Charge Nurse RN or LPN

About the Role

The primary purpose is to provide direct nursing care to residents and supervise the day-to-day activities performed by nursing assistants. This supervision must be in accordance with current federal, state, and local guidelines and regulations governing the facility. You will ensure the highest degree of quality care is maintained at all times. As Charge Nurse, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties.

Responsibilities

Administrative Functions

• Direct the day-to-day functions of nursing assistants in accordance with facility rules, regulations, and guidelines.
• Ensure compliance with written policies and procedures established by the facility.
• Periodically review and recommend revisions to department policies, procedure manuals, and job descriptions.
• Plan shifts' services, programs, and activities with assigned nursing staff and support personnel.
• Maintain and ensure compliance with the Nursing Service Procedures Manual.
• Make written and oral reports concerning shift activities as required.
• Coordinate with other resident services to maintain the resident's total regimen of care.
• Ensure nursing service personnel comply with their respective job descriptions.
• Participate in the development and implementation of the facility's quality assurance program for nursing services.
• Participate in facility surveys and inspections by authorized government agencies.
• Review and update residents' written discharge plans as required.
• Admit, transfer, and discharge residents as required.
• Complete accident/incident reports and maintain the Daily Census Report.
• Perform administrative duties such as completing medical forms, reports, evaluations, and charting.
• Protect resident and facility information by not disclosing assigned user ID codes, passwords, or protected health information.
• Report unauthorized attempts to access facility information systems.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon resident admission, transfer, and/or discharge.
• Encourage physicians to review treatment plans and record/sign orders and progress notes.
• Receive and record telephone orders from physicians on the Physicians' Order Form.
• Transcribe physician's orders to resident charts, cardex, medication cards, and treatment/care plans.
• Document charge nurses' notes reflecting care provided and resident responses.
• Complete and submit accident/incident reports.
• Chart all reports of accidents/incidents involving residents.
• Record new/changed diet orders and forward information to the Food Services Department.
• Report discrepancies in physician's orders, diet changes, or charting errors to the Nurse Supervisor.
• Complete transfer forms and ensure appropriate documentation for unauthorized discharges.
• Perform routine charting duties and sign/date all entries in the resident's medical record.

Drug Administration Functions

• Prepare and administer medications as ordered by the physician.
• Verify resident identity before administering medication or treatment.
• Ensure prescribed medication for one resident is not administered to another.
• Maintain an adequate supply of floor stock medications, supplies, and equipment.
• Order prescribed medications, supplies, and equipment as necessary.
• Ensure narcotic records are accurate for your shift and report discrepancies.
• Review medication cards for completeness and accuracy.
• Notify the attending physician of automatic stop orders prior to the last dosage.
• Dispose of drugs and narcotics in accordance with established procedures.

Personnel Functions

• Participate in employee performance evaluations and determine shift staffing requirements.
• Make recommendations concerning employee dismissals and transfers.
• Inform the Nurse Supervisor of staffing needs and report absentee call-ins.
• Review and evaluate the department's workforce and make recommendations.
• Develop work assignments and assist in completing them.
• Provide leadership to nursing personnel assigned to your unit/shift.
• Make daily rounds to ensure nursing service personnel perform work assignments according to standards.
• Ensure all nursing assistants are enrolled in or have graduated from an approved training program.
• Supervise nurse aide trainees under the direct supervision of a licensed nurse.
• Meet with shift nursing personnel to identify and correct problem areas.
• Ensure compliance with department policies and procedures by personnel, residents, and visitors.
• Maintain a good working rapport with inter-departmental personnel.
• Create and maintain a calm, positive environment throughout the unit.
• Review complaints and grievances from assigned personnel and report to the Nurse Supervisor.
• Administer disciplinary action fairly and without bias.
• Receive and give nursing reports at the start and end of shifts.
• Report occupational exposures to blood, body fluids, or hazardous chemicals.
• Report known or suspected incidents of fraud to the Administrator.
• Ensure unattended workstations are properly logged off or password-protected.

Nursing Care Functions

• Inform nursing personnel of new admissions, room assignments, and expected arrival times.
• Prepare rooms for new admissions and greet residents upon arrival.
• Participate in the orientation of new residents and family members.
• Make rounds with physicians as necessary.
• Requisition and arrange for diagnostic and therapeutic services as ordered by the physician.
• Consult with the resident's physician regarding care, treatment, and rehabilitation.
• Review resident charts for treatments, medication orders, and diets.
• Implement and maintain established nursing objectives and standards.
• Evaluate the resident's physical and emotional status through periodic checks.
• Ensure direct nursing care is provided by qualified personnel.
• Coordinate social and activity programs with nursing service schedules.
• Notify the resident's physician and next-of-kin of changes in the resident's condition or accidents/incidents.
• Carry out restorative and rehabilitative programs, including self-help and care.
• Inspect nursing service treatment areas daily to ensure they are clean and safe.
• Administer professional services such as catheterization, tube feedings, suction, wound care, and range of motion exercises.
• Use restraints when necessary and in accordance with established policies.
• Obtain specimens for lab tests as ordered.
• Monitor and record vital signs as necessary.
• Check foods brought in by family/visitors to ensure dietary compliance.
• Ensure direct care is provided in accordance with the resident's care plan and wishes.
• Frequently check residents who are unable to call for help.
• Meet with residents and/or family members as necessary.
• Assist in arranging transportation for discharged residents.
• Escort discharged residents to the pick-up area.
• Inform family members of resident deaths and call funeral homes as requested.
• Follow established post-mortem procedures.

Staff Development

• Participate in developing, planning, conducting, and scheduling in-service training classes.
• Implement and maintain an effective orientation program for new employees.