- Contact the resident’s physician regarding issues of care and treatment.
- Closely monitor resident change of condition, promptly notify physician and appropriate family members or legal representative of such changes or accidents.
- Ensure resident care is properly administered by all nursing personnel.
- Coordinate nursing care with resident’s individual Care Plan; review each plan for appropriate goals and approaches; notify Care Plan Coordinator of need for revision and document resident’s progress toward care plan goals in the medical record.
- Monitor daily Certified Nursing Assistant’s documentation for accurate recording of resident nutrition and hydration intake, elimination patterns and ADLs.
- Ensure that food and fluids provided each resident is according to ordered diet and fluid consistency.
- Assess resident behaviors, monitor episodes quantitatively and refer to Social Service Designee when behaviors not medically caused.
- Apply and monitor restraints only with physician order and in compliance with Federal and State regulations and facility policy.
- Obtain ordered specimens and process lab requisitions as needed.
- Arrange for diagnostic and therapeutic services as ordered.
- Receive resident report from off-going Charge Nurse at shift start and give resident report to on-coming Charge Nurse at shift end.
Medication and Treatment Administration Functions:
- Prepare and administer medications and treatments per physician order accurately and timely. Ensure accuracy and privacy of all medication and treatment records. Ensure the five RIGHTS of Medication Administration.
- Document all administered medications and treatments, including PRN Medications and treatments as ordered with resident outcomes.
- Ensure adequate supply of medications, equipment and supplies to meet resident needs by ordering such in a timely manner. Report all needs, shortages and malfunctioning equipment to the Director of Nursing.
- Records, returns or disposes of discontinued or expired medication per pharmacy and facility regulation and procedure.
- Monitor, document and report to physician all adverse or side effect of medication experienced by resident.
- Monitor and record all controlled medications; report discrepancies to the Director of Nursing immediately. Participate in controlled medication count at beginning and end of shift with off-going and on-coming Charge Nurse.
Charting and Documentation Functions:
- Process physician orders according to facility policy and procedure.
- Chart resident status in the nurses notes at least weekly; chart all pertinent notes immediately. Sign and date all entrees.
- Complete accident report at time of resident injury or accident, initiate follow- up per facility policy and document in nurses notes.
- Complete in-house Communication Form and distribute appropriately to maintain communication between departments.
- Maintain the 24 Hour Report.
- Document in the nurses notes all care given and resident’s response.
- Document in the nurses notes all physician contact and family notification.
Staff Development Functions:
- Attend mandatory in-services as required by Federal, State and facility policy.
- Participate in continuing educational programs to update nursing practice and skills.
- Assist in the orientation of new employees regarding policies, procedures, regulations and job description duties.
- In-service nursing personnel as needed.
Safety and Sanitation Functions:
- Ensure nursing personnel operate equipment safely; provide in-servicing to personnel regarding safe operation when needed; report all malfunctioning or unsafe equipment to the Director of Nursing.
- Ensure all fire and safety drills are conducted in a safe and professional manner. Notify Director of Nursing if personnel require review or in-servicing.
- Ensure personnel utilize proper hand washing technique at appropriate times;
- Ensure personnel follow correct infection control regarding precaution procedures; in-service as needed.
- Ensure only authorized and trained personnel operate equipment; in-service as needed.
- Monitor that nursing personnel dispose of contaminated linens, trash, personal protective equipment and bodily fluids are disposed of safely; in-service as needed.
Resident Rights Function:
- Ensure that all residents are treated with dignity, respect and kindness by staff, families, visitors, other residents and all others.
- Maintain the privacy and confidentiality of all resident protected health information.
- Promptly forward any resident grievances or concerns to the Social Service Designee and the Director of Nursing.
- Provide a review of resident rights for staff.