Job Summary: The Registered Nurse is responsible for providing direct nursing care to the residents.  Such care must be delivered in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services designee.

Job Functions: 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.

Essential Job Functions:

Nursing Care Functions

• Inform nursing personnel of new admissions, their expected time of arrival, room, assignment, etc.
• Ensure that rooms are ready for new admissions.
• Greet newly admitted residents upon admission and participate in the orientation of new residents/family members to the facility.
• Make rounds with physicians as appropriate.
• Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with established procedures.
• Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as appropriate.
• Cooperate with and coordinate social and activity programs with nursing service schedules.
• Notify the resident’s attending physician when the resident is involved in an accident or incident.
• Carry out restorative and rehabilitative programs, to include self-help and care.
• Administer services within the applicable scope of nursing practice
• Take and record TPRs, blood pressures, etc., as appropriate.
• Check foods brought into the facility by the resident’s family/visitors to ensure that it is within the resident’s dietary allowances. Report problem areas to the Nurse Supervisor and Dietary Supervisor.
• Meet with residents, and/or family members as appropriate.
• Admit, transfer, and discharge residents as appropriate.
• Assist in arranging transportation for discharged residents as appropriate.

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 to meet the nursing needs of the residents.
• Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage being administered.
• Dispose of drugs and narcotics as required, and in accordance with established procedures.

Charting and Documentation

• Receive and record telephone orders, and document the prescribed treatments on the resident charts, cardex, medication cards, and/or treatment/care plans as appropriate.
• Chart nurses’ notes in professional and appropriate manner that timely, accurately and thoroughly reflects the care provided to the resident, as well as the resident’s response to the care.
• Chart all reports of accidents/incidents involving residents..
• Chart all changes in resident condition and the response to those changes.
• Chart all communications with the resident’s attending physician regarding the resident, the resident’s treatment, or the response to that treatment.
• Record new/changed diet orders and communicate information to the Dietary Department.
• Fill out and complete transfer forms in accordance with established procedures.
• Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.
• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations.
• Sign and date all entries made in the resident’s medical record.

Care Plan and Assessment Functions

• Review care plans daily to verify that appropriate care is being rendered.
• Verify that nurses’ notes reflect that the care plan is being followed when administering nursing care or treatment.
• Ensure that assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNAs refer to the resident’s care plan prior to administering daily care to the resident.

Physical Demands

 The following are the physical demands of this job

Resident Rights

• Maintain the confidentiality of all resident care information.
• Treat all residents fairly, and with kindness, dignity and respect.
• Provide nursing care in privacy and knock before entering the resident’s room.
• Report and investigate all allegations of resident abuse and/or misappropriation of resident property.
• Honor the resident’s treatment requests (including refusals) and advance directives, and encourage the resident’s participation in his/her medical care and treatment plan.
• Be familiar with the rights of residents in a skilled nursing facility and act in a manner consistent with and respectful of those rights.

General Functions

• Make written and oral reports/recommendations concerning the patient care activities occurring on your shift as appropriate.
• Cooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.
• Periodically review the resident’s written discharge plan.  Participate in the updating of the resident’s discharge plan as appropriate.
• Assist in planning the nursing services portion of the resident’s discharge plan as appropriate.
• Admit, transfer, and discharge residents as appropriate.

Working Conditions

• Works in office areas as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.).
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
• Is subject to hostile and emotionally upset residents, family members, personnel and visitors.
• Communicates with the medical staff, nursing personnel, and other department supervisors.
• Works beyond normal working hours, and in other positions temporarily, when necessary.
• Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
• Attends and participates in continuing educational programs.
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• May be subject to handling of and exposure to hazardous chemicals.
• Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.

Education

Must possess, as a minimum, a Nursing Degree from an accredited college or university, or be a graduate of an approved LPN/LVN program.

Experience

None.  On-the-job training provided.

Specific Requirements

• Must possess a current, unencumbered, active license to practice as an RN or LPN/LVN in this state.
• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
• Must be able to relate information concerning a resident’s health.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements (With or Without the Aid of Mechanical Devices)

• Must be able to move intermittently throughout the work day.
• Must be able to speak and write the English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
• Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel and support agencies.
• Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination.
• Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and at times, hostile people within the facility.
• Must be able to lift up to 20 pounds.  Requires infrequent lifting of more weight up to 50 pounds and up to 100 pounds with assistance.  Frequently pushes and pulls carts and transports residents.
• May be necessary to assist in the evacuation of residents during emergency situations.

Acknowledgment

I have read this job description and fully understand the requirements set forth therein. I hereby accept the position of Registered/Licensed Nurse and agree to perform the identified essential functions in a safe manner and in accordance with the facility’s established procedures. I understand that as a result of my employment, I may be exposed to blood, body fluids, infectious diseases, air contaminants (including tobacco smoke), and hazardous chemicals and that the facility will provide instructions on how to prevent and control such exposures. I further understand that I may also be exposed to the Hepatitis B Virus and that the facility will make available to me, free of charge, the Hepatitis B vaccination.

I understand that my employment is at-will, and thereby understand that my employment may be terminated, with or without cause, either by the facility or myself, and such termination can be effected with or without notice.