PT LVN 10p-6a

General Purpose

Provide direct nursing care to residents and supervise day-to-day nursing activities performed by nursing assistants in accordance with federal, state, and local standards, guidelines, and regulations governing the facility, as required by the Director of Nursing Services or Nurse Supervisor, to ensure the highest degree of quality care is maintained at all times.

Administrative Functions

• Direct day-to-day functions of nursing assistants in accordance with current rules, regulations, and guidelines governing the long-term care facility.
• Ensure all nursing personnel assigned comply with written policies and procedures established by the facility.
• Periodically review department policies, procedure manuals, job descriptions, etc., and make recommendations for revisions.
• Meet with assigned nursing staff and support personnel in planning shift services, programs, and activities.
• Ensure Nursing Service Procedures Manual is current and reflects day-to-day nursing procedures performed in the facility.
• Ensure all nursing service personnel comply with procedures set forth in the Nursing Service Procedures Manual.
• Make written and oral reports/recommendations concerning shift activities as required.
• Cooperate with other resident services when coordinating nursing services to ensure total regimen of care is maintained.
• Ensure all nursing service personnel are in compliance with their respective job descriptions.
• Participate in development, maintenance, and implementation of the facility's quality assurance program for the nursing service department.
• Participate in facility surveys (inspections) made by authorized government agencies as requested.
• Periodically review and participate in updating resident's written discharge plan as required.
• Assist in planning nursing services portion of resident's discharge plan as necessary.
• Interpret department policies and procedures to personnel, residents, visitors, and government agencies as required.
• Admit, transfer, and discharge residents as required.
• Complete accident/incident reports as necessary.
• Write resident charge slips and forward to Business Office.
• Maintain Daily Census Report and submit to Business Office as required.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
• Agree not to disclose assigned user ID code and password for accessing resident/facility information; promptly report suspected or known violations of such disclosure to the Administrator.
• Agree not to disclose resident's protected health information; promptly report suspected or known violations to the Administrator.
• Report any known or suspected unauthorized attempt to access facility's information system.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon resident's admission, transfer, and/or discharge.
• Encourage attending physicians to review treatment plans, record and sign orders, progress notes, etc., in accordance with established policies.
• Receive telephone orders from physicians and record on Physicians' Order Form.
• Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans, as required.
• Chart nurses' notes in an informative and descriptive manner reflecting care provided and resident's response to care.
• Fill out and complete accident/incident reports; submit to Director as required; chart all reports of accidents/incidents involving residents following established procedures.
• Record new/changed diet orders; forward information to Food Services Department.
• Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to Nurse Supervisor.
• Fill out and complete transfer forms in accordance with established procedures.
• Ensure appropriate documentation concerning unauthorized discharges is entered in resident's medical record in accordance with established procedures.
• Perform routine charting duties as required in accordance with established policies and procedures.
• Sign and date all entries made in resident's medical record.

Drug Administration Functions

• Prepare and administer medications as ordered by physician.
• Verify identity of resident before administering medication/treatment.
• Ensure prescribed medication for one resident is not administered to another.
• Ensure adequate supply of floor stock medications, supplies, and equipment is on hand; report needs to Nurse Supervisor.
• Order prescribed medications, supplies, and equipment as necessary in accordance with established policies.
• Ensure narcotic records are accurate for your shift; notify Nurse Supervisor of all drug and narcotic discrepancies noted.
• Review medication cards for completeness of information, accuracy in transcription of physician's order, and adherence to stop order policies.
• Notify attending physician of automatic stop orders prior to last dosage being administered.
• Dispose of drugs and narcotics as required in accordance with established procedures.

Personnel Functions

• Participate in employee performance evaluations, determining shift staffing requirements, and making recommendations to Nurse Supervisor concerning employee dismissals, transfers, etc.
• Inform Nurse Supervisor of staffing needs when assigned personnel fail to report to work; report absentee call-ins.
• Review and evaluate department's work force; make recommendations to Nurse Supervisor.
• Develop work assignments and/or assist in completing and performing such assignments.
• Provide leadership to nursing personnel assigned to unit/shift.
• Make daily rounds to ensure nursing service personnel are performing work assignments in accordance with acceptable nursing standards; report problem areas to Nurse Supervisor.
• Ensure all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program.
• Ensure all nurse aide trainees are under direct supervision of a licensed nurse.
• Meet with shift nursing personnel on a regularly scheduled basis to assist in identifying and correcting problem areas and/or to improve services.
• Ensure department personnel, residents, and visitors follow established policies and procedures at all times.
• Develop and maintain good working rapport with inter-departmental personnel and other departments to ensure nursing services can be adequately maintained to meet resident needs.
• Create and maintain atmosphere of warmth, personal interest, positive emphasis, and calm environment throughout unit and shift.
• Review complaints and grievances made or filed by assigned personnel; make appropriate reports to Nurse Supervisor as required; follow facility's established procedures.
• Ensure departmental disciplinary action is administered fairly without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
• Receive/give nursing report upon reporting in and ending shift duty hours.
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with facility policies and procedures governing accidents and incidents.
• Report known or suspected incidents of fraud to Administrator.
• Ensure departmental computer workstations left unattended are properly logged off or password-protected automatic screen-saver activates within established policy guidelines.

Nursing Care Functions

• Inform nursing personnel of new admissions, expected time of arrival, room assignment, etc.; ensure rooms are ready.
• Greet newly admitted residents upon admission; escort to rooms as necessary.
• Participate in orientation of new residents/family members to the facility.
• Make rounds with physicians as necessary.
• Requisition and arrange for diagnostic and therapeutic services as ordered by physician in accordance with established procedures.
• Consult with resident's physician in providing care, treatment, rehabilitation, etc., as necessary.
• Review resident's chart for specific treatments, medication orders, diets, etc., as necessary.
• Implement and maintain established nursing objectives and standards.
• Make periodic checks to ensure prescribed treatments are properly administered by certified nursing assistants and to evaluate resident's physical and emotional status.
• Ensure direct nursing care is provided by a licensed nurse, certified nursing assistant, and/or nurse aide trainee qualified to perform the procedure.
• Cooperate with and coordinate social and activity programs with nursing service schedules.
• Notify resident's attending physician when resident is involved in an accident or incident.
• Notify resident's attending physician and next-of-kin when there is a change in resident's condition.
• Carry out restorative and rehabilitative programs, including self-help and care.
• Inspect nursing service treatment areas daily to ensure they are maintained in a clean and safe manner.
• Administer professional services such as catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, blood draws, massages and range of motion exercises, care for dead/dying, etc., as required.
• Use restraints when necessary in accordance with established policies and procedures.
• Obtain sputum, urine, and other specimens for lab tests as ordered.
• Take and record TPRs, blood pressures, etc., as necessary.
• Monitor seriously ill residents as necessary.
• Check foods brought into facility by resident's family/visitors to ensure they are within dietary allowances; report problem areas to Nurse Supervisor and Dietary Supervisor.
• Ensure personnel providing direct care are doing so in accordance with resident's care plan and wishes.
• Ensure residents unable to call for help are checked frequently.
• Meet with residents and/or family members as necessary; report problem areas to Nurse Supervisor.
• Admit, transfer, and discharge residents as necessary.
• Assist in arranging transportation for discharged residents as necessary; ensure discharged residents are escorted to pick-up area.
• Inform family members of death of resident; call funeral homes when requested by family; ensure established post-mortem procedures are followed.

Staff Development

• Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on "how to do the job" and ensure a well-educated nursing service department.
• Implement and maintain effective orientation program that orients new employees to shift, policies and procedures, and job position and duties.