LPN (7pm-7am)

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 adhere to 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 comply with their job descriptions.
• Participate in the facility’s quality assurance program for the nursing service department.
• 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.
• Protect resident and facility information by not disclosing assigned user ID codes, passwords, or protected health information.
• Report unauthorized access attempts or suspected violations of information security.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon resident admission, transfer, or discharge.
• Encourage physicians to review treatment plans and sign orders in accordance with policies.
• Receive and record telephone orders from physicians on the Physicians’ Order Form.
• Transcribe physician orders to resident charts, cardex, medication cards, and treatment/care plans.
• Chart nurses’ notes descriptively to reflect care provided and resident responses.
• Complete and submit accident/incident reports as required.
• Record new or changed diet orders and forward information to the Food Services Department.
• Report discrepancies in physician 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 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, or other staffing needs.
• Inform the Nurse Supervisor of staffing needs due to absences or call-ins.
• Review and evaluate the department’s workforce and recommend 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 work assignments according to 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.
• Meet regularly with nursing personnel to address problem areas and improve services.
• Ensure compliance with department policies and procedures by personnel, residents, and visitors.
• Maintain a good working rapport with inter-departmental personnel.
• Create a warm, positive, and calm environment throughout the unit and shift.
• Review and address complaints and grievances filed by 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, or hazardous chemicals.
• Report suspected incidents of fraud to the Administrator.
• Ensure unattended workstations are 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 physicians.
• Consult with physicians regarding resident 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 or qualified nursing assistants.
• 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, and range of motion exercises.
• Use restraints when necessary and in accordance with policies.
• Obtain specimens for lab tests as ordered (e.g., sputum, urine).
• Monitor 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 family members to address concerns.
• Admit, transfer, and discharge residents as necessary.
• Assist in arranging transportation for discharged residents.
• 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.