FT PM LVN

About the role

Provide direct nursing care to residents and supervise the day-to-day nursing activities performed by nursing assistants, in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility.

Administrative Functions

• Direct the day-to-day functions of nursing assistants in accordance with current rules, regulations, and guidelines governing the long-term care facility
• Ensure all nursing personnel assigned to you comply with written facility policies and procedures
• Periodically review department policies, procedure manuals, job descriptions, and make recommendations for revisions
• Meet with assigned nursing staff and support personnel in planning shift services, programs, and activities
• Ensure the Nursing Service Procedures Manual is current and reflects day-to-day nursing procedures
• Ensure all nursing service personnel comply with procedures set forth in the Nursing Service Procedures Manual
• Make written and oral reports/recommendations concerning activities of your shift as required
• Cooperate with other resident services when coordinating nursing services to maintain the resident's total regimen of care
• Ensure all nursing service personnel are in compliance with their respective job descriptions
• Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing service department
• Participate in facility surveys (inspections) made by authorized government agencies as requested
• Periodically review the resident's written discharge plan and participate in updating it as required
• Assist in planning the nursing services portion of the resident's discharge plan as necessary
• Interpret department policies and procedures to personnel, residents, visitors, and government agencies as required
• Admit, transfer, and discharge residents as required
• Complete accident/incident reports as necessary
• Write resident charge slips and forward to the Business Office
• Maintain the Daily Census Report and submit to the Business Office as required
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary
• Report any known or suspected unauthorized attempt to access facility's information system

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon resident admission, transfer, and/or discharge
• Encourage attending physicians to review treatment plans, record and sign orders, progress notes, etc., in accordance with established policies
• Receive telephone orders from physicians and record on the Physicians' Order Form
• Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans, as required
• Chart nurses' notes in an informative and descriptive manner reflecting care provided and resident's response
• Fill out and complete accident/incident reports and submit to Director as required
• Chart all reports of accidents/incidents involving residents following established procedures
• Record new/changed diet orders and forward information to the Food Services Department
• Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor
• Fill out and complete transfer forms in accordance with established procedures
• Ensure appropriate documentation concerning unauthorized discharges is entered in the resident's medical record
• Perform routine charting duties as required and in accordance with established charting and documentation 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 identity of the resident before administering medication/treatment
• Ensure prescribed medication for one resident is not administered to another
• Ensure adequate supply of floor stock medications, supplies, and equipment is on hand; report needs to the Nurse Supervisor
• Order prescribed medications, supplies, and equipment as necessary in accordance with established policies
• Ensure narcotic records are accurate for your shift
• Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift
• Review medication cards for completeness of information, accuracy in transcription, and adherence to stop order policies
• Notify attending physician of automatic stop orders prior to the last dosage being administered
• Dispose of drugs and narcotics as required in accordance with established procedures

Personnel Functions

• Participate in employee performance evaluations, determining shift staffing requirements, and making recommendations to the Nurse Supervisor concerning employee dismissals, transfers, etc.
• Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work
• Report absentee call-ins to the Nurse Supervisor
• Review and evaluate department workforce and make recommendations to the Nurse Supervisor
• Develop work assignments and/or assist in completing and performing such assignments
• Provide leadership to nursing personnel assigned to your unit/shift
• Make daily rounds of your unit/shift to ensure nursing service personnel are performing work assignments in accordance with acceptable nursing standards; report problem areas to the Nurse Supervisor
• Ensure all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program
• Ensure all nurse aide trainees are under direct supervision of a licensed nurse
• Meet with shift nursing personnel on a regularly scheduled basis to identify and correct problem areas and/or improve services
• Ensure department personnel, residents, and visitors follow department established policies and procedures at all times
• Develop and maintain good working rapport with inter-departmental personnel and other departments to ensure nursing services and activities can be adequately maintained
• Create and maintain an atmosphere of warmth, personal interest, positive emphasis, and a calm environment throughout the unit and shift
• Review complaints and grievances made or filed by assigned personnel; make appropriate reports to the Nurse Supervisor as required
• Ensure departmental disciplinary action is administered fairly without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status
• Receive/give the nursing report upon reporting in and ending shift duty hours
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with facility policies and procedures
• Ensure departmental computer workstations left unattended are properly logged off or the password-protected automatic screen-saver activates within established policy guidelines

Nursing Care Functions

• Inform nursing personnel of new admissions, expected time of arrival, room assignment, etc.; ensure rooms are ready for new admissions
• Greet newly admitted residents upon admission; escort them to their rooms as necessary
• Participate in orientation of new residents/family members to the facility
• Make rounds with physicians as necessary
• Requisition and arrange for diagnostic and therapeutic services as ordered by the physician in accordance with established procedures
• Consult with the resident's physician in providing resident care, treatment, rehabilitation, etc., as necessary
• Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary
• Implement and maintain established nursing objectives and standards
• Make periodic checks to ensure prescribed treatments are properly administered by certified nursing assistants and to evaluate resident's physical and emotional status
• Ensure direct nursing care is provided by a licensed nurse, certified nursing assistant, or nurse aide trainee qualified to perform the procedure
• Cooperate with and coordinate social and activity programs with nursing service schedules
• Notify the resident's attending physician when resident is involved in an accident or incident
• Notify resident's attending physician and next-of-kin when there is a change in resident's condition
• Carry out restorative and rehabilitative programs, including self-help and care
• Inspect nursing service treatment areas daily to ensure they are maintained in a clean and safe manner
• Administer professional services including catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, drawing blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required
• Use restraints when necessary in accordance with established policies and procedures
• Obtain sputum, urine, and other specimens for lab tests as ordered
• Take and record TPRs, blood pressures, etc., as necessary
• Monitor seriously ill residents as necessary
• Check foods brought into the facility by family/visitors to ensure they are within resident's dietary allowances; report problem areas to the Nurse Supervisor and Dietary Supervisor
• Ensure personnel providing direct care to residents do so in accordance with the resident's care plan and wishes
• Ensure residents who are unable to call for help are checked frequently
• Meet with residents and/or family members as necessary; report problem areas to the Nurse Supervisor
• Assist in arranging transportation for discharged residents as necessary
• Ensure discharged residents are escorted to the pick-up area
• Inform family members of the death of the resident; call funeral homes when requested by family
• Ensure established post-mortem procedures are followed

Staff Development

• Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on "how to do the job" and ensure a well-educated nursing service department
• Implement and maintain an effective orientation program that orients new employees to your shift, its policies and procedures, and to their job position and duties