Nurse LPN

About the Role

The primary purpose of this position is to provide direct nursing care to residents and to supervise the day-to-day nursing activities performed by nursing assistants. Supervision must align with current federal, state, and local standards, guidelines, and regulations governing the facility, ensuring the highest degree of quality care is maintained at all times.

As a Licensed Practical Nurse, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties, in accordance with the LPN scope of practice defined by the Pennsylvania Nurse Practice Act.

Safety Factors: This role involves exposure to blood, body fluids, or tissues (Category I), requiring the use of personal protective equipment.

Responsibilities

Administrative Functions

• Direct the day-to-day functions of nursing assistants in accordance with facility rules, regulations, and guidelines.
• Ensure compliance with written policies and procedures for all assigned nursing personnel.
• Review and recommend revisions to department policies, procedure manuals, and job descriptions.
• Plan shifts’ services, programs, and activities with assigned nursing staff and support personnel.
• Maintain and ensure compliance with the Nursing Service Procedures Manual.
• Submit 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 facility’s quality assurance program for the nursing service department.
• Participate in facility surveys/inspections by authorized government agencies.
• Review and update residents’ written discharge plans as required.
• Assist in planning the nursing services portion of residents’ discharge plans.
• Interpret department policies 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, and charting.

Charting and Documentation

• Complete and file required recordkeeping forms/charts for resident admissions, transfers, and discharges.
• Encourage physicians to review treatment plans and sign orders/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, reflecting care provided and resident responses.
• Complete and submit accident/incident reports.
• Record new/changed diet orders and forward to the Dietary Department.
• Report discrepancies in physician’s orders, diet changes, or charting errors.
• Complete transfer forms and ensure 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/treatment.
• Ensure medications are not administered to the wrong resident.
• Maintain an adequate supply of floor stock medications, supplies, and equipment.
• Order prescribed medications, supplies, and equipment as necessary.
• Maintain accurate narcotic records and report discrepancies.
• Review medication cards for completeness and accuracy.
• Notify physicians of automatic stop orders prior to the last dosage.
• Dispose of drugs and narcotics in accordance with established procedures.

Personnel Functions

• Participate in employee performance evaluations and staffing requirement determinations.
• Make recommendations for employee dismissals or transfers.
• Inform the Nurse Supervisor of staffing needs due to absences.
• Review and evaluate the department’s workforce and make recommendations.
• Develop work assignments and assist in completing them.
• Provide leadership to nursing personnel assigned to your unit/shift.
• Conduct daily rounds to ensure nursing personnel perform duties according to standards.
• Supervise nurse aide trainees under the direct supervision of a licensed nurse.
• Hold regular meetings with shift personnel to address problem areas and improve services.
• Ensure compliance with department policies and procedures by personnel, residents, and visitors.
• Maintain a good working rapport with inter-departmental personnel.
• Create a warm, positive, and calm environment for residents and staff.
• Review complaints and grievances from assigned personnel and report to the Nurse Supervisor.
• Administer disciplinary action fairly and without bias.
• Receive/give nursing reports at shift changes.
• Report occupational exposures to blood, body fluids, or hazardous chemicals.

Nursing Care Functions

• Inform nursing personnel of new admissions, room assignments, and expected arrival times.
• Prepare rooms for new admissions and participate in resident/family orientation.
• Make rounds with physicians as necessary.
• Requisition and arrange for diagnostic and therapeutic services as ordered by physicians.
• Consult with physicians regarding resident care, treatment, and rehabilitation.
• Review resident charts for treatments, medication orders, and diets.
• Implement and maintain nursing objectives and standards in accordance with the plan of care.
• Monitor certified nursing assistants to ensure proper administration of prescribed treatments.
• Cooperate with social and activity programs to align with nursing service schedules.
• Notify attending physicians and next-of-kin of changes in resident condition.
• 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, colostomy care, specimen collection, and range-of-motion exercises, as authorized by the Pennsylvania Nurse Practice Act.
• Use restraints when necessary and in accordance with established policies.
• Obtain specimens for lab tests as ordered (e.g., sputum, urine).
• Monitor vital signs (TPRs, blood pressures) as necessary.
• Monitor seriously ill residents as required.
• Check foods brought by family/visitors to ensure dietary compliance.
• Ensure direct care personnel follow the resident’s care plan and wishes.
• Frequently check residents unable to call for help.
• Meet with residents and/or family members to address concerns.
• Assist in arranging transportation for discharged residents.
• Escort discharged residents to the pick-up area.
• Inform family members of resident deaths and call funeral homes as requested.
• Follow established post-mortem procedures.

Staff Development

• Participate in developing, planning, and conducting in-service training classes.
• Provide instructions on job-specific tasks to ensure a well-educated nursing service department.
• Implement training programs to enhance staff skills and knowledge.