Departmental:

• Carry out direct care to residents based on the care plan, nursing procedures, facility policy and nursing standards of practice.

• Observes the resident for change in physical, social or mental status and documents signs and symptoms and status of residents and related matters through written/oral reports to RN/RN Manager/ Supervisor/ Designee/ Medical Staff and Family as indicated.

• Participates in admission, transfer and discharge including resident teaching as directed and documents same. Communications response to teaching to RN/ RN Manager/ Supervisor/ Designee.

• Administers clinical services such as medication treatments, diabetic testing, nutritional needs and vital signs according to facility policies and procedures and nursing standards of practice.

• Administers medications and/or treatments as prescribed by the Medical Staff. Observe for side effects.

• Counts controlled substances ensuring that records and counts are correct at all times and checks medication records, treatment records, and order sheets on residents to ascertain that orders written have been picked up and telephone orders have been countersigned and dated.

• Participate in the development and review of resident care plans for appropriate resident goals, problems, strengths, approaches, and revisions based on nursing needs.

• Assist and oversee distribution of food trays.

• Care of the dying resident, including care of the body and personal effects after death.

• Participates in and carries out job functions in the Nursing Department’s Program and activities as directed, in accordance with current Federal, State and Local guidelines and regulations, accepted standards of practice and as may be directed by Registered Nurse and/or VP of Nursing, or their designee.

• Receive and review complaints and grievances may be directed by Registered Nurse and/or VP of Nursing, or their designee.

• Receive and review complaints and grievances made by the resident and reports to the supervisor/ RN Manager/ Designee immediately.

• Inform the supervisor of staffing needs when assigned personnel fail to report to work.

• Attends comprehensive care plan meetings as applicable.

• Maintain the confidentiality of all residents’ information as per HIPAA guidelines.

• Review order sheets, medication/treatment records and resident care records for accuracy and completeness.

• Reviews medication administration records and treatment administration records prior to use. Corrects computer errors and/or adds new orders.

• Give/receive the report at the start and end of shift.

• Performs documentation duties such as completing medical forms, reports, evaluations, charting, etc. as necessary.

• Picks up and transcribes physician orders and ensures that all orders are implemented on a timely basis.

• Notifies the nursing office, informs next of kin, prepares transfer form and makes appropriate entries in progress notes and on condition report for residents who require hospitalization.

• Participates in regularly scheduled unit staff meetings for problem solving and information exchange.

• Ensure that nursing station is current, including, but not limited to reference materials and supplies.

• Ensure prompt customer service including, but not limited to answer resident calls promptly, address resident concerns, and seek assistance when necessary.

• Meet with residents, and/or family members, as necessary. Report problem areas to RN/RN Manager/ Supervisor/Designee.

• Maintenance of personal belongings such as clothing, dentures, eyeglasses, hearing aids and prostheses.

• Makes rounds of the nursing unit including medication and treatment areas, storage area, etc. daily to ensure that they are maintained in a clean and safe manner, and supplies are maintained at determined pars.

• Identifies educational needs of Nursing Staff and provides individual, group and unit education/in-service while overseeing Nursing Department personnel in assigned areas.

• Keeps Administration/Nursing Administration advised of potential/actual safety hazards.

• Performs other duties as assigned.