PRN LVN

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 be in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as required by the Director of Nursing Services or Nurse Supervisor to ensure the highest degree of quality care is maintained at all times.

Responsibilities

• Direct the day-to-day functions of nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
• Ensure all nursing personnel comply with written policies and procedures established by the facility.
• Periodically review department policies, procedure manuals, and job descriptions; make recommendations for revisions.
• Meet with assigned nursing staff and support personnel to plan shift services, programs, and activities.
• Ensure the Nursing Service Procedures Manual is current and reflects daily nursing procedures; verify compliance with its procedures.
• Make written and oral reports/recommendations concerning shift activities as required.
• Coordinate nursing services 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 conducted by authorized government agencies.
• Periodically review and update resident discharge plans as required; assist in planning the nursing portion of discharge plans.
• Interpret department policies and procedures to personnel, residents, visitors, and government agencies.
• Admit, transfer, and discharge residents as required.
• Complete accident/incident reports as necessary; write resident charge slips and forward to the Business Office.
• Maintain the Daily Census Report and submit to the Business Office.
• Perform administrative duties including completing medical forms, reports, evaluations, studies, and charting.
• Ensure compliance with user ID code, password, and protected health information policies; report suspected violations.
• Report unauthorized attempts to access facility information systems.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon resident admission, transfer, and/or discharge.
• Encourage attending physicians to review, record, and sign treatment plans, orders, and progress notes in accordance with policies.
• Receive telephone orders from physicians and record on the Physicians’ Order Form; transcribe 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 response.
• Fill out and complete accident/incident reports; submit to Director as required.
• Chart all accident/incident reports involving residents following established procedures.
• Record new/changed diet orders and forward information to the Food Services Department.
• Report discrepancies in physician’s orders, diet changes, charting errors, etc., to the Nurse Supervisor.
• Fill out and complete transfer forms in accordance with established procedures.
• Ensure documentation of unauthorized discharges in the resident’s medical record per established procedures.
• Perform routine charting duties in accordance with established policies; sign and 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 prescribed medication is not administered to another resident.
• Maintain an adequate supply of floor stock medications, supplies, and equipment; report needs to the Nurse Supervisor.
• Order prescribed medications, supplies, and equipment in accordance with established policies.
• Ensure narcotic records are accurate for your shift; notify the Nurse Supervisor of all drug and narcotic discrepancies.
• Review medication cards for completeness, accuracy of transcribed orders, and adherence to stop order policies.
• Notify attending physicians of automatic stop orders prior to the last dosage being administered.
• Dispose of drugs and narcotics as required and in accordance with established procedures.

Personnel Functions

• Participate in employee performance evaluations and determine shift staffing requirements; make recommendations to the Nurse Supervisor regarding dismissals, transfers, etc.
• Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work; report absentee call-ins.
• Review and evaluate the department’s workforce; make recommendations to the Nurse Supervisor.
• Develop work assignments and/or assist in completing and performing such assignments.
• Provide leadership to nursing personnel assigned to your unit/shift.
• Make daily rounds to ensure nursing service personnel perform work assignments in accordance with acceptable nursing standards; report problem areas.
• Ensure all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program; ensure nurse aide trainees are under direct supervision of a licensed nurse.
• Meet regularly with shift nursing personnel to identify and correct problem areas and improve services.
• Ensure department personnel, residents, and visitors follow established policies and procedures.
• Develop and maintain a positive working rapport with inter-departmental and other facility departments to support resident needs.
• Create and maintain a warm, supportive, and calm environment throughout the unit and shift.
• Review complaints and grievances filed by assigned personnel; make appropriate reports to the Nurse Supervisor.
• Ensure disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
• Receive/give the 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 the Administrator.
• Ensure unattended departmental computer workstations are logged off or protected by password-activated screen savers per facility policy.

Nursing Care Functions

• Inform nursing personnel of new admissions, expected arrival times, and room assignments; ensure rooms are ready.
• Greet newly admitted residents and escort them to their rooms as necessary.
• Participate in 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.
• Consult with the resident’s physician in providing care, treatment, and rehabilitation as necessary.
• Review resident charts for treatments, medication orders, diets, etc.
• Implement and maintain established nursing objectives and standards; periodically check that prescribed treatments are properly administered by certified nursing assistants.
• Evaluate residents’ physical and emotional status; ensure direct nursing care is provided by qualified personnel.
• Coordinate social and activity programs with nursing service schedules.
• Notify the resident’s attending physician and next-of-kin of accidents, incidents, or changes in condition.
• 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 changes, colostomy and drainage care, blood draws, massages, range of motion exercises, post-mortem care, etc., as required.
• Use restraints when necessary and in accordance with established policies and procedures.
• 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.
• Check foods brought in by family/visitors to ensure compliance with dietary allowances; report issues to Nurse Supervisor and Dietary Supervisor.
• Ensure personnel provide care in accordance with the resident’s care plan and wishes; check frequently on residents unable to call for help.
• Meet with residents and/or family members as necessary; report problem areas to the Nurse Supervisor.
• Assist in arranging transportation for discharged residents; ensure discharged residents are escorted to the pick-up area.
• Inform family members of a resident’s death; call funeral homes when requested; ensure post-mortem procedures are followed.

Staff Development

• Participate in developing, planning, conducting, and scheduling in-service training classes to ensure a well-educated nursing service department.
• Implement and maintain an effective orientation program that orients new employees to the shift, its policies and procedures, and their job positions.