MDS Nurse LVN/LPN-S

Responsibilities

• Administer patient assessments, oversee the assessment process, set assessment schedules, and ensure assessments are done accurately and timely.
• Coordinate care plans according to regulatory requirements.
• Create schedules for Medicare and Medicaid, initiate Medicare coverage for newly qualified patients, and send denial letters as needed.
• Stay updated on Medicare coverage changes and determine documents required for Medicaid reimbursement.
• Direct day-to-day functions of nursing assistants in compliance with facility rules, regulations, and guidelines.
• Ensure nursing personnel comply with facility policies and procedures, and periodically review departmental policies, procedure manuals, and job descriptions for revisions.
• Plan shifts’ services, programs, and activities with assigned nursing staff and support personnel.
• Maintain and ensure compliance with the Nursing Service Procedures Manual.
• Make written and oral reports concerning shift activities as required.
• Coordinate with other resident services to maintain the resident’s total regimen of care.
• Ensure nursing service personnel comply 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 and inspections by authorized government agencies.
• Review and update residents’ written discharge plans as required.
• Interpret department policies and procedures to personnel, residents, visitors, and government agencies.
• Admit, transfer, and discharge residents as required.
• Complete and submit accident/incident reports, resident charge slips, and the Daily Census Report.
• Perform administrative duties such as completing medical forms, reports, evaluations, and charting.
• Ensure confidentiality of assigned user ID codes, passwords, and resident’s protected health information.
• Report unauthorized attempts to access the facility’s information system.
• Complete and file required recordkeeping forms/charts upon resident admission, transfer, and/or discharge.
• Encourage physicians to review treatment plans and record/sign orders and progress notes.
• Receive and transcribe telephone orders from physicians to resident charts and related documents.
• Chart nurses’ notes descriptively reflecting care provided and resident responses.
• Fill out and submit accident/incident reports and chart all related incidents.
• Record new/changed diet orders and forward information to the Food Services Department.
• Prepare and administer medications as ordered by the physician, ensuring proper resident identification.
• Ensure an adequate supply of medications, supplies, and equipment, and report needs to the Nurse Supervisor.
• Maintain accurate narcotic records and report discrepancies.
• Review medication cards for completeness and accuracy, and notify physicians of automatic stop orders.
• Dispose of drugs and narcotics according to established procedures.
• Participate in employee performance evaluations and determine staffing requirements.
• Inform the Nurse Supervisor of staffing needs and absentee call-ins.
• Review and evaluate the department’s workforce and make recommendations for improvements.
• Develop work assignments and provide leadership to nursing personnel.
• Make daily rounds to ensure nursing service personnel perform duties according to standards.
• Ensure nursing assistants are enrolled in or have graduated from an approved training program.
• Meet regularly with nursing personnel to address and correct problem areas.
• Ensure compliance with department policies and procedures by personnel, residents, and visitors.
• Develop and maintain good working relationships with interdepartmental personnel.
• Create a positive and calm environment for residents and staff.
• Review and address complaints and grievances from assigned personnel.
• Administer disciplinary action fairly and without bias.
• Receive and give nursing reports at the start and end of shifts.
• Report occupational exposures to hazardous materials according to facility policies.
• Inform nursing personnel of new admissions, room assignments, and prepare rooms for new residents.
• Greet and escort newly admitted residents to their rooms.
• Participate in the orientation of new residents and family members.
• Make rounds with physicians as necessary and arrange for diagnostic and therapeutic services.
• Consult with physicians regarding resident care, treatment, and rehabilitation.
• Review resident charts for specific treatments, medication orders, and diets.
• Implement and maintain established nursing objectives and standards.
• Perform periodic checks to ensure prescribed treatments are administered properly.
• Ensure direct nursing care is provided by qualified personnel.
• Coordinate social and activity programs with nursing service schedules.
• Notify attending physicians and next of kin of changes in resident conditions or accidents/incidents.
• Carry out restorative and rehabilitative programs, including self-help and care.
• Inspect nursing service treatment areas daily for cleanliness and safety.
• Administer professional services such as catheterization, tube feedings, suction, wound care, and more.
• Use restraints when necessary and in accordance with policies.
• Obtain specimens for lab tests as ordered and take vital signs as necessary.
• Monitor seriously ill residents and check on residents unable to call for help.
• Ensure foods brought by family/visitors comply with resident dietary allowances.
• Meet with residents and/or family members to address concerns.
• Assist in arranging transportation for discharged residents and escort them to pick-up areas.
• Inform family members of resident deaths and coordinate with funeral homes as requested.
• Follow established post-mortem procedures.
• Participate in developing, planning, and conducting in-service training classes.
• Implement and maintain an effective orientation program for new employees.