RN

POSITION SUMMARY: The Registered Nurse provides direct nursing care to the residents, and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. ESSENTIAL JOB FUNCTIONS:

A.Role Responsibilities – Administrative Duties:

1.Directs the day-to-day functions of the nursing assistants in accordance with current rules, regulations,and guidelines that govern the long-term care facility

2.Ensures that all nursing personnel assigned to you comply with the written policies and proceduresestablished by this facility

3.Reviews the department's policies, procedure manuals, job descriptions, etc. periodically and makesrecommendations for revisions

4.Meets with assigned nursing staff, as well as support personnel, in planning the shifts' services,programs, and activities

5.Ensures that the Nursing Service Procedures Manual is current and reflects the day-to-day nursingprocedures performed in this facility

6.Ensures that all nursing service personnel comply with the procedures set forth in the Nursing ServiceProcedures Manual

7.Makes written and oral reports/recommendations concerning the activities of your shift as required

8.Cooperates with other resident services when coordinating nursing services to ensure that theresident's total regimen of care is maintained

9.Ensures that all nursing service personnel are in compliance with their respective job descriptions

10.Participates in the development, maintenance, and implementation of the facility's quality assuranceprogram for the nursing service department

11.Provides data to the Quality Assurance & Assessment Committee as requested

12.Participates in facility surveys (inspections) made by authorized government agencies as may berequested

13.Reviews the resident's written discharge plan periodically and participates in the updating of theresident's written discharge plan as required

14.Assists in planning the nursing services portion of the resident's discharge plan as necessary

15.Interprets the department's policies and procedures to personnel, residents, visitors, and governmentagencies as required

16.Completes accident/incident reports as necessary

RN 2

17.Writes resident charge slips and forward to the Business Office

18.Maintains the Daily Census Report and submit to the Business Office as required

19.Performs administrative duties such as completing medical forms, reports, evaluations, studies,charting, etc., as necessary

B.Role Responsibilities – Charting and Documentation:

1.Completes and files required record keeping forms/charts upon the resident's admission, transfer,and/or discharge

2.Encourages attending physicians to review treatment plans, record and sign their orders, progressnotes, etc., in accordance with established policies

3.Receives telephone orders from physicians and record on the Physicians' Order Form

4.Transcribes physician's orders to resident charts, cardex, and medication cards, treatment/care plans, asrequired

5.Charts nurses' notes in an informative and descriptive manner that reflects the care provided to theresident, as well as the resident's response to the care

6.Charts all reports of accidents/incidents involving residents. Follow established procedures

7.Records new/changed diet orders and forwards information to the Dietary Department

8.Reports all discrepancies noted concerning physician's orders, diet change, charting error, etc., to theNurse Supervisor

9.Fills out and completes transfer forms in accordance with established procedures

10.Ensures that appropriate documentation concerning unauthorized discharges is entered in the resident'smedical record in accordance with established procedures

11.Performs routine charting duties as required and in accordance with established charting anddocumentation policies and procedures

12.Signs and dates all entries made in the resident's medical record

C.Role Responsibilities – Drug Administration:

1.Prepares and administers medications as ordered by the physician

2.Verifies the identity of the resident before administering the medication/treatment

3.Ensures that prescribed medication for one resident is not administered to another

4.Ensures that an adequate supply of floor stock medications, supplies, and equipment is on hand tomeet the nursing needs of the residents and reports needs to the Nurse Supervisor

5.Orders prescribed medications, supplies, and equipment as necessary, and in accordance withestablished policies

6.Ensures that narcotic records are accurate for your shift

7.Notifies the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift

8.Reviews medication cards for completeness of information, accuracy in the transcription of thephysician's order, and adherence to stop order policies

9.Notifies the attending physician of automatic stop orders prior to the last dosage being administered

10.Disposes of drugs and narcotics as required, and in accordance with established procedures

D.Role Responsibilities – Personnel Duties:

1.Participates in employee performance evaluations, determining your shift's staffing requirements, andmaking recommendations to the Nurse Supervisor concerning employee dismissals, transfers, etc.

2.Informs the Nurse Supervisor of staffing needs when assigned personnel fail to report to work andreports absentee call-ins

3.Reviews and evaluates your department's work force and make recommendations to the NurseSupervisor

4.Develops work assignments and/or assist in completing and performing such assignments

5.Provides leadership to nursing personnel assigned to your unit/shift

RN 3

6.Makes daily rounds of your unit/shift to ensure that nursing service personnel are performing theirwork assignments in accordance with acceptable nursing standards. Report problem areas to the NurseSupervisor

7.Ensures that all nurse aide trainees are under the direct supervision of a licensed nurse

8.Meets with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying andcorrecting problem areas, and/or to improve services

9.Ensures that department personnel, residents, and visitors follow the department's established policiesand procedures at all times

10.Reviews complaints and grievances made or filed by your assigned personnel. Make appropriatereports to the Nurse Supervisor as required or as may be necessary

11.Ensures that departmental disciplinary action is administered fairly and without regard to anyprotected class under federal or state law

12.Receives/gives the nursing report upon reporting in and ending shift duty hours

E.Role Responsibilities – Nursing Care:

1.Informs nursing personnel of new admissions, their expected time of arrival, room assignment, etc.

