A clinically competent, registered, professional nurse who assumes responsibility and accountability for a group of patients/residents through the nursing process of assessment, planning, intervention, implementation and evaluation. Effectively interacts with patients/residents, family members, responsible party and other health team members, while maintaining standards of professional nursing. The RN plans, supervises and evaluates care of each patient/resident. The RN ensures that the status of the patient/resident condition is effectively communicated to the physician.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Assessment: Performs assessments on patients/residents and reassessments as per policy.
- Planning/Implementation/Evaluation: Develops and implements appropriate plan of care based on assessment and diagnosis tailored to meet each individual’s needs (physical, cultural and psychosocial), evaluates plan of care and makes necessary changes, works to meet individual patient/resident needs.
- Medication Administration: Demonstrates knowledge of medications and their correct administration based on age of the patient/resident and their clinical condition. Evaluates patient/resident responses to medications.
- Patient/Resident/Family Education: Plans for and provides patient/resident, family and caregiver education, identifies learning needs, clearly communicates information and documents patient/resident response to education.
- Documentation: Documents according to current standards and policies.
- Discharge Planning: Plans for patient/resident discharge, anticipates and plans for long-term and/or short-term patient/resident needs, collaborates with the discharge planner when appropriate and assesses the patient/resident prior to discharge.
- Delegation/Collaboration: Delegates and collaborates in providing patient/resident care according to licensure and skill levels, follows up to ensure success
- Assures resident safety by identifying safety hazards and emergency situations and initiates corrective action as appropriate.
- Other duties as assigned
- Interprets existing policies and procedures to certified nursing assistants, certified medication aides, residents, and families.
- Supervises staff, evaluates the provision of direct resident care, and initiates corrective action as necessary.
- Follows staffing guidelines and make nursing assignments according to qualifications of staff and characteristics of the resident population
- Participates in the employee evaluation process by providing information on the clinical performance of certified nurse assistants and certified medication aides to the DON or DCS.
- Monitors staff compliance with infection control, personal protection equipment, blood borne pathogens, hazardous material handling and fire safety.
- Ensures HIPAA compliance with resident and employee information.