Job Descriptions For Winning Wheels

Licensed Nurse

PURPOSE OF YOUR JOB POSITION

The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing (DON) to ensure that the highest degree of quality care is maintained at all times.

DELEGATION OF AUTHORITY

As Staff Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

JOB FUNCTIONS

Every effort has been made to keep your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position.

RISK EXPOSURE CATEGORIES:

1 = Tasks may involve exposure to blood/body fluids.
2 = Tasks do not involve contact with blood/body fluids but could result in performing a Category 1 task.
3 = Tasks do not involve any risk of exposure to blood/body fluids.

ADMINISTRATIVE FUNCTIONS:

  • Direct 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
  • Ensure that the written policies and procedures that govern the day-to-day functions of the nursing service department are followed by all nursing personnel assigned to you. 3
  • Ensure that the Nursing Service Procedures Manual is followed in rendering nursing care. 2
  • Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained. 3
  • Ensure that all nursing service personnel are following their respective job descriptions. 3
  • Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. 3
  • Participate in the development, maintenance and implementation of the facility's quality assurance program for the nursing service departments.
  • Assist in planning the nursing services portion of the resident's discharge plan as necessary. 3
  • Participate in surveys (inspections) made by authorized government agencies. 2
  • Make written and oral reports/recommendations concerning the activities of your shift as required. 3
  • Periodically review the department's policies, procedure manuals, job description, etc. Make recommendations for revisions. 3
  • Meet with your assigned nursing staff, as well as support personnel, in planning the shifts services, programs, and activities. 3
  • Interpret the department's policies and procedures to personnel, residents, visitors, and government agencies as required. 3
  • Admit, transfer, and discharge residents as required. 2
  • Complete accident/incident reports as necessary. 3
  • Maintain the Daily Census Report and submit to the Business Office as required. 3

CHARTING AND DOCUMENTATION:

  • Chart all accidents/incidents involving the resident. Follow established procedures. 3
  • Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies. 3
  • Chart nurse notes in a timely, informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. 3
  • Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge. 3
  • Receive telephone orders from physicians and record on the Physicians' Order Form and Nurses notes as directed. 3
  • Record new/changed diet orders. Forward information to the Dietary Department in a timely manner. 3
  • Transcribe physician's orders to resident charts, medication cards, treatment/care plans, as required. 3
  • Assure that appropriate documentation concerning unauthorized discharges and/or resident refusal of treatment is entered in the resident's medical record in accordance with established procedures. 3
  • Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Director of Nursing. 3
  • Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures. 3
  • Sign and date all entries made in the resident's medical record. 3
  • Fill out and complete Transfer Forms in accordance with established procedures. 3
  • Complete skin integrity reports weekly as directed and maintain documentation on each resident�s Treatment Administration Record in a thorough and timely manner. 3

DRUG ADMINISTRATION FUNCTIONS:

  • Prepare and administer medications as ordered by the physician. 2
  • Assure that prescribed medication for one resident is not administered to another. 3
  • Verify the identity of the resident before administering the medication/treatment. 2
  • Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies. 3
  • Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hand to meet the nursing needs of the residents and report needs to the pharmacy and Director of Nursing as necessary. 3
  • Ensure that narcotic records are accurate for your shift and are completed in accordance with facility policy. 3
  • Dispose of drugs and narcotics as required, and in accordance with our established procedures. 3
  • Notify the attending physician of automatic stop orders prior to the last dosage being administered. 3
  • Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies. 3
  • Notify the Charge Nurse of all drug and narcotic discrepancies noted on your shift. 3

PERSONNEL FUNCTIONS:

