Under the supervision of the Resident Care Manager/Director of Nursing, a RN assumes responsibility and accountability for a group of residents/patients for a shift of duty. Nursing care is provided through assessment, implementations, and evaluation of the plan of care. The RN adheres to the standards of care for the area, manages the environment to maintain resident/patient safety, and supervises the resident/patient care activity performance by nursing assistants and helpers. Follows all policies and procedures and performs duties as defined by the State Nurse Practice Act.
Makes frequent rounds to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards.
• Gives/receives the nursing report upon reporting in and ending shift duty hours.
• Ensures assigned work area (i.e. nurse station, med. Cart, medication room, etc.), resident/patient care rooms and treatment areas are maintained in a clean and sanitary manner.
• Monitors supplies and orders as needed.
• Responsible for resident/patient care during his/her respective shift.
• Reviews care plans, at least daily, to ensure appropriate care.
• Notifies the Director of Nursing/Residence Care Manager/patient changes in condition.
• Receives and transcribes physician's orders to resident's/patient's charts, Kardex/Care Plan A, Medication Administration Record (â€œMARâ€), treatment/care plans, as required.
• Prepares and administers medications and performs treatments as ordered by the physician.
• Charts nurses notes in an informative and descriptive manner that reflects the care provided as well as the resident's/patient's response to the care.
• Documents all pertinent data as required by Medicare, Medicaid and company standards and policies.
• Completes the required forms upon admission, transfer, and/or discharge.
• Informs physician of resident/patient change of condition.
• Counts all controlled drugs with other nurse at shift change and notifies the Director of Nursing / Resident Care Manager of all drug and narcotic discrepancies noted on your shift.
• Keeps medication room and medication cart locked according to regulations. Responsible for security of keys.
• Keeps medication room and medication cart clean and orderly.
• Follows and adheres to policies and procedures implementing HIPAA requirements for the privacy and security of protected health information.
• Uses and/or discloses only minimum amount of Protected Health Information necessary to complete assigned tasks.
• Performs other tasks/duties as assigned
• Must possess a current RN license. License must be in good standings.
• Must have a minimum 1 year of experience as a supervisor in a healthcare setting.
• Must have training in rehabilitative and restorative nursing practices.
• Knowledgeable of nursing and medical practices and procedures, as well as laws, regulations and guidelines that pertain to nursing care facilities.