2.Ensures that rooms are ready for new admissions

3.Participates in the orientation of new residents/family members to the facility

4.Makes rounds with physicians as necessary

5.Requests and arranges for diagnostic and therapeutic services, as ordered by the physician, and inaccordance with our established procedures

6.Consults with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., asnecessary

7.Reviews the resident's chart for specific treatments, medication orders, diets, etc., as necessary

8.Implements and maintains established nursing objectives and standards

9.Makes periodic checks to ensure that certified nursing assistants are properly administering prescribedtreatments and to evaluate the resident's physical and emotional status

10.Cooperates with and coordinates social and activity programs with nursing service schedules

11.Notifies the resident's attending physician when the resident is involved in an accident or incident

12.Notifies the resident's attending physician and next-of-kin when there is a change in the resident'scondition

13.Carries out restorative and rehabilitative programs, to include self-help and care

14.Inspects the nursing service treatment areas daily to ensure that they are maintained in a clean and safemanner

15.Administers professional services such as; catheterization, tube feedings, suction, applying andchanging dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages andrange of motion exercises, care for the dead/dying, etc., as required

16.Uses restraints when necessary and in accordance with established policies and procedures

17.Obtains sputum, urine and other specimens for lab tests as ordered

18.Takes and records TPRs, blood pressures, etc., as necessary

19.Monitors seriously ill residents as necessary

20.Checks foods brought into the facility by the resident's family/visitors to ensure that it is within theresident's dietary allowances and reports problem areas to the Nurse Supervisor and DietarySupervisor

21.Ensures that personnel providing direct care to residents are providing such care in accordance withthe resident's care plan and wishes

22.Ensures that residents who are unable to call for help are checked frequently

23.Meets with residents, and/or family members, as necessary and reports problem areas to the NurseSupervisor

24.Admits, transfers and discharges residents as necessary

25.Assists in arranging transportation for discharged residents as necessary

RN 4

26.Ensures that discharged residents are escorted to the pick-up area

27.Informs family members of the death of the resident

28.Calls funeral homes when requested by the family and ensures that established post-mortemprocedures are followed.

F.Role Responsibilities – Staff Development

1.Participates in developing, planning, conducting, and in-service training classes that provideinstructions on "how to do the job," and ensures a well-educated nursing service department

2.Implements and maintains an effective orientation program that orients the new employee to yourshift, its policies and procedures, and to his/her job position and duties

3.Assists in standardizing the methods in which work will be accomplished

4.Assists in training department personnel in identifying tasks that involve potential exposure toblood/body fluids

5.Attends and participates in outside training programs

6.Attends and participates in annual OSHA and CDC in-service training programs for hazardcommunication, TB management, and bloodborne pathogens standard

7.Attends and participates in continuing education programs designed to keep you abreast of changes inyour profession, as well as to maintain your license on a current status

G.Role Responsibilities - Interpersonal Skills:

1.Must function independently and have flexibility, personal integrity, and the ability to work effectivelywith the residents, personnel, and support agencies

2.Is involved with residents, personnel, visitors, government agencies/personnel, etc., under allconditions and circumstances

3.Cooperates with inter-departmental personnel, as well as other facility personnel to ensure that nursingservices can be adequately maintained to meet the needs of the residents

4.Creates and maintains an atmosphere of warmth, personal interest, and positive emphasis, as well as aclam environment throughout the unit and shift

5.Maintains a liaison with the residents, their families, support departments, etc., to adequately plan forthe residents’ needs

6.Communicates with the medical staff, nursing personnel, and other department supervisors

H.Role Responsibilities - Safety:

1.Monitors assigned personnel to ensure that they are following established safety regulations in the useof equipment and supplies

2.Ensures that established departmental policies and procedures, including dress codes, are followed byassigned nursing personnel

3.Ensures that assigned personnel participate in and conduct all fire safety and disaster preparednessdrills in a safe and professional manner

4.Participates in the development, implementation and maintenance of the procedures for reportinghazardous conditions or equipment

5.Ensures that all personnel wear and/or use safety equipment and supplies (e.g., back brace, mechanicallifts, etc.) when lifting or moving residents

6.Reports missing/illegible labels and MSDSs to the safety officer or other designated person

7.Reports all accidents/incidents, safety violations, hazardous conditions, or defective equipment tosupervisor

8.Reports occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals inaccordance with the facility's policies and procedures governing accidents and incidents

9.Follows established safety, fire, disaster, emergency, and evacuation policies and procedures

10.Uses only supplies/equipment trained to use and operates all equipment and use all supplies in a safemanner and according to established procedures

RN 5

I.Role Responsibilities – Infection Control & Sanitation:

1.Assists the Director and/or Infection Control Coordinator in identifying, evaluating, and classifyingroutine and job-related functions to ensure that tasks in which there is potential exposure toblood/body fluids are properly identified and recorded

2.Participates in the development, implementation, and maintenance of the infection control program formonitoring communicable and/or infectious diseases among the residents and personnel

