Assess patient health problems and needs, develop and implement nursing care plans, and maintain medical records. Administer nursing care to residents. Registration required.
1. Monitor, record, and report symptoms or changes in residents' conditions.
2. Maintain accurate, detailed reports and records.
3. Record residents' medical information.
4. Modify resident's care plans as indicated by patients' responses and conditions.
5. Direct or supervise LPN/CNA/RA staff or supervise a particular unit.
6. Consult and coordinate with healthcare team members to assess, plan, implement, or evaluate residents care plans.
7. Perform physical assessments, notify physician as indicated and follow medical directives.
8. Follow facility infection control programs, advising or consulting with specified personnel about necessary precautions.
9. Address residents needs and determine how to assist them.
10. Administer prescribed medications as ordered by physician(s) or in response to emergency situations, per medical directives. Record times, amounts, and summaries on resident chart.
11. Observe residents, charting and reporting changes in patients' conditions, such as adverse reactions to medication or treatment, and acute change of conditions and take appropriate action.
12. Record all medical, Medicare and medication data accurately and report changes in condition or errors and omissions to ensure records are accurate.
13. Assist in the development and implementation of skilled and restorative nursing care measures and plan of care.
14. Ensure compliance with infection control pragmas, advising or consulting with specified personnel regarding necessary precautions.
15. Assist in the development, monitoring and updating of individualized care plans.
16. Facilitate transfers to hospitals or triage centers.
17. Perform medical procedures such as IV/Saline locks, lab specimen collection (urine, stool), glucose, INR monitor, bladder scan, suction. Ensure procedures are continued as indicated in medical orders.
18. PFV/VOW: Admits residents to Assisted Living. Coordinate with resident aides, residents, and resident families for resident intake.
Department: Nursing/Assisted Living
FLSA Status: Non- Exempt
Reports to: DON/Nurse Coordinator/Nurse Manager/Resident Care Manager/Administrator
Amount of Travel Required: 0%
Positions Supervisor: CNA, LPN
Resident Assistants, Resident Assistant Leads (VOW & PFV)
Associate's Degree from an accredited school of nursing.