Wound Care Nurse

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.

Responsibilities

Administrative Functions

• Direct the day-to-day functions of nursing assistants in accordance with facility rules, regulations, and guidelines.
• Ensure compliance with facility policies and procedures, including periodic reviews and recommendations for revisions.
• 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 and inspections by authorized government agencies.
• Review and update residents' written discharge plans as required.
• Interpret department policies to personnel, residents, visitors, and government agencies.
• Admit, transfer, and discharge residents as required.
• Complete and submit accident/incident reports, daily census reports, and resident charge slips.
• Perform administrative duties such as completing medical forms, evaluations, and charting.
• Safeguard resident and facility information, reporting any unauthorized access attempts.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon resident admission, transfer, and/or discharge.
• Encourage physicians to review treatment plans and sign orders in accordance with policies.
• Receive and record telephone orders from physicians on the Physicians' Order Form.
• Transcribe physician orders to resident charts, cardex, medication cards, and treatment/care plans.
• Chart nurses' notes descriptively, reflecting care provided and resident responses.
• Fill out and submit accident/incident reports.
• Record new/changed diet orders and forward to the Food Services Department.
• Report discrepancies in physician orders, diet changes, or charting errors to the Nurse Supervisor.
• 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 or 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.
• Ensure narcotic records are accurate and report discrepancies to the Nurse Supervisor.
• 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 determine staffing requirements.
• Make recommendations concerning employee dismissals, transfers, etc.
• Inform the Nurse Supervisor of staffing needs and absentee call-ins.
• 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.
• Make daily rounds to ensure nursing personnel perform duties according to standards.
• Ensure nursing assistants are enrolled in or have graduated from an approved training program.
• Supervise nurse aide trainees under the direct supervision of a licensed nurse.
• Meet with nursing personnel to identify and correct problem areas.
• Ensure compliance with department policies by personnel, residents, and visitors.
• Maintain a good working rapport with inter-departmental personnel.
• Create a warm, positive, and calm environment throughout the unit.
• Review and address complaints and grievances from assigned personnel.
• Administer disciplinary action fairly and without bias.
• Receive and give nursing reports at the start and end of shifts.
• Report occupational exposures to blood, body fluids, or hazardous chemicals.
• Report suspected fraud or unauthorized access to facility information systems.
• Ensure unattended workstations are logged off or password-protected.

Nursing Care Functions

• Inform nursing personnel of new admissions, room assignments, and prepare rooms for arrivals.
• Greet newly admitted residents and escort them to their rooms.
• Participate in the orientation of new residents and family members.
• Make rounds with physicians as necessary.
• Requisition and 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 established nursing objectives and standards.
• Evaluate residents' physical and emotional status through periodic checks.
• Ensure direct nursing care is provided by qualified personnel.
• Coordinate social and activity programs with nursing service schedules.
• Notify attending physicians and next-of-kin of changes in resident condition or accidents.
• 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, dressings, colostomy care, and more.
• Use restraints when necessary and in accordance with policies.
• Obtain specimens for lab tests as ordered.
• Monitor and record vital signs (TPRs, blood pressures) as necessary.
• Monitor seriously ill residents and check on those unable to call for help.
• Inspect foods brought by family/visitors to ensure dietary compliance.
• Ensure care is provided in accordance with the resident's care plan and wishes.
• Meet with residents and/or family members to address concerns.
• Assist in arranging transportation for discharged residents.
• Follow established post-mortem procedures and inform family members of resident death.

Staff Development

• Participate in developing, planning, conducting, and scheduling in-service training classes.
• Implement and maintain an effective orientation program for new employees.