  • Make attempts to fill staffing needs when assigned personnel fail to report to work. Alert the Director of Nursing of any staffing problem trends. 3
  • Develop work assignments, and/or assist in completing and performing such tasks. 3
  • Make daily rounds of your unit to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Director of Nursing. 2
  • Report absentee call-ins by completing the required documentation. 3
  • Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the DON as required or as may be necessary. 3
  • Ensure that disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status. 3
  • Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility to assure that nursing services and activities can be adequately maintained to meet the needs of the residents. 3
  • Assure that department personnel, residents, and visitors follow the departments established policies and procedures at all times. 3
  • Create and maintain an atmosphere of warmth, personal interest and positive environment throughout the unit and shift. 3
  • Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or the improvement of services. 3
  • Review and evaluate your department's work force and make recommendations to the Director of Nursing. 3
  • Participate in employee performance evaluations, and making recommendations to the DON concerning employee dismissals, transfers, etc. 3
  • Give/receive the nursing report upon reporting in and ending shift duty hours. 3
  • Provide leadership to nursing personnel assigned to your unit/shift. 3

NURSING CARE FUNCTIONS:

  • Inform nursing personnel of new admissions, their expected time of arrival, room assignment, etc. 3
  • Ensure that rooms are ready for new admissions. 3
  • Greet newly admitted residents upon admission and complete all admission paperwork in a timely and accurate manner. 2
  • Make rounds with physicians as necessary. 2
  • Implement and maintain established nursing objectives and standards. 3
  • Cooperate with and coordinate social services and recreational therapy programs with nursing service schedules. 3
  • Make independent decisions concerning nursing care. 3
  • Notify the resident's attending physician when the resident is involved in an accident or incident. 3 Make periodic checks to assure that prescribed treatments are being properly administered by nursing assistants and to evaluate the resident's physical and emotional status. 2
  • Administer professional services such as: catheterization, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care of the dead/dying, etc., as required. 1/2
  • Participate in the orientation of new residents/family members to the facility. 3
  • Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures. 3
  • Meet with residents, and/or family members, as necessary. Report problem areas to the Charge Nurse. 3
  • Admit, transfer and discharge residents as necessary. 3
  • Assist in arranging transportation for discharged residents as necessary. 3
  • Ensure that discharged residents are escorted to the pick-up area. 3
  • Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary. 3
  • Carry out restorative and rehabilitative programs, to include self-help and care. 2
  • Check foods brought into the facility by the resident's family/visitors to assure that it is within the resident's dietary allowances. Report problem areas to the DON and Dietary Supervisor. 3
  • Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner. 2
  • Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary. 3
  • Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition in a timely manner. 3
  • Work with the facility's consultants and implement those changes authorized by the DON. 3
  • Call funeral homes when requested by the family. Ensure that established postmortem procedures are followed. 2
  • Use restraints only in accordance with our facilities policies and procedures. 2
  • Make independent decisions concerning nursing care. 3
  • Obtain sputum, urine, and other lab tests as ordered. 1
  • Take and record TPR'S, blood pressures, etc., as necessary. 1
  • Monitor seriously ill residents as necessary. 1
  • Inform family members of the death of resident as necessary. 3
  • Do not permit residents to maintain medications (even non-prescription medications) in their rooms. 3

STAFF DEVELOPMENT:

Participate in the development, planning, conducting, and scheduling of in-service training classes that provide instructions on "how to do the job", and ensures a well-educated nursing services department. 3 Implement, and maintain an effective orientation that orients the new employee to your shift, its policies and procedures, and to his/his job position and duties. 3 Assist in standardizing the methods in which work will be accomplished. 3 Attend and participate in continuing educational programs designed to keep you abreast of changes in your profession, as well as to maintain your license on a current status. 3 Assure the organization has a copy of your current license on file at all times. Update as necessary. 3

SAFETY AND SANITATION:

  • Monitor your assigned personnel to assure that they are following established safety regulations in the use of equipment and supplies. 3
  • Ensure that your assigned work areas (i.e. nurses' stations, medicine carts, etc.,) are maintained in a clean and sanitary manner. 2
  • Ensure that your unit's resident care rooms, treatment areas, etc., are maintained in a clean, safe and sanitary manner. 2
  • Ensure that your assigned nursing personnel follow established departmental policies and procedures, including dress codes. 3
  • Ensure that your assigned personnel participate in all fire safety and disaster preparedness drills in a safe and professional manner. 3
  • Participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel. 2
  • Ensure that your assigned personnel follow established infection control procedures when isolation precautions become necessary. 2
  • Participate in the development, implementation and maintenance of the procedures for reporting hazardous conditions or equipment. 2
  • Ensure that your personnel follow established handwashing techniques in the administering of nursing care procedures. 2

