• Confer with the Medical Director and the attending physician regarding specific residents assigned to you.
• Consult with the physician concerning resident evaluation and assist the Director of Nursing Services in planning and developing the nursing services to be performed for the resident.
• Initiate requests for consultation or referral. Respond to requests from the resident, physician, or nursing staff.
• Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional or mental problems.
• Determine when to refer the resident to a physician for evaluation, supervision, or directions.
• Perform administrative duties regarding assigned residents, such as completing medical forms, reports, evaluations, studies, charting, etc.
• Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control. Interpret these to the physician, resident, family members, and public, as appropriate.
• Make written and oral reports/recommendations to the attending physician, Medical Director, or the Administrator concerning the status and care of the assigned resident.
• Participate in the planning and evaluation of the written policies and procedure that govern the day-to-day functions of the nursing service department.
• Participate in facility surveys (inspections) made by authorized government agencies.
• Resolves complaints and grievances made by nursing department personnel.
• Ensures that nursing department employment actions are administered fairly and in compliance with the facility's Policy Against Discrimination, Harassment and Retaliation.
• Supervises and assists in management of the infection control program including ensuring that personal protective equipment is used in the handling of infectious materials by nursing personnel.
• Assists in the development of preliminary and comprehensive assessments of the nursing needs of each resident are performed in furtherance of the resident care planning policy.
• Observes medication passes and treatments to ensure quality.
• Administer services within the applicable scope of nursing practice, which may include: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as appropriate and in accordance with applicable standards.
• Prepare and administer medications as ordered by the physician.
• Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies.
• 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.
• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations.
• Ensures that adequate stock levels of medications, medical supplies and equipment are maintained.
• Assist the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies.
• Performs other duties as may be assigned.
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