RN

About the Role

The primary purpose of this position is to provide direct nursing care to residents and 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 an RN, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties within the RN scope of practice as defined by the Ohio Nurse Practice Act/ORC Chapter 4723.

This position 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 nurses and nursing assistants in accordance with facility rules, regulations, and guidelines.
• Ensure compliance with facility policies and procedures for all assigned nursing personnel.
• Review and recommend revisions to department policies, procedure manuals, and job descriptions.
• Plan and coordinate shift services, programs, and activities with assigned nursing staff and support personnel.
• Maintain and update the Nursing Service Procedures Manual to reflect current practices.
• Report and recommend improvements concerning unit activities to the Director of Nursing.
• Coordinate with other resident services to maintain the resident’s total regimen of care.
• Ensure nursing service personnel adhere to their job descriptions.
• Participate in the development and implementation of the facility’s quality assurance program for nursing services.
• Participate in facility surveys and inspections by authorized government agencies.
• Prepare the unit for pending facility surveys.
• Review and update resident discharge plans as required.
• Assist in planning the nursing services portion of resident discharge plans.
• Participate in weekly care conferences conducted by the physiatrist.
• Interpret department policies to personnel, residents, visitors, and government agencies.
• Admit, transfer, and discharge residents as required.
• Ensure accuracy of accident/incident reports.
• Complete administrative duties such as medical forms, reports, evaluations, and charting.

Charting and Documentation

• Complete and file required recordkeeping forms/charts for resident admission, transfer, and discharge.
• Review new admission charts for accuracy and completeness; follow up on identified areas.
• Encourage attending physicians to review treatment plans and sign orders.
• Review physician order processes for accuracy and transcribe orders to resident charts.
• Review nurse’s notes to ensure compliance with facility charting guidelines.
• Chart all reports of accidents/incidents involving residents.
• Report discrepancies in physician orders, diet changes, or charting errors to the Director of Nursing.
• Complete transfer forms and ensure appropriate documentation for unauthorized discharges.
• Perform routine charting duties in accordance with established policies.
• Sign and date all entries made in the resident’s medical record.

Drug Administration Functions

• Ensure unit staff prepare and administer medications as ordered by the physician.
• Maintain an adequate supply of floor stock medications, supplies, and equipment.
• Order prescribed medications, supplies, and equipment as necessary.
• Ensure accuracy of narcotic records and report discrepancies to the Director of Nursing.
• Review medication records for completeness and adherence to stop order policies.
• Notify attending 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 determine unit staffing requirements.
• Make recommendations to the Director of Nursing concerning employee dismissals or transfers.
• Inform the Director of Nursing 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 the unit.
• Make 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 nursing personnel to address and correct problem areas.
• Ensure compliance with department policies and procedures by unit personnel, residents, and visitors.
• Maintain a good working rapport with inter-departmental personnel.
• Create and maintain a warm, calm, and positive environment on the unit.
• Review and address complaints and grievances filed by assigned personnel.
• Administer disciplinary action fairly and without bias.
• Receive and give nursing reports at the start and end of duty hours.
• Report occupational exposures to blood, body fluids, or hazardous chemicals.

Nursing Care Functions

• Inform nursing personnel of new admissions, including arrival time and room assignment.
• Prepare rooms for new admissions.
• Participate in the orientation of new residents and family members.
• Arrange for diagnostic and therapeutic services as ordered by the physician.
• Consult with the resident’s physician regarding 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.
• Conduct periodic checks to ensure prescribed treatments are administered properly.
• Coordinate social and activity programs with nursing service schedules.
• Notify attending physicians of accidents, incidents, or 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, and range of motion exercises.
• Use restraints when necessary and in accordance with established policies.
• Obtain sputum, urine, and other lab specimens as ordered.
• Monitor vital signs (TPRs, blood pressures) as necessary.
• Monitor seriously ill residents as required.
• Check food brought in by family/visitors for 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 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 follow post-mortem procedures.

Staff Development

• Participate in developing, planning, and conducting in-service training classes.
• Implement and maintain an effective orientation program for new employees.
• Assist in standardizing work methods for department personnel.
• Train department personnel in identifying tasks that involve exposure risks.