LVN/LPN

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, as directed by the Director of Nursing Services or Nurse Supervisor.

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 facility policies and procedures
• Periodically review department policies, procedure manuals, job descriptions, and make revision recommendations
• 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 procedures
• Ensure all nursing service personnel comply with 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 maintain total regimen of care
• Ensure all nursing service personnel comply with their job descriptions
• Participate in development, maintenance, and implementation of quality assurance program for nursing service department
• Participate in facility surveys/inspections by authorized government agencies as requested
• Periodically review resident's written discharge plan and participate in updating as required
• Assist in planning nursing services portion of 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 Business Office
• Maintain Daily Census Report and submit to Business Office as required
• Perform administrative duties including completing medical forms, reports, evaluations, studies, charting, etc.
• Protect confidentiality of user ID codes, passwords, and resident protected health information; promptly report suspected/known violations or unauthorized access attempts

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.
• Receive telephone orders from physicians and record on Physicians' Order Form
• Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans as required
• Chart nurses' notes in informative and descriptive manner reflecting care provided and resident's response
• Complete and submit accident/incident reports to Director as required
• Chart all reports of accidents/incidents involving residents per established procedures
• Record new/changed diet orders and forward to Food Services Department
• Report discrepancies concerning physician's orders, diet changes, charting errors to Nurse Supervisor
• 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 per established policies and procedures
• Sign and date all entries made in resident's medical record

Drug Administration Functions

• Prepare and administer medications as ordered by physician
• Verify resident identity 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; report needs to Nurse Supervisor
• Order prescribed medications, supplies, and equipment as necessary per established policies
• Ensure narcotic records are accurate for shift; notify Nurse Supervisor of all drug and narcotic discrepancies
• Review medication cards for completeness, accuracy of 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 per established procedures

Personnel Functions

• Participate in employee performance evaluations, determining shift staffing requirements, and making recommendations to Nurse Supervisor concerning dismissals, transfers, etc.
• Inform Nurse Supervisor of staffing needs when assigned personnel fail to report; report absentee call-ins
• Review and evaluate department workforce and make recommendations to Nurse Supervisor
• Develop work assignments and/or assist in completing and performing such assignments
• Provide leadership to nursing personnel assigned to unit/shift
• Make daily rounds of unit/shift to ensure nursing service personnel perform work assignments in accordance with acceptable standards; report problem areas to Nurse Supervisor
• Ensure all nursing assistants are enrolled in or have graduated from approved training program
• Ensure all nurse aide trainees are under direct supervision of 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 to adequately maintain nursing services and activities
• Create and maintain atmosphere of warmth, personal interest, positive emphasis, and calm environment
• Review complaints and grievances made or filed by assigned personnel; make appropriate reports to Nurse Supervisor per established procedures
• 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 per facility policies
• Report known or suspected incidents of fraud to Administrator
• Ensure departmental computer workstations left unattended are properly logged off or password-protected screen-saver activates per policy

Nursing Care Functions

• Inform nursing personnel of new admissions, expected arrival time, room assignment, etc.; ensure rooms are ready
• Greet newly admitted residents upon admission; escort them to rooms as necessary
• Participate in 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 physician per established procedures
• Consult with resident's physician in providing care, treatment, rehabilitation, etc., as necessary
• Review 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 and to evaluate resident's physical and emotional status
• Ensure direct nursing care is provided by appropriately qualified personnel (licensed nurse, CNA, or nurse aide trainee)
• Cooperate with and coordinate social and activity programs with nursing service schedules
• Notify resident's attending physician when resident is involved in accident/incident
• Notify resident's attending physician and next-of-kin when change in resident's condition occurs
• 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 including catheterization, tube feedings, suction, dressing/bandage changes, packs, colostomy and drainage bags, blood draws, massage and range of motion exercises, post-mortem care, etc.
• Use restraints when necessary 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 in by family/visitors to ensure they are within resident's 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 as necessary
• Assist in arranging transportation for discharged residents; ensure they 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 performance to ensure well-educated nursing service department
• Implement and maintain effective orientation program for new employees to shift, policies, procedures, and job position duties