LVN 12 hrs 6a-6p

General Purpose

Provide direct nursing care to residents and supervise day-to-day nursing activities performed by nursing assistants, in accordance with federal, state, and local standards, guidelines, and regulations governing the facility, and as required by the Director of Nursing Services or Nurse Supervisor to maintain the highest degree of quality care at all times.

Administrative Functions

• Direct day-to-day functions of nursing assistants in accordance with current rules, regulations, and guidelines governing long-term care
• Ensure all nursing personnel comply with written policies and procedures
• Periodically review department policies, procedure manuals, job descriptions; make recommendations for revisions
• Meet with assigned nursing staff and support personnel to plan shift services, programs, and activities
• Ensure 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 shift activities
• Cooperate with other resident services when coordinating nursing services to ensure total regimen of care is maintained
• Ensure all nursing service personnel comply with respective job descriptions
• Participate in development, maintenance, and implementation of facility's quality assurance program
• Participate in facility surveys (inspections) by authorized government agencies
• Periodically review and participate in updating resident's written discharge plan
• Assist in planning nursing services portion of resident's discharge plan
• Interpret department policies and procedures to personnel, residents, visitors, and government agencies
• Admit, transfer, and discharge residents
• Complete accident/incident reports
• Write resident charge slips and forward to Business Office
• Maintain Daily Census Report and submit to Business Office
• Perform administrative duties including completing medical forms, reports, evaluations, studies, and charting
• Protect resident/facility information: do not disclose assigned user ID code and password; promptly report suspected or known violations of disclosure
• Protect resident's protected health information; promptly report suspected or known violations of disclosure
• 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's 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 Physicians' Order Form
• Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans
• Chart nurses' notes in informative and descriptive manner reflecting care provided and resident's response
• Fill out and complete accident/incident reports; submit to Director as required
• Chart all reports of accidents/incidents involving residents following established procedures
• Record new/changed diet orders; forward information to Food Services Department
• Report all discrepancies concerning physician's orders, diet change, charting errors, etc., to Nurse Supervisor
• Fill out and complete transfer forms in accordance with established procedures
• Ensure appropriate documentation concerning unauthorized discharges is entered in resident's medical record
• Perform routine charting duties as required and in accordance with established policies
• Sign and date all entries made in resident's medical record

Drug Administration Functions

• Prepare and administer medications as ordered by physician
• Verify identity of 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 Nurse Supervisor
• Order prescribed medications, supplies, and equipment as necessary
• Ensure narcotic records are accurate for your shift; notify Nurse Supervisor of all drug and narcotic discrepancies
• 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 last dosage being administered
• Dispose of drugs and narcotics as required and in accordance with established procedures

Personnel Functions

• Participate in employee performance evaluations; determine shift staffing requirements; make recommendations to Nurse Supervisor concerning employee dismissals, transfers, etc.
• Inform Nurse Supervisor of staffing needs when assigned personnel fail to report; report absentee call-ins
• Review and evaluate department work force; make recommendations to Nurse Supervisor
• Develop work assignments and/or assist in completing and performing assignments
• Provide leadership to nursing personnel assigned to unit/shift
• Make daily rounds to ensure nursing service personnel perform work assignments in accordance with acceptable nursing standards; report problem areas to 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 regularly to identify and correct problem areas and improve services
• Ensure department personnel, residents, and visitors follow established policies and procedures
• Develop and maintain good working rapport with inter-departmental personnel
• Create and maintain atmosphere of warmth, personal interest, positive emphasis, and calm environment throughout unit and shift
• Review complaints and grievances made by assigned personnel; make appropriate reports to 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 nursing report upon reporting in and ending shift duty hours
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals
• Report known or suspected incidents of fraud to Administrator
• Ensure departmental computer workstations left unattended are properly logged off or password-protected automatic screen-saver activates

Nursing Care Functions

• Inform nursing personnel of new admissions, expected time of arrival, room assignment; ensure rooms are ready
• Greet newly admitted residents; escort them to rooms as necessary
• Participate in orientation of new residents/family members to facility
• Make rounds with physicians as necessary
• Requisition and arrange for diagnostic and therapeutic services as ordered by physician
• Consult with resident's physician in providing resident's care, treatment, rehabilitation, etc.
• Review resident's chart for specific treatments, medication orders, diets, etc.
• Implement and maintain established nursing objectives and standards
• Make periodic checks to ensure prescribed treatments are properly administered by certified nursing assistants and 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 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 clean and safe environment
• Administer professional services including catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, blood draws, massages and range of motion exercises, care for the dead/dying
• Use restraints when necessary in accordance with established policies
• Obtain sputum, urine, and other specimens for lab tests as ordered
• Take and record TPRs, blood pressures, etc.
• Monitor seriously ill residents as necessary
• Check foods brought into facility by resident's family/visitors to ensure within dietary allowances; report problem areas to Nurse Supervisor and Dietary Supervisor
• Ensure personnel providing direct care do so in accordance with resident's care plan and wishes
• Ensure residents unable to call for help are checked frequently
• Meet with residents and/or family members as necessary; report problem areas to Nurse Supervisor
• Admit, transfer, and discharge residents; assist in arranging transportation for discharged residents as necessary
• Ensure discharged residents are escorted to pick-up area
• Inform family members of resident's death; 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 providing instructions on job duties
• Implement and maintain effective orientation program for new employees to shift, policies and procedures, and job position