to evaluate effectiveness of care delivery. Maintains awareness of comfort and safety need resident.
- Prepares equipment and aids Physician during treatment and examination of resident.
- Observes resident, records significant conditions and reactions, and notifies supervisor or Physician of resident’s condition and reaction to drugs, treatments, and significant incidents.
- Takes temperature, pulse, blood pressure, and other vital signs to detect deviations from normal and assess condition of resident.
- Responds to emergency situations based upon nursing standards, policies, procedures, and protocol.
- Assists in completion of the care plans *(*acute and long term) and is involved in the care conference as deemed necessary.
- Participates, reports to DON/Administrator and conducts (as appropriate) investigations related to any alleged abuse.
- Ensures that the progress notes are reflective of the care plan and that the approaches on the care plan are being followed.
- Assures that team is aware of the resident care plan, and ensure personnel refer to the care plan prior to administering care.
- Problem solving
- Responsible for all other RN duties as required.
- Perform additional duties as assigned.
EDUCATION / REQUIREMENTS:
Current State Registered Nurse license with a minimum of 2 years related experience; or equivalent combination of education and experience. Good standing in the state registry is required.