MDS RN-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 department 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 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 accident/incident reports and maintain the Daily Census Report.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, and charting.
• Protect resident and facility information by not disclosing assigned user ID codes, passwords, or protected health information.
• Report unauthorized attempts to access the facility's information system and any suspected violations.

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 their orders and progress notes.
• Receive and record telephone orders from physicians on the Physicians' Order Form.
• Transcribe physician's orders to resident charts, cardex, medication cards, and treatment/care plans.
• Chart nurses' notes in an informative and descriptive manner reflecting care provided and resident's response.
• Complete and submit accident/incident reports.
• Record new or changed diet orders and forward information to the Food Services Department.
• Report discrepancies concerning physician's orders, diet changes, or charting errors to the Nurse Supervisor.
• Complete transfer forms and ensure appropriate documentation for unauthorized discharges.
• Perform routine charting duties and sign/date all entries in the resident's medical record.

Drug Administration Functions

• Prepare and administer medications as ordered by the physician.
• Verify resident identity before administering medication or treatment.
• Ensure prescribed medication for one resident is not administered to another.
• Maintain an adequate supply of floor stock medications, supplies, and equipment.
• Report needs to the Nurse Supervisor and order prescribed medications, supplies, and equipment as necessary.
• Ensure narcotic records are accurate for your shift and report discrepancies to the Nurse Supervisor.
• Review medication cards for completeness, accuracy, and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage.
• Dispose of drugs and narcotics according to established procedures.

Personnel Functions

• Participate in employee performance evaluations and determine staffing requirements for your shift.
• Make recommendations concerning employee dismissals, transfers, etc.
• Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work.
• Review and evaluate the department's workforce and make recommendations to the Nurse Supervisor.
• Develop work assignments and assist in completing them.
• Provide leadership to nursing personnel assigned to your unit/shift.
• Make daily rounds to ensure nursing service personnel perform their work according to acceptable standards.
• Ensure all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program.
• Ensure nurse aide trainees are under the direct supervision of a licensed nurse.
• Meet with shift nursing personnel regularly to identify and correct problem areas or improve services.
• Ensure department personnel, residents, and visitors follow established policies and procedures.
• Develop and maintain good working relationships with interdepartmental personnel and other departments.
• Create and maintain a positive, calm environment throughout the unit and shift.
• Review complaints and grievances from assigned personnel and report to the Nurse Supervisor as necessary.
• Administer disciplinary action fairly and without bias.
• Receive and give nursing reports at the start and end of shift duty hours.
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals.
• Report known or suspected incidents of fraud to the Administrator.
• Ensure unattended computer workstations are properly logged off or password-protected.

Nursing Care Functions

• Inform nursing personnel of new admissions, their expected arrival time, and room assignments.
• Ensure rooms are ready for new admissions and greet newly admitted residents.
• Participate in the orientation of new residents and family members to the facility.
• Make rounds with physicians as necessary.
• Requisition and arrange for diagnostic and therapeutic services as ordered by the physician.
• Consult with the resident's physician regarding care, treatment, and rehabilitation.
• Review resident charts for specific treatments, medication orders, and diets.
• Implement and maintain established nursing objectives and standards.
• Make periodic checks to ensure prescribed treatments are administered properly and evaluate the resident's physical and emotional status.
• Ensure direct nursing care is provided by a licensed nurse, certified nursing assistant, or qualified nurse aide trainee.
• Coordinate social and activity programs with nursing service schedules.
• Notify the resident's attending physician and next of kin of any changes in the resident's condition or accidents/incidents.
• Carry out restorative and rehabilitative programs, including self-help and care.
• Inspect nursing service treatment areas daily to ensure they are clean and safe.
• Administer professional services such as catheterization, tube feedings, suction, dressings/bandages, colostomy care, and more.
• Use restraints when necessary and in accordance with established policies.
• Obtain sputum, urine, and other specimens for lab tests as ordered.
• Take and record vital signs (TPRs, blood pressures) as necessary.
• Monitor seriously ill residents as needed.
• Check foods brought into the facility by family/visitors to ensure compliance with dietary allowances.
• Ensure personnel provide care in accordance with the resident's care plan and wishes.
• Frequently check on residents who are unable to call for help.
• Meet with residents and/or family members as necessary and report problem areas to the Nurse Supervisor.
• Admit, transfer, and discharge residents as needed.
• Assist in arranging transportation for discharged residents and ensure they are escorted to the pickup area.
• Inform family members of a resident's death and call funeral homes when requested.
• Follow established post-mortem procedures.

Staff Development

• Participate in developing, planning, conducting, and scheduling in-service training classes.
• Implement and maintain an effective orientation program for new employees.
• Assist in educating the nursing service department to ensure well-trained staff.