3.Ensures that assigned personnel follow established infection control procedures when isolationprecautions become necessary

4.Ensures that nursing personnel follow established procedures in the use and disposal of personalprotective equipment

5.Ensures that all personnel performing tasks that involve potential exposure to blood/body fluidsparticipate in appropriate in-service training programs prior to performing such tasks

6.Ensures that an adequate supply of personal protective equipment is on hand and are readily availableto personnel who perform procedures that involve exposure to blood or body fluids

7.Ensures that your unit's resident care rooms, treatment areas, etc., are maintained in a clean, safe, andsanitary manner

8.Ensures that assigned personnel follow established handwashing techniques in the administering ofnursing care procedures

9.Ensures that your assigned work areas (i.e., nurses' stations, medicine preparation rooms, etc.) aremaintained in a clean and sanitary manner

10.Follows established isolation, personal protective equipment, and infection control precautions andprocedures

11.Follows established policies concerning exposure to blood/body fluids

12.Demonstrates proper hand-washing techniques and disposes of waste properly

J.Role Responsibilities – Equipment and Supplies:

1.Recommends to the Nurse Supervisor the equipment and supply needs of your unit/shift

2.Ensures that an adequate stock level of medications, medical supplies, equipment, etc., is maintainedon your unit/shift at all times to meet the needs of the residents

3.Participates in the development and implementation of the procedures for the safe operation of allnursing service equipment

4.Ensures that all personnel operate nursing service equipment in a safe manner

5.Monitors nursing procedures to ensure that nursing service supplies are used in an efficient manner toavoid waste

K.Role Responsibilities – Care Plan:

1.Reviews care plans to ensure that appropriate care is being rendered

2.Informs the Nurse Supervisor of any changes that need to be made on the care plan

3.Ensures that your nurses' notes reflect that the care plan is being followed when administering nursingcare or treatment

4.Reviews resident care plans for appropriate resident goals, problems, approaches, and revisions basedon nursing needs

5.Ensures that assigned certified nursing assistants (CNAs) are aware of the resident care plans

6.Assists the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising theMDS, including the implementation of RAPs and Triggers

L.Role Responsibilities – Resident Care/Dignity:

1.Maintains the confidentiality of all resident care information

RN 6

2.Monitors nursing care to ensure that all residents are treated fairly, and with kindness, dignity, andrespect

3.Ensures that all nursing care is provided in privacy and that nursing service personnel knock beforeentering the resident's room

4.Ensures that all nursing service personnel are knowledgeable of the residents' responsibilities andrights including the right to refuse treatment

5.Reviews complaints and grievances made by the resident and make a written/oral report to the NurseSupervisor indicating what action(s) were taken to resolve the complaint or grievance. Follow thefacility's established procedures

6.Maintains a written record of the resident's complaints and/or grievances that indicates the action takento resolve the complaint and the current status of the complaint

7.Reports and investigates all allegations of resident abuse and/or misappropriation of resident property

8.Ensures that nursing staff personnel honor the resident's refusal of treatment request and ensures thatsuch requests are in accordance with the facility's policies governing advance directives

EDUCATION/EXPERIENCE:

1.Must possess, as a minimum, a RN Degree.2.Participation in continuing education classes, workshops, and seminars affiliated with outside nursing organizations desirable3.Must possess a current, unencumbered, active license to practice as an RN in this state4.Must be able to understand and carry out oral and written instructions5.Must be able to read, write, speak, understand, and communicate effectively in English6.Must be able to handle stressful situations and be flexible and adaptable7.Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care8.Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel9.Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care10.Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents11.Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices12.Must be able to relate information concerning a resident's condition

WORKING ENVIRONMENT:

1.Works in office areas as well as throughout the nursing service area (nurses’ stations, resident rooms)

2.Moves intermittently during working hours

3.Is subject to frequent interruptions

4.Is subject to hostile and emotionally upset residents, family members, personnel, and visitors

5.Works beyond normal working hours, on weekends and holidays, and in other positions temporarily,when necessary

6.Is subject to call back during emergency conditions

7.Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well asto reactions to dust, disinfectants, tobacco smoke, and other air contaminants

8.Is subject to exposure to infectious waste, diseases, conditions, etc., including TB, AIDS, and HepatitisB Virus

9.Is exposed to blood, body fluids, or tissues, and requires use of personal protective equipment

10.May be subject to the handling of and exposure to hazardous chemicals

11.May be necessary to assist in the evacuation of residents during emergency situations

RN 7

PHYSICAL REQUIREMENTS:

1.Must be able to move intermittently throughout the work day

2.Must be able to cope with the mental and emotional stress of the position

3.Must be able to see and hear (with or without aid) to ensure that the requirements of this position canfully be met

4.Must not pose a direct threat to the health and safety of other individuals in the workplace

5.Must be able to push, pull, move, and/or lift a minimum of thirty-five pounds

6.Must meet health assessment requirements set forth by the policies of this facility, including medicaland physical examination, two stage Mantoux skin tests and one-step annually thereafter

7.Must be capable of performing the essential functions of the job, with or without reasonableaccommodations