Day Nurse

About the Role

The primary purpose of this position is to provide direct nursing care to residents and supervise the day-to-day nursing activities performed by nursing assistants. Supervision must align with current federal, state, and local standards, guidelines, and regulations governing the facility, ensuring the highest degree of quality care is maintained at all times.

Responsibilities

Administrative Functions

• Direct the day-to-day functions of nursing assistants in accordance with facility rules, regulations, and guidelines.
• Ensure compliance with facility policies and procedures for all assigned nursing personnel.
• 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.
• Submit 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 adhere to their job descriptions.
• Participate in the development, maintenance, 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.
• Interpret department policies to personnel, residents, visitors, and government agencies.
• Admit, transfer, and discharge residents as required.
• Complete and submit accident/incident reports, daily census reports, and resident charge slips.
• Perform administrative duties such as completing medical forms, evaluations, and charting.
• Maintain confidentiality of assigned user ID codes, passwords, and resident protected health information.
• Report unauthorized attempts to access facility information systems or violations of confidentiality policies.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon resident admission, transfer, and/or discharge.
• Encourage physicians to review treatment plans and document 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.
• Chart nurses’ notes descriptively, reflecting care provided and resident responses.
• Complete and submit accident/incident reports.
• Record new or 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 in accordance with established policies and procedures.
• Sign and date all entries made 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 medications prescribed for one resident are not administered to another.
• Maintain an adequate supply of floor stock medications, supplies, and equipment.
• Report supply needs to the Nurse Supervisor and order as necessary.
• Maintain accurate narcotic records and report discrepancies to the Nurse Supervisor.
• Review medication cards for completeness, accuracy, and adherence to stop order policies.
• Notify attending physicians 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 staffing requirements for your shift.
• Make recommendations concerning employee dismissals, transfers, and other staffing needs.
• Inform the Nurse Supervisor of staffing needs due to absences or call-ins.
• Review and evaluate the department’s workforce and make recommendations for improvements.
• Develop work assignments and assist in completing them.
• Provide leadership to nursing personnel assigned to your unit/shift.
• Make daily rounds to ensure nursing personnel perform duties according to acceptable standards.
• Ensure 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.
• Hold regular meetings with shift 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 warm, calm, and positive environment for residents and staff.
• Review and address complaints and grievances from assigned personnel.
• 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, infectious materials, 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, including arrival times and room assignments.
• 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.
• Periodically check that prescribed treatments are administered properly and evaluate resident status.
• Ensure direct nursing care is provided by licensed nurses, certified nursing assistants, or qualified trainees.
• Coordinate social and activity programs with nursing service schedules.
• Notify attending physicians and next-of-kin of changes in resident condition or accidents/incidents.
• Carry out restorative and rehabilitative programs, including self-help and care.
• Inspect nursing service treatment areas daily to ensure cleanliness and safety.
• Administer professional services such as catheterization, tube feedings, suction, dressings, colostomy care, blood draws, massages, and range of motion exercises.
• Use restraints when necessary and in accordance with established policies.
• Obtain specimens for lab tests as ordered (e.g., sputum, urine).
• Take and record vital signs (TPRs, blood pressures) as necessary.
• Monitor seriously ill residents as required.
• Check foods brought in by family/visitors to ensure compliance with dietary allowances.
• Ensure direct care aligns with the resident’s care plan and wishes.
• Frequently check on residents unable to call for help.
• Meet with residents and/or family members to address concerns.
• Assist in arranging transportation for discharged residents and escort them to pick-up areas.
• Inform family members of resident deaths and coordinate with 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.