This position provides skilled professional nursing care and treatment for patients of the Edward J. Healey Rehabilitation and Nursing Center including long term care residents, rehabilitation residents, complex care residents and terminally ill persons. This position is part of the managed care team and works collaboratively with ancillary personnel in the provision of proper medical services and treatment. This position assists persons in achieving highest physical, mental, and psychosocial level of functioning. Employees in this position perform duties in accordance with established regulations, policies, nursing standards, and medical instructions.Responsibilities
Assesses residents and identify and document residents’ problems, symptoms, or behavioral changes.
Implements and provides care in accordance with the assessed resident care needs and medical condition.
Completes assessments and documentation of new admissions/transfers and discharges including the interim plan of care.
Obtains and transcribes physician orders for new admissions or any required orders from changes in conditions. Ensure orders are received in accordance with facility policy and format.
Ensures that orders are transcribed and carried out as ordered and all related procedures are followed for each order including labs, radiography, outside appointments.
Orders medications from pharmacy and in-house supply to ensure that residents receive medications at the correct time.
Reviews clinical reports (such as lab and radiography) and reports variances to the physician or A.R.N.P. and document same.
Assigns various aspects of resident care to selective personnel, as commensurate with the authority of an RN and the scope of practice of the personnel.
Supervises and evaluates all direct resident care provided and initiate appropriate action as needed.
Reports any employee performance which is not in accordance with facility standards to the Nurse Manager.
Provides supervision of residents during meal time and assist with feeding as needed.
Encourages residents to participate in activities and ensure residents are taken to selected activities
Administers medications and therapeutic treatments (dressings, respiratory treatments, tracheotomy care, G.U. care) to residents according to established resident care plans and documents accurately and in accordance with facility policy and standards of practice.
Provides assistance to residents in need of personal care (e.g., bathing, dressing, transporting, feeding).
Ensures call lights are answered in a timely manner and answer call lights as needed.
Performs considerable administrative support work in documenting, reviewing, and maintaining records, files, charts, forms, and reports.
Completes and charts vital signs, (TPR, blood pressure, pain), food and liquid intake, and related data.
Provides complex nursing care of patients/residents in accordance with physician orders.
Ensures safety of patients during administering of all medical and therapeutic procedures.
Notifies attending physician/A.R.N.P. of changes in resident conditions.
Notifies family/HC surrogate of changes in condition in accordance with OBRA regulations.
Completes reports for any resident with an unusual occurrence and conduct the assessment and notifications necessary. Monitors any resident with an incident for 72 hours post incident.
Accompanies physician on routine rounds.
Conducts walking rounds at the start and end of each shift visually checking each resident and provide a written end-of-shift report.
Maintains security of controlled drugs. Counts the controlled drugs at the start of the shift to ensure an accurate count at the start of the shift. Records all medications administered at the time of administration on the ‘count sheets’. Reconciles the count with the oncoming nurse at the end of the shift. Turns keys to the oncoming shift after the count is completed and signed as accurate.
Acts as a perception when assigned and assist with the clinical orientation of new nursing staff.
Assists with C.N.A.s, L.P.N.s performance evaluations as assigned.
Ensures the proper functioning of emergency equipment including checks of the emergency cart and document the outcome.
Participates in care planning and conferences for resident care.
Maintain all equipment in accordance with facility and infection control policies and manufacturer instructions. Document as required.
Conducts emergency care as needed.
Emergency duty may be required of the incumbent that includes working in Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.