EQUIPMENT AND SUPPLIES:

Recommend to the DON the equipment and supply needs of your unit. 3 Assure that a stock level of medications, medical supplies, equipment, etc., is maintained on your unit at all times to adequately meet the needs of the resident. 3 Participate in the development and implementation of the procedures for the safe operation of all nursing service equipment. 2 Ensure that only trained and authorized personnel operate your unit's equipment. 3 Ensure that all personnel operate nursing service equipment in a safe manner. 3 Monitor nursing procedures to ensure that nursing service supplies are used in an efficient manner to avoid waste. 3

CARE PLAN AND ASSESSMENT FUNCTIONS:

Review care plans daily to ensure that appropriate care is being rendered. 3 Inform the Rehabilitation Nurse or DON of any changes that need to be made on the care plan. 3 Ensure that your nurses' notes reflect that the care plan is being followed. 3 Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. 3 Ensure that your assigned nursing assistants are aware of the resident care plans and that they are used in administering daily care to the resident. 3 Update nursing assistants in a timely manner of any changes in resident condition. 3

RESIDENT RIGHTS:

Maintain the confidentiality of all resident care information. 3 Monitor nursing care to assure that all residents are treated fairly, and with kindness, dignity, and respect. 2 Ensure that all nursing care is provided in privacy and that nursing service personnel knock before entering the resident's room. 3 Ensure that all nursing service personnel are knowledgeable of the residents' rights and responsibilities. 3 Review complaints and grievances made by the resident and make a written/oral report to the DON indicating what action(s) were taken to resolve the complaint or grievance. 2

MISCELLANEOUS:

Assist in training department personnel in identifying tasks that involve potential exposure to blood/body fluids. 2 Assist the Director in planning clinical supervision for nurse aides in training. 3 Provide data to the Quality Assurance & Assessment Committee as requested. 3 Assure that nursing personnel follow established procedures in the use and disposal of personal protective equipment. 3

WORKING CONDITIONS

  • Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses' stations, resident rooms, etc.).
  • Sits, stands, bends, lifts and moves intermittently during working hours.
  • Is subject to frequent interruptions.
  • Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
  • Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.
  • Communicates with the medical staff, nursing personnel, and other department supervisors.
  • Works beyond normal working hours, and in other positions temporarily, when necessary.
  • Attends and participates in continuing educational programs.
  • Is subject to falls, burns from equipment, odors, etc., throughout the workday.
  • Is subject to exposure to infectious waste, diseases, conditions, etc., including the AIDS and Hepatitis B viruses.
  • Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents'.

EDUCATION

Must be, as a minimum, a licensed nurse in the State of Illinois.

EXPERIENCE

None. On-the-job training. Long-term care experience preferred

SPECIFIC REQUIREMENTS

Must:

  • Possess a current, unencumbered Illinois license to practice as a RN;
  • Be able to read, write, speak, and understand the English language;
  • Possess the ability to make independent decisions when circumstances warrant such action;
  • Possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public;
  • Be able to relate information concerning a resident's condition.
  • Be knowledgeable of nursing and medical practices and procedures;
  • Possess leadership and supervisory ability and the willingness to work harmoniously with professional and non-professional personnel;
  • Possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care;
  • Have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult;
  • Be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices;

PHYSICAL AND SENSORY REQUIREMENTS (With or Without the Aid of Mechanical Devices)

Must be able to:

  • Move intermittently throughout the work day;
  • Speak and write the English language in an understandable manner;
  • Cope with the mental and emotional stress of the position;
  • See and hear or use prosthetics that will enable these senses to function adequately to assure that the requirements of this position can be fully met;
  • Function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, support agencies;
  • Be in good general health and demonstrate emotional stability;
  • Relate to and work with the ill, disabled, emotionally upset, and, at times, hostile people within the facility;
  • Lift, push, pull, and move a minimum of 50 pounds;
  • Assist in the evacuation of residents.

Tasks assigned to this position may involve potential and/or direct exposure to blood or body fluids.