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Job Summary: The Charge Nurse’s primary function is to assess residents’ health problems and needs, develop and implement nursing care plans, and maintain medical records. In addition, this position provides clinical supervision to Nursing Assistants (CNA and CMA) who provide direct resident care.
Essential Functions / Duties:
- Conduct resident rounds daily; report problems to the ADON and initiate corrective action; obtain a report at the start of shift from the nurse being relieved and on that report record sufficient information to implement appropriate follow‑up action as necessary; provide a report at the end of each shift to the nurse coming on duty, including sufficient information for follow‑up action if necessary.
- Count narcotics, check emergency kit, and exchange keys.
- Order medications as necessary; administer PRN medications and treatments as necessary; receive medication delivery from pharmacy and check all drugs received and document proof of medications received.
- Document weekly progress notes; update resident care plan when doing weekly progress notes; document daily skilled notes as necessary
- Supervise nursing assistants providing direct resident care; counsel nursing assistants and recommend disciplinary action, when necessary, to the ADON; Participate in the employee evaluation process by providing information on the clinical performance of nursing assistants to the ADON.
- Prepare nursing assistants' assignments and explain all pertinent resident care.
- Supervise the application and removal of all postural supports and restraints.
- Supervise distribution of nourishments.
- Follow staffing guidelines and make nursing assignments according to qualifications of staff and characteristics of the resident population.
- Change linens on all residents as necessary.
- Turn residents as necessary.
- Prepare, administer, and document medications and treatments per the physician's order and accurately record all care provided.
- Perform comprehensive assessment of each resident; document comprehensive assessment of each resident; document resident care provided and resident's response or lack of response to care provided; report changes in residents' conditions to a physician, ADON, and responsible party promptly and to take follow‑up action as necessary.
- Follow facility admission, discharge or transfer procedures and communicate resident admission, discharge or transfer to other departments, physicians, and ancillary service providers.
- Participate in facility education programs and coordinate student activities with the ADON.
- Attend staff meetings, in‑service classes, and committee meetings as assigned; complete report for facility committees.
- Participate in resident care conferences as assigned.
- Supervise response to resident's call for assistance.
- Responsible for the safety of residents under his/her supervision.
- Listen to resident, family, or physician concerns and initiate corrective action and/or report concerns to ADON.
- Develop an accurate comprehensive care plan based on each resident's comprehensive assessment; review and revise resident care plans as necessary and as required by regulations; review and revise resident care plan when documenting weekly and daily notes.
- Identify special nursing problems and emergency situations quickly; initiate immediate “life-saving” measures in the absence of a physician.
- Must be able to work any shift as directed by the ADON.
- Comply with federal, state, and company policies, procedures, and regulations.
- Operate computers programmed with software needed to record, store, and analyze resident information; operate copy/fax/printer machines to send documents and produce documents.
- Perform other related duties as directed by the Administrator.
Shift Specific Duties:
- Check breakfast and noon meal trays to ensure proper diet is served and residents are assisted as necessary; supervise the passing of afternoon nourishments.
o Check dinner trays to ensure proper diet is served and residents are assisted as necessary; supervise the passing of evening nourishments.