LVN Full Time - CCHC

General Purpose

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

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 the facility's written policies and procedures.
• Periodically review department policies, procedure manuals, job descriptions, etc., 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 shift activities as required.
• Cooperate with other resident services when coordinating nursing services to ensure the resident's total regimen of care is maintained.
• 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 its updating 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.
• Do not disclose assigned user ID code and password for accessing resident/facility information; promptly report suspected or known violations of such disclosure to the Administrator.
• Do not disclose resident protected health information; promptly report suspected or known violations to the Administrator.
• Report any known or suspected unauthorized attempt to access the 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, and treatment/care plans as required.
• Chart nurses' notes in an informative and descriptive manner reflecting the care provided and the resident's response.
• Fill out and complete accident/incident reports and submit to Director as required; chart all reports of accidents/incidents 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 changes, charting errors, 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 the 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 to meet resident nursing needs; report needs to the Nurse Supervisor.
• Order prescribed medications, supplies, and equipment as necessary and in accordance with established policies.
• Ensure narcotic records are accurate for your shift; notify the Nurse Supervisor of all drug and narcotic discrepancies noted.
• Review medication cards for completeness of information, accuracy in transcription of physician's orders, 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 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 the 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 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 and that all nurse aide trainees are under the direct supervision of a licensed nurse.
• Meet with shift nursing personnel on a regularly scheduled basis to assist in identifying and correcting problem areas and/or improving services.
• Ensure department personnel, residents, and visitors follow department policies and procedures at all times.
• Develop and maintain good working rapport with inter-departmental personnel and other departments to ensure nursing services can be adequately maintained to meet resident needs.
• 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 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.
• Report known or suspected incidents of fraud to the Administrator.
• Ensure 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, expected time of arrival, room assignment, etc.; ensure rooms are ready for new admissions.
• Greet newly admitted residents upon admission and 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 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 the resident's physical and emotional status.
• Ensure direct nursing care is provided by a licensed nurse, certified nursing assistant, and/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 the resident is involved in an accident or incident and when there is a change in the resident's condition.
• 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, 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 such as 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 and 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 the resident's dietary allowances; report problem areas to the Nurse Supervisor and Dietary Supervisor.
• Ensure personnel providing direct care to residents are doing 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.
• Admit, transfer, and discharge residents as necessary.
• 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 the 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" to 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 their job position and duties.