The registered nurse (RN) is responsible for assessing, planning, providing and documenting nursing care for a designated group of residents in accordance with the physician’s plan of care. The RN delegates and supervises care provided by certified nursing assistants (CNAs) and license practical nurses (LPNs). She coordinates services and care provided to assigned residents by other disciplines including respiratory therapists (RTs), phlebotomists, radiation technicians, dietitians, and others.
Essential job duties:
- Administrative Functions:
- Document in the computerized medical records system progress notes, medication administration, treatment administration, admission assessments, change in condition assessments, and care plans.
- Document any accident and incident in the computerized incident reporting system.
- Participate in performance evaluation process.
- Participate in Quality Assurance Performance Improvement (QAPI) process.
- Report to Director of Nursing/Nursing Home Administrator any significant events/incidents.
- Report and initiate investigation for allegations of abuse/neglect as assigned.
2. Admission, Transfer, and discharge functions:
- Take physician’s verbal orders for admissions, transfers, and discharges.
- Follow procedure to communicate with pharmacy and acquire medications.
- Get pain medication and other medications if available from interim box.
- Orient resident and family member to the unit.
- Provide resident with name band to be worn at all times.
- Perform admission assessments and implement 48- hour care plans.
- Plan of care will be developed using admission history and information gathered through responsible agent interview. Responsible agent is asked to provide information on resident’s health, developmental and social history. Responsible agent is asked about usual routines, and any cultural needs.
- Introduce resident to his/her roommate and other personnel.
- Make resident comfortable (i.e. put to bed, change clothing, orient to room nursing unit, the call light system and TV) as necessary. Provide age/developmentally appropriate equipment and supplies.
- Complete transfer summary, print MAR, TAR, and advance directives to accompany resident.
- Complete discharge summary, educate family/caregiver, and get prescription for discharge medications.
3. Nursing Care Functions:
- Responsible for resident care during shift.
- Conduct required assessments and interventions.
- Develop person-centered care plans and reviews and revises for appropriateness of care.
- Appraise DON/Supervisor of resident status and change in condition.
- Take or appropriately delegate the recording of blood pressure and vital signs based on staff’s competencies.
- Administer catheter care as required.
- Provide respiratory care (i.e. oxygen, nebulizer treatments, suctioning, monitoring ventilator)
- Communicate in a courteous, professional, and empathetic manner with residents, and families.
- Coordinate care with other disciplines as resident’s care needs require (i.e. respiratory therapy, physical therapy).
- Communicate in a courteous and professional manner with peers, subordinates, and supervisors.
- Resolve resident and family concerns within personal ability, and refer other concerns to the appropriate discipline. Communicate resolution steps to resident and family.
- Notify attending physician and responsible agent of changes in condition.
- Receive and transcribe physician’s orders to resident’s computerized medical records.
- Prepare and administer medications and perform treatments as ordered by physicians.
- Chart nurse’s progress notes in an informative and descriptive manner that reflects the care provided as well as resident’s response to care.
- Document pertinent information as required by resident’s payer source (i.e. Medicaid, HMO etc.) and as per facility standards and policy.
- Count Controlled drugs with other nurse at shift change and notify DON/Supervisor of all drug and narcotic discrepancies noted.
- Keep medication room and medication cart locked.
- Keep medication room and medication cart free from expired medications. Disposes of expired medications as per facility policy.
- Report and document any incidents or accidents of residents, staff or visitors to the appropriate facility personnel.
- Conduct weekly shift meetings with nursing assistants.
- Participate in the interdisciplinary plan of care.
- Use required protective equipment.
4. Personnel Function:
- Follow work assignments, and, or work schedules in completing and performing your assigned responsibilities.
- Provide assignments to CNAs and LPNs.
- Perform all assigned tasks in accordance with established policies and procedures, and as instructed by DON.
- Notify the facility when you will be late or absent from work in accordance with facility policy.
- Swipe in and out of the time clock system in accordance with facility policy.
- Make sure complaints and grievances are documented in the appropriate form and given to DON/Social Worker.
- Cooperate with personnel from other departments to meet the resident’s needs.
- Work cooperatively with other disciplines to maintain the health, safety, and well-being of the residents and families.
- Supervise and direct CNAs, and LPNs.
- Create and maintain an atmosphere of warmth and calm environment.
- Participate in performance evaluation for staff as assigned.
- Attend and participate in scheduled training, educational classes, orientation programs and activities.
- Conduct in-service training as assigned.
5. Resident Rights:
- Help residents and their responsible agent exercise and/or protect their rights.
- Maintain the confidentiality of all resident care information.
- Ensure that all nursing care is provided in privacy.
- Knock before entering the resident room at all times.
- Make sure that grievances and complaints are documented and handed to DON/Social Worker.
- Address each resident by preferred name.
- Acknowledge the resident right to be free of verbal, mental, sexual or physical abuse and involuntary seclusion.
- Explain to the resident each activity to be undertaken prior to the activity.
- Be an advocate for the resident. Greet friends and family and address concerns.
- Encourage resident participation in care activities and making choices.
- Ensure that each resident is dressed to enhance individual’s self-esteem their preference, age, and life style.
- Residents/families have a right to report problems with staff without retaliation.
- Answer all call lights promptly and assist residents as needed and requested by family or other staff members.
- Residents have a right to keep their personal belongings. When a resident expresses concern that they are missing personal property, you are to report it to ensure it is documented in the grievance and concern form and handed to DON/Social Worker.
- All resident will be treated in manner which maintains and enhances their dignity.
Other job duties:
- May perform other duties in addition to those outlined in this job description.
1. 2 years of experience in a skilled or acute care setting.
2. Experience working with ventilator dependent patients preferred.
3. Experience working with special needs children or young adults preferred.
- Current RN license in the District of Columbia
- Current CPR certification
- Must be a graduate from an accredited nursing program.
- Bachelor in science in nursing preferred