MDS RN-S

Responsibilities

• Administer patient assessments, oversee the assessment process, set assessment schedules, and ensure assessments are completed 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 the 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 and recommend revisions to departmental policies, procedure manuals, and job descriptions.
• Plan and coordinate shifts’ services, programs, and activities with assigned nursing staff and support personnel.
• Maintain and ensure compliance with the Nursing Service Procedures Manual.
• Provide 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.
• Maintain confidentiality of assigned user ID codes, passwords, and resident protected health information.
• Report unauthorized attempts to access facility information systems and suspected violations of confidentiality policies.

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 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 descriptively to reflect care provided and resident’s response.
• Complete and submit accident/incident reports as required.
• Record new or changed diet orders and forward information to the Food Services Department.
• Report discrepancies in 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 ensure all entries in the resident’s medical record are signed and dated.

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.
• 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., to the Nurse Supervisor.
• Inform the Nurse Supervisor of staffing needs due to absences or call-ins.
• 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 duties according to standards.
• Ensure all nursing assistants are enrolled in or have graduated from an approved training program.
• Supervise nurse aide trainees under the direct supervision of a licensed nurse.
• Meet regularly with nursing personnel to identify and correct problem areas or improve services.
• Ensure compliance with department policies and procedures by personnel, residents, and visitors.
• Develop and maintain good working relationships with interdepartmental personnel.
• Create a positive, 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 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, prepare rooms, and greet newly admitted residents.
• 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 residents’ physicians regarding care, treatment, and rehabilitation.
• Review resident charts for specific treatments, medication orders, and diets.
• Implement and maintain established nursing objectives and standards.
• Evaluate residents’ physical and emotional status through periodic checks.
• 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 residents’ conditions or accidents/incidents.
• 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 such as catheterization, tube feedings, suction, wound care, and range of motion exercises.
• Use restraints when necessary and in accordance with established policies.
• Obtain specimens for lab tests as ordered and monitor vital signs.
• Monitor seriously ill residents as necessary.
• Check foods brought in by family/visitors to ensure compliance with dietary allowances.
• Ensure direct care personnel follow residents’ care plans and wishes.
• Frequently check on residents unable to call for help.
• Meet with residents and/or family members as needed and report issues to the Nurse Supervisor.
• Admit, transfer, and discharge residents as necessary, including arranging transportation.
• Follow established post-mortem procedures and inform family members of resident deaths.

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 planning in-service education programs to ensure a well-educated nursing service department.