LPN (Night Shift 6p-6a) *Long-Term Care Nurse - Palm Valley Post Acute

About the role

Provide direct nursing care to residents and supervise day-to-day nursing activities performed by nursing assistants in accordance with federal, state, and local regulations, under the direction of the Director of Nursing Services or Nurse Supervisor.

Administrative Functions

• Direct day-to-day functions of nursing assistants in compliance with long-term care regulations and facility policies
• Review and recommend revisions to department policies, procedure manuals, and job descriptions
• Meet with nursing staff and support personnel to plan shift services and activities
• Ensure Nursing Service Procedures Manual is current and followed by all personnel
• Make written and oral reports on shift activities as required
• Coordinate nursing services with other resident services to maintain total regimen of care
• Ensure compliance of all nursing personnel with job descriptions
• Participate in quality assurance program development and implementation
• Participate in facility surveys by government agencies as requested
• Review and update resident discharge plans as required
• Interpret department policies to personnel, residents, visitors, and government agencies
• Admit, transfer, and discharge residents as required
• Complete accident/incident reports as necessary
• Write resident charge slips and maintain Daily Census Report
• Complete medical forms, reports, evaluations, studies, and charting
• Protect confidential resident and facility information; report suspected disclosure violations or unauthorized access attempts

Charting and Documentation

• Complete and file required recordkeeping forms upon resident admission, transfer, and discharge
• Encourage attending physicians to review treatment plans and record orders
• Receive and transcribe physician telephone orders to resident charts, cardex, medication cards, and treatment/care plans
• Chart nurses' notes reflecting care provided and resident response
• Complete and submit accident/incident reports following established procedures
• Record new/changed diet orders and forward to Food Services
• Report discrepancies in physician's orders, diet changes, or charting errors to Nurse Supervisor
• Complete transfer forms and ensure proper documentation of unauthorized discharges
• Perform routine charting in accordance with established policies
• Sign and date all entries in resident medical records

Drug Administration Functions

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

Personnel Functions

• Participate in employee performance evaluations and make recommendations on dismissals and transfers
• Inform Nurse Supervisor of staffing needs and report absentee call-ins
• Review department workforce and make recommendations to Nurse Supervisor
• Develop work assignments and provide leadership to nursing personnel
• Make daily rounds to ensure performance meets acceptable nursing standards
• Report problem areas to Nurse Supervisor
• Ensure nursing assistants are enrolled in or have graduated from approved training programs
• Ensure nurse aide trainees are under direct licensed nurse supervision
• Meet regularly with shift nursing personnel to identify and correct problem areas
• Ensure residents and visitors follow established policies and procedures
• Develop and maintain working rapport with inter-departmental personnel
• Create atmosphere of warmth, personal interest, and calm environment
• Review complaints from assigned personnel and make reports to Nurse Supervisor
• Ensure disciplinary action is administered fairly without discrimination
• Give and receive nursing reports at shift changes
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals
• Report known or suspected fraud to Administrator
• Ensure computer workstations are properly logged off or password-protected when unattended

Nursing Care Functions

• Inform nursing personnel of new admissions, expected arrival times, and room assignments
• Ensure rooms are ready for new admissions; greet and escort new residents
• Participate in orientation of new residents and family members
• Make rounds with physicians as necessary
• Requisition diagnostic and therapeutic services as ordered by physician
• Consult with resident's physician on care, treatment, and rehabilitation as necessary
• Review resident charts for treatments, medication orders, and diets
• Implement and maintain established nursing objectives and standards
• Make periodic checks to ensure prescribed treatments are properly administered and evaluate resident status
• Coordinate social and activity programs with nursing service schedules
• Notify attending physician of accidents, incidents, or changes in resident condition
• Notify next-of-kin when there is a change in resident condition
• Carry out restorative and rehabilitative programs including self-help and care
• Inspect nursing service treatment areas daily for cleanliness and safety
• Administer professional services including catheterization, tube feedings, suction, dressings/bandages, colostomy care, drainage bags, blood draws, massages, range of motion exercises, and post-mortem care
• Use restraints when necessary in accordance with established policies
• Obtain sputum, urine, and other specimens for lab tests
• Take and record TPRs, blood pressures, and other vital signs
• Monitor seriously ill residents as necessary
• Check foods brought in by family/visitors for dietary compliance; report concerns to Nurse Supervisor and Dietary Supervisor
• Ensure direct care is provided in accordance with resident's care plan and wishes
• Ensure residents unable to call for help are checked frequently
• Meet with residents and family members as necessary
• Assist in arranging transportation for discharged residents and ensure they are escorted to pick-up area
• Inform family members of resident death and call funeral homes when requested
• Ensure established post-mortem procedures are followed

Staff Development

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