Job Description

Essential Job Functions:

1. Responsible for total care of all assigned residents on his/her unit and supervision of direct care staff to ensure residents' needs are met.
2. Ensure that restorative nursing care measures are performed as indicated and ordered.
3. Help to maintain the self-respect, personal dignity, and physical safety of each resident.
4. Maintain open communication with nursing management regarding conditions on the nursing unit and concerns related to staff, residents, and visitors.
5. Explain treatment goals and expectations to the resident and family/representative, in an effort to obtain feedback and cooperation.
6. Supervise/manage personnel on assigned hall/unit(s)..
7. Verify that medical records are properly maintained and updated.
8. Review daily assignments of nursing staff on the unit/hall to assure that assigned duties are consistent with ability, training, and within scope of practice.
9. Assist and instruct nursing staff on unit/hall in special treatments and nursing care.
10. Ensure that all ordered treatments are carried out as ordered.
11. Ensure that lab work and x-rays are conducted according to physician order and results are reported to the physician in a timely manner.
12. Make rounds with physicians and assist with examinations, as indicated.
13. Assess residents on unit/hall, upon admission, as well as when indicated for problems/concerns or change in condition. Take necessary action, including emergency measures.
14. Initiate and update the nursing care plan for residents on the unit/hall and participate in the interdisciplinary care plan conference, as requested, or assigned.
15. Responsible for the security of narcotic and controlled substances.
16. Ensure that supplies are stocked on the unit per facility practice.
17. Assist staff in delivery of direct resident nursing care.
18. Assist with the discharge plan for resident. Instruct the resident and/or family member(s)/representitive; and assess understanding of information provided.
19. Receive report from off-going charge nurse. Give thorough report to on-coming nurse at change of shift.
20. Count narcotics at beginning and end of each shift and maintain accurate narcotic records.
21. Make rounds on all residents with careful attention to those reported as in need of increased monitoring.
22. Administer and document all medications at appropriate times.
23. Notify medical providers as necessary regarding orders and visits.
24. Confer and collect all data from staff (re: resident care problems, needs, turning and positioning, intake output, etc.). Notify medical provider of recognition of signs and symptoms of early disease or complication(s).
25. Charting/documentation to be completed according to facility schedule. In accordance, document anything unusual or any change in condition and/or treatments for all residents.
26. Responsible for the performance of the following nursing measures to ensure quality of care:

a. Maintenance of resident personal hygiene.

b. Maintenance of adequate hydration.

c. Promotion of normal elimination patterns.

d. Maintenance and promotion of maximum range of motion.

e. Promotion of normal sleep patterns.

f. Protection from accidents, neglect, or abuse.

g. Maintenance of infection control.

h. Promotion of resident socialization.

i. Promote resident self-esteem and preservation of human dignity. Offer encouragement to resident to function at maximum level.

1. Assist residents in psychosocial acceptance of their limitations.
2. Assist in the evaluation of nursing staff supervised on the unit.
3. Coordinate nursing service with other services: Dietary, Social Services, Activities, Physical therapy, etc.
4. Participate in mandatory in-service training as mandated by State rule and facility policy.
5. Inform nursing staff, as indicated, of facility policies and procedures.
6. Draw blood for lab work, as ordered, if applicable per facility policy.
7. Assist in the orientation of new employees on the unit/hall as necessary.
8. Assure that a clean, safe environment for residents and staff exists on the unit.
9. Adhere to facility safety and infection control policies and procedures.
10. Maintain confidentiality of resident information.
11. Carefully observe all new admission orders, new orders, incident reports, memos, to promote timely care and implementation of necessary interventions.
12. Make rounds to directly supervise the serving of the residents as well as to observe residents while they are eating, offering substitutes in the event a resident does not accept the meal.
13. Monitor for provision of proper diet as ordered.
14. Monitor utility, linen and shower rooms for order and cleanliness.
15. Other duties as assigned.

Physical, Sensory, and Communication Requirements:

1. Ability to read and write in English, ability to communicate with residents, families, personnel and support agencies and ability to remain calm under stress.
2. Bending, lifting, walking, grasping, fine hand coordination, ability to distinguish smells, tastes and temperatures, ability to discern colors, ability to hear and respond to pages.