LPN

Essential Duties

• Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
• Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
• Periodically review the department’s policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.
• Meet with your assigned nursing staff, as well as support personnel, in planning the shifts’ services, programs, and activities.
• Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this facility.
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual.
• Made written and oral reports/recommendations concerning the activities of your shift as required.
• Cooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.
• Avoid disclosing assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
• 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.
• Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.
• Charting and Documentation
• Complete and file required recordkeeping forms/charts upon the resident’s admission, transfer, and/or discharge.
• Encourage attending physicians to review treatment plans, record and sign their 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 that reflects the care provided to the resident, as well as the resident’s response to the care.
• Fill out and complete accident/incident reports.
• Submit to Director as required.
• Chart all reports of accidents/incidents involving residents.
• Follow established procedures.
• Record new/changed diet orders.
• 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 that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.
• 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 the identity of the resident before administering the medication/treatment.
• Ensure that prescribed medication for one resident is not administered to another.
• Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents.
• Report needs to the Nurse Supervisor.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
• Ensure that 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 the transcription of the physician’s order, and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage being administered.
• Dispose of drugs and narcotics as required, and in accordance with established procedures.
• Personnel Functions
• Participate in employee performance evaluations, determining your shift’s 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 your department’s work force 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 that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards.
• Report problem areas to the Nurse Supervisor.
• Ensure that all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program.
• Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.
• Meet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services.
• Ensure that department personnel, residents, and visitors follow the department’s established policies and procedures at all times.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.
• Review complaints and grievances made or filed by your assigned personnel.
• Make appropriate reports to the Nurse Supervisor as required or as may be necessary.
• Follow facility’s established procedures.
• Ensure that departmental disciplinary action is administered fairly and 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 the facility’s policies and procedures governing accidents and incidents.
• Report known or suspected incidents of fraud to the Administrator.
• Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.
• Nursing Care Functions
• Inform nursing personnel of new admissions, their expected time of arrival, room assignment, etc.
• Ensure that rooms are ready for new admissions.
• Greet newly admitted residents upon admission.
• Escort them to their rooms as necessary.
• Participate in the 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, and in accordance with our established procedures.
• Consult with the resident’s physician in providing the resident’s 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 that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident’s physical and emotional status.
• Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and/or a 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 the resident is involved in an accident or incident.
• Notify the resident’s attending physician and next-of-kin when there is a change in the resident’s condition.
• Carry out restorative and rehabilitative programs, to include self-help and care.
• Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.
• Administer professional services such as; catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required.
• Use restraints when necessary and in accordance with established policies and procedures.
• Obtain sputum, urine and other specimens for lab tests as ordered.
• Monitor seriously ill residents as necessary.
• Check foods brought into the facility by the resident’s family/visitors to ensure that it is within the resident’s dietary allowances.
• Report problem areas to the Nurse Supervisor and Dietary Supervisor.
• Ensure that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.
• Ensure that 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.
• Admit, transfer and discharge residents as necessary.
• Assist in arranging transportation for discharged residents as necessary.
• Ensure that discharged residents are escorted to the pick-up area.
• Inform family members of the death of the resident.
• Call funeral homes when requested by the family.
• Ensure that 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 the new employee to your shift, its policies and procedures, and to his/her job position and duties.