Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.
Administrative Functions
Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
Periodically review the department's policies, procedure manuals, job descriptions, etc.
Make recommendations for revisions.
Meet with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs, and activities.
Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this facility.
Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual.
Make written and oral reports/recommendations concerning the activities of your shift as required.
Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained.
Ensure that all nursing service personnel are in compliance with their respective job descriptions.
Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing service department.
Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
Periodically review the resident's written discharge plan.
Participate in the updating of the resident's written discharge plan as required.
Assist in planning the nursing services portion of the resident's discharge plan as necessary.
Interpret the department's policies and procedures to personnel, residents, visitors, and government agencies as required.
Admit, transfer, and discharge residents as required.
Complete accident/incident reports as necessary.
Write resident charge slips and forward to the Business Office.
Maintain the Daily Census Report and submit to the Business Office as required.
Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
Report any known or suspected unauthorized attempt to access the facility's information system.
Charting and Documentation
Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge.
Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
Receive telephone orders from physicians and record them on the Physicians' Order Form.
Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans, as required.
Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident and the resident's response.
Fill out and complete accident/incident reports and submit them to the Director as required.
Chart all reports of accidents/incidents involving residents.
Record new/changed diet orders and forward the information to the Food Services Department.
Report discrepancies noted concerning physician's orders, diet changes, charting errors, etc., to the Nurse Supervisor.
Complete transfer forms in accordance with established procedures.
Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident's medical record.
Perform routine charting duties as required and in accordance with policies and procedures.
Sign and date all entries made in the resident's medical record.
Drug Administration Functions
Prepare and administer medications as ordered by the physician.
Verify the identity of the resident before administering the medication/treatment.
Ensure that prescribed medication for one resident is not administered to another.
Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand.
Report needs to the Nurse Supervisor.
Order prescribed medications, supplies, and equipment as necessary.
Ensure that narcotic records are accurate for your shift.
Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
Review medication cards for completeness and accuracy.
Notify the attending physician of automatic stop orders prior to the last dosage.
Dispose of drugs and narcotics as required.
Personnel Functions
Participate in employee performance evaluations.
Determine shift staffing requirements.
Make recommendations to the Nurse Supervisor concerning employee dismissals, transfers, etc.
Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work.
Report absentee call-ins to the Nurse Supervisor.
Review and evaluate your department's workforce and make recommendations.
Develop work assignments and/or assist in completing them.
Provide leadership to nursing personnel on your shift.
Make daily rounds to ensure acceptable nursing standards are met.
Report problem areas to the Nurse Supervisor.
Ensure that all nursing assistants are enrolled in or have graduated from an approved training program.
Ensure that nurse aide trainees are under the supervision of a licensed nurse.
Meet regularly with shift nursing personnel to improve services.
Ensure department personnel and visitors follow policies and procedures.
Develop and maintain good rapport with interdepartmental personnel.
Create a calm, personal, and positive environment throughout the unit.
Review complaints/grievances and report them to the Nurse Supervisor.
Ensure fair administration of disciplinary action.
Receive/give the nursing report at shift changes.
Report occupational exposures and suspected fraud.
Log off computer workstations or ensure screen saver activation when unattended.
Nursing Care Functions
Inform staff of new admissions and expected details.
Prepare rooms and greet new residents.
Escort and orient residents and families to the facility.
Make rounds with physicians.
Arrange for diagnostic/therapeutic services.
Consult with the physician as needed.
Review resident charts and ensure nursing objectives are met.
Monitor treatment administration and resident condition.
Coordinate nursing care with certified personnel.
Cooperate with activity/social programs.
Notify physicians/families of accidents/incidents or status changes.
Carry out restorative/rehabilitative programs.
Inspect treatment areas for cleanliness and safety.
Administer professional services and use restraints per policy.
Obtain lab specimens.
Monitor residents' vital signs.
Monitor seriously ill residents.
Check food brought in by visitors.
Ensure care aligns with care plans and resident wishes.
Check frequently on residents who cannot call for help.