PT LVN 2P-10P

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, and as directed by the Director of Nursing Services or Nurse Supervisor.

Administrative Functions

• Direct day-to-day functions of nursing assistants in accordance with current rules, regulations, and guidelines governing long-term care.
• Ensure nursing personnel comply with facility written policies and procedures.
• Periodically review department policies, procedure manuals, and job descriptions; make revision recommendations.
• Meet with assigned nursing staff and support personnel to plan shift services, programs, and activities.
• Ensure Nursing Service Procedures Manual reflects current day-to-day procedures and that personnel comply with it.
• Make written and oral reports/recommendations concerning shift activities as required.
• Cooperate with other resident services to coordinate total regimen of care.
• Ensure nursing service personnel comply with their job descriptions.
• Participate in developing, maintaining, and implementing the facility's quality assurance program.
• Participate in facility surveys/inspections by authorized government agencies as requested.
• Periodically review and participate in updating resident discharge plans.
• 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 and write resident charge slips; forward to Business Office.
• Maintain Daily Census Report and submit to Business Office as required.
• Complete medical forms, reports, evaluations, studies, and charting as necessary.
• Protect confidential resident/facility information; report suspected/known violations or unauthorized access attempts.

Charting and Documentation

• Complete and file required forms/charts upon resident admission, transfer, and discharge.
• Encourage physicians to review treatment plans and sign orders/progress notes per policy.
• Receive and record telephone orders from physicians on Physician's Order Form.
• Transcribe physician's orders to resident charts, cardex, medication cards, and treatment/care plans as required.
• Chart nurses' notes descriptively reflecting care provided and resident response.
• Complete and submit accident/incident reports as required; chart all incidents.
• Record new/changed diet orders and forward information to Food Services.
• Report discrepancies concerning physician orders, diet changes, charting errors, etc., to Nurse Supervisor.
• Complete transfer forms and documentation for unauthorized discharges per procedures.
• Perform routine charting and sign/date all entries in resident medical records.

Drug Administration Functions

• Prepare and administer medications as ordered by the physician; verify resident identity before administration.
• Ensure medications are not administered to the wrong resident.
• Ensure adequate floor stock medications, supplies, and equipment are on hand; report needs to Nurse Supervisor.
• Order prescribed medications, supplies, and equipment per established policies.
• Ensure narcotic records are accurate for your shift; notify Nurse Supervisor of any discrepancies.
• Review medication cards for completeness, transcription accuracy, and adherence to stop order policies.
• Notify attending physician of automatic stop orders prior to last dosage.
• Dispose of drugs and narcotics per established procedures.

Personnel Functions

• Participate in employee performance evaluations, staffing determinations, and recommendations regarding dismissals/transfers.
• Inform Nurse Supervisor of staffing needs due to absenteeism or call-ins.
• Review and evaluate workforce; make recommendations to 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 staff perform assignments in accordance with acceptable nursing standards.
• Ensure nursing assistants are enrolled in or have graduated from an approved training program and that trainees are under direct licensed nurse supervision.
• Meet regularly with shift nursing personnel to identify and correct problem areas and improve services.
• Ensure department personnel, residents, and visitors follow department policies.
• Develop good working rapport with inter-departmental personnel to maintain adequate nursing services.
• Maintain a warm, personal, positive, and calm environment throughout the unit and shift.
• Review complaints/grievances from assigned personnel and report to Nurse Supervisor as required.
• Administer discipline fairly without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
• Give and receive nursing reports at shift change.
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals per policy.
• Report suspected incidents of fraud to the Administrator.
• Ensure workstations are logged off or password-protected screens are active when unattended.

Nursing Care Functions

• Inform nursing personnel of new admissions, arrival times, and room assignments.
• Ensure rooms are ready and greet newly admitted residents; escort them to rooms as needed.
• Participate in orientation of new residents and family members.
• Make rounds with physicians as necessary.
• Requisition and arrange diagnostic and therapeutic services as ordered by the physician.
• Consult with the resident's physician regarding care, treatment, and rehabilitation as necessary.
• Review resident charts for treatment, medication orders, diets, etc.
• Implement and maintain nursing objectives and standards.
• Periodically check that certified nursing assistants properly administer prescribed treatments; evaluate residents' physical and emotional status.
• Ensure direct nursing care is provided only by licensed nurses, certified nursing assistants, or qualified nurse aide trainees.
• Cooperate and coordinate social and activity programs with nursing schedules.
• Notify attending physician when resident is involved in an accident/incident or has a change in condition; notify next-of-kin as appropriate.
• Carry out restorative and rehabilitative programs including self-help and care.
• Inspect nursing treatment areas daily for cleanliness and safety.
• Administer professional services such as catheterization, tube feedings, suction, dressing changes, colostomy and drainage bag care, blood draws, massages, range of motion exercises, post-mortem care, etc., as required.
• Use restraints in accordance with established policies.
• Obtain specimens for lab tests as ordered.
• Take and record TPRs, blood pressures, etc., as necessary.
• Monitor seriously ill residents as needed.
• Check food brought in by family/visitors to ensure it meets dietary allowances; report problems to Nurse Supervisor and Dietary Supervisor.
• Ensure direct care personnel provide care according to resident care plans and wishes.
• Check frequently on residents unable to call for help.
• Meet with residents and/or family members as necessary; report problems to Nurse Supervisor.
• Arrange transportation and escort discharged residents to pick-up area.
• Inform family of death and call funeral homes when requested; ensure post-mortem procedures are followed.

Staff Development

• Participate in developing, planning, conducting, and scheduling in-service training classes providing job instruction.
• Implement and maintain an effective orientation program for new employees to your shift, policies, procedures, and job duties.