This position provides care to assigned residents in a caring, safe and efficient manner and is responsible to perform the following according to location standards, procedures and individualized resident care plans:
Completes comprehensive nursing assessment of all residents on admission and on an ongoing basis according to state and federal regulations using the nursing process (assessment, diagnosis, intervention and evaluation). Demonstrates competence in clinical skills as identified on Competency Verification and Training Checklist. Assures assigned residents receive ordered medication, treatments and other procedures within defined time frames, utilizing appropriate infection control procedures. Demonstrates familiarity with the therapeutic effects and side effects of all medications administered. Obtains equipment / supplies to provide care as needed. Assures procedures are followed for pressure ulcers, dehydration, malnutrition, incontinence, pain and medication administration. Accurately completes glucometer testing and control monitoring according to procedure. Implements specific approaches to deal with behavior, enhances residents' mood state according to resident care plan. Assures resident care for assigned residents is completed through reviewing documentation and updating as necessary. Uses the EMR accurately. Documents actions and notations for all resident condition changes according to policy and procedure. Documents all actions taken related to admission, discharge, transfers or death. Documents incidents or accidents in resident record and all necessary forms (incident reports, etc.) Completes behavior documentation according to policy and procedure. Completes seven-day observation tool. Assists/participates in quality improvement process, including audits and corrective procedures as assigned. May complete the assigned portions of the MDS for Nursing and sign the MDS forms to signify completion of the process. Assures physician's orders are processed and physicians notified in a timely manner. Makes rounds with physicians as assigned. Attends or obtains resident report prior to beginning shift. Receives and shares information; observes and reports residents' conditions. Responds promptly to resident call lights. Directs and assists with resident, family/significant other education. Notifies family on condition changes etc. Reports / assures timely follow up of signs / symptoms of resident infections.