Job Description
JOB Summary:Responsible for resident care and assessment within the training and scope of service for the residents directly assigned within the unit working; and coordinates care and treatment of each resident to provide resident centered care.Follows established policies and procedures of the facility and standards of practice associated with one's state license; provides residents with quality care; checks rooms routinely to insure residents are provided the care expected and ordered; ensures unit is adequately supplied and organized for efficient and effective resident care; provides resident and family education and information regarding their care and treatment.Additionally, performs general nursing duties in all areas of the facility with adequate supervision; participates in Quality Assessment Performance Improvement plan of the organization; demonstrates the knowledge and skills necessary to provide care appropriate to the age of the residents served; must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the resident's status and interpret the appropriate information needed to identify each resident's requirements relative to his or her age-specific needs, and provide the care needed as described in the facility policies and procedures.WORKING CONDITIONS:Works in well-lighted, well-ventilated rooms and halls.Sits, stands, bends, stoops and walks intermittently during the work day.May adjust and move residents and equipment.Subject to burns from equipment falls, bruises, scratches, etc., from residents and may be exposed to infections and odors.Must handle emergencies, give emergency care and give emergency instructions and deal with public, visitors, and residents tact fully.ESSENTIAL FUNCTIONS AND DUTIES:1.Conducts chart reviews to check staff's work and documentation for accuracy and completeness.Discuss incomplete work with staff upon finding work not done.If incomplete work continues after discussions of incomplete work of more than 3 different occasions, then communicate with DON.2.Make daily rounds on residents.Observations to include:Follow-up with family issues, Medication Administration issues, Physician visits/outstanding orders, etc.3.Prepares and administers medications, as ordered by the Physician.4.Utilizes LTC consistently and accurately and serves as a resource person for staff 5.Ensures an admission note is written on all new admissions - Ensures care plan and care guide are established in LTC 6.Assist with entering Physician Orders in LTC.7.Ensures clinical staff completes orientation materials and required education and training expected by Facility policies and procedures.8.Works with staff to ensure Call Lights are answered within 5 minutes.9.Assist with feeding residents in dining room or resident room.10.Ensures daily skill notes are completed correctly and quarterly assessments timely 11.Assist in Care Plan meetings when ask.12.Administer professional services such as; catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, taking blood, and care POST Mortem & Palliative care, as required.13.Review resident care plans for appropriate resident goals, problems, approaches and revisions based on nursing needs.14.Handles all problems and employees in a professional, consistent and fair manner.15.Maintains correct and professional communications with the public, residents, employees and other agencies, reflecting the mission of Quality Rehab and Health Care.16.Ensures adequate staffing is available.17.Ensures Incidents or medication error reports are completed before end of shift correctly with all information on checklist.Completes the section of investigation.18.Reviews 24 hours Nursing Report for accuracy and completeness:a.New orders b.Changes in resident conditions C.Behavior changes d.New Admissions & Discharges e.Suspected or confirmed Infections 19.Charts notes in LTC in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care.20.Take and records TPR's and blood pressures, as necessary and records in LTC.21.Ensures that assigned work areas are maintained in a clean, safe and sanitary manner.Monitors CNA's to ensure that they practice Universal Precautions and safety regulations in the use of equipment and supplies.22.Interacts with co-workers, physicians, residents and all other customers in a manner which encourages harmonious working relationships, enhances the image and reputation of the facility and promotes positive customer relations 23.Transcribes physician orders in a timely and accurate manner, and in accordance with Woodcrest policies and procedures 24.Provides a brief written report to DON of any chart reviews for documentation and assessments, family or resident issues, employee issues, medication observations, any LTC issues, a