General job duties. Types of procedures required:
Provides, oversees and coordinates nursing care in cooperation with other care providers to meet the needs of the residents. Contributes to the completion of the comprehensive assessment and care plan for each resident and provides cares in accordance with the individualized plan of care. Provides leadership for the nursing team by directing, overseeing and coordinating resident cares provided by nursing and aides. Provides nursing assessment and intervention as needed to insure medical needs are met.
Performs responsibilities related to the provision of Resident Care.
• Administers resident care, utilizing nursing process in a proficient and professional manner consistent with current standards of practice.
• Reviews, discusses and implements physician orders appropriately
• Takes appropriate measures if there are questions
• Transcribes and notes orders per facility standards
• Communicates orders to other departments as appropriate and schedules follow-ups as directed
• Contributes to, monitors & implements resident plan of care
• Provides Assessment of resident condition as needed and takes appropriate measures for follow-up, which includes documentation of assessment and subsequent changes in plan of care.
• Follows all aspects of the Eden Philosophy to provide care
• Responds to call lights and resident needs in a timely fashion
• Recognizes significant changes in resident condition, establishes priorities and takes appropriate action.
• Serves as a resident advocate
• Demonstrates expertise in provision of Activities of Daily Living for residents and delivers such care in a professional and caring manner.
Participates as an effective member of the Care Team and performs in a Team Lead capacity for department workflow and activities, as assigned or requested by manager.
• Assigns staffing to promote quality care
• Makes effective assignments based on resident needs and monitors and modifies assignments as needed to maximize care
• Anticipates staffing needs for oncoming shift
• Oversees and directs resident care provided by support staff.
• Monitors that care plan interventions are followed by staff.
• Takes appropriate action immediately when staff do not follow policies & procedures and/or resident plan of care.
• Takes responsibility for the direction and monitoring of medication administration provided by a medication aide during an assigned shift.
• Maintains responsibility for observation of desired effects, side effects, interactions and contraindications associated with medication administration, and responsible for taking appropriate actions as needed.
• Responds to Resident/Family concerns and provides immediate interventions when possible.
• Provides written communication of concerns to necessary departments for appropriate follow-up.
• Adapts to changes in workload and completes assignments while maintaining quality care.
• Initiates and performs duties which need to be completed although not directly assigned.
• Promotes team work through effective interpersonal relationships.
• Demonstrates initiative and flexibility in provision of care.
• Serves as a resource and role model for co-workers.
• Maintains professionalism.
• Holds co-workers to facility standards and initiates disciplinary action, as needed.
Provides and supports activities that insure and promote Resident Safety.
• Administers medications and treatments in a timely and safe manner according to physician orders and nursing policy.
• Assesses resident’s response to medical treatment and provides timely follow up as appropriate.
• Demonstrates proficient technical/clinical skills and operational knowledge of equipment within the Nursing Home.
• Reports variation in resident condition, staff conduct, equipment malfunctions or work conditions that may compromise safe, efficient resident care, to appropriate personnel.
• Communicates effectively with co-workers regarding resident conditions, nursing care needs, nursing assessments, new orders and recommendations.
• Shift change report
• Ongoing communication with current shift team
• Communication to care plan team
• Collaborates with other health team members ensuring that they are kept informed of resident’s condition and /or orders.
• Social Services
• Business office
• Communicates with Physicians regarding resident needs, nursing assessments and recommendations.
• Provides accurate, complete information to physician in a timely fashion
• Provides appropriate follow-up if timely response is not obtained
• Informs supervisor regarding resident care/quality of life issues.
• Communicates changes in resident condition/resident needs to family as appropriate.
Performs and maintains documentation in a compliant, accurate, and timely manner.
• Documents resident care and needs in medical record accurately.
• Follows facility policy and procedures of documentation (approved abbreviations and corrections made in medical record)
• Documents medication and treatments administered per facility standards.
• Documents variances in care as needed and in a timely fashion.
• Medication errors
• Quality variance reports
• Injury of Unknown Origin reports
• Fall reports
• Abuse reporting
Participates in Performance Improvement & Personal Growth.
• Observes for and reports potential or actual process concerns and actively problem solves for the solutions.
• Participates in department meetings and training opportunities to keep informed of changes affecting nursing care.
• Shares knowledge and expertise by participating in training for co-workers and orientation of new staff.
• Serves on committees to improve services.
• Provides positive role model for co-workers.
• Identifies and participates in company committees, performance improvement and quality initiatives and other activities which support the health center and department operations.
Complies with the state and federal regulatory requirements related to the performance of company operations and requirements.
Compliance Program, including but not limited to the Service Excellence Standards, the Compliance Policy, Safety and Infection Control, all department and organization-wide policies, Long Term Care Regulations, Federal and State of Nebraska regulations.
Participates in professional growth and development requirements and opportunities by attending department meetings, participation in required and voluntary educational programs and in-service meetings, including current literature, workshops, and other developmental opportunities.
Performs other duties as assigned.
Equipment utilized in the unit/dept.: Kiosk system for charting
- Current nursing license in the state of Nebraska (either RN or LPN)
- Current BLS certification