Position Purpose The primary purpose of the Registered Nurse is to provide direct nursing care to the residents and to monitor the day-to-day nursing activities performed by nursing assistants. The performance of these duties must be in accordance with the current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required and communicated by the Director of Nursing (DON) or Administrator to ensure that the highest degree of quality care is maintained at all times. Essential Job Functions Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. Essential functions are those duties listed below. Organizational Responsbilities Adhere to St. Francis Health Services’ Mission and C ore Values while performing company business. Maintain confidentiality of company and resident related information at all times. Serve on, participate in, and attend various committees of the facility as appointed by the Director of Nursing or Administrator. Perform administrative requirements, such as completing necessary forms, reports, etc. and submitting such to the Director of Nursing or Administrator as required. Participate in quality improvement activities as delegated. Rate Organizational Responsibilities: Identify specific Standards that contribute to Rating. Resident Care Responsibilities Does not disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator. Ensure that all care is provided in privacy, as appropriate, and to knock before entering a resident’s room or resident care area such as tub rooms. Report all grievances and complaints made by the resident, family, or visitors to the appropriate supervisor following the facility’s established procedures. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Provide direct resident care and monitoring. Identify self to the resident and family, obtain history and evaluate resident condition. Assess physical and emotional condition of the resident and recognize need for immediate attention. Report issues or concerns to the appropriate personnel and document findings. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Follow and recommend updates to the plan of care for residents, including immediate and long-term goals. Initiate plan of care at time of admission for each resident, review care plans and recommend revisions as needed. Maintain knowledge of current nursing care plan for each resident and inform the nursing staff of objectives and/or goals, psycho/social needs, and physical needs. Monitor nursing care to assure it is in compliance with the care plan. Monitor residents for significant changes and report to DNS any observed changes in resident’s condition. Document changes in resident medical condition, incidents, responses to treatment and resident and/or family concerns. Assist in coordinating and planning the resident’s discharge plan. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Perform basic nursing procedures safely and efficiently and maintain technical skills, in accordance with facility policies and procedures. Possess knowledge about techniques and principals involved in procedures and appropriate use of equipment. Plan ahead for procedures by knowing location of all equipment and supplies. Monitor and document resident’s physical and emotional response during and after treatment as necessary. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Ensure medications are safely administered as ordered by the physician. Know the dosage and effects of medication prior to administration and is alert to potential side effects. C heck special precautions that are parameters for administering or holding a medication (e.g., taking apical pulse before giving Lanoxin noting respiratory rate before giving a narcotic) and notify physician when resident condition indicates. Obtain medication from the pharmacy as needed. Order, check and store medication according to policy and procedure. Know and practice the eight rights of passing medications (i.e. right resident, right reason, right medication, right dose, right time [includes right order], right route [includes right technique], right documentation, right response). C larify with physician regarding unusual dosages or routes of administration. C orrectly chart medication administered for that shift. Observe and document resident’s response to medication (especially PRN medications, new or adjusted doses). Report medication errors as soon as discovered and complete written report according to policy. Follow established procedures for drug control (e.g., locking medication carts, reordering medications, returning unused drugs to pharmacy, signing out controlled drugs, locking medication room door when unattended, etc.). Ensure that the counting and starting of narcotics meets State and Federal regulations and report discrepancies to the DON and Administrator. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Maintain a complete clinical record of each resident’s stay. Document changes in resident’s medical condition, incidents, and responses to treatment and resident and/or family concerns in accordance with facility policies and practice. C omplete pertinent daily charting. C hart concisely, descriptively, legibly and in logical sequence, resident’s progress, using proper terminology. Ensure accurate completion of resident’s vital signs, neuro checks, weights and records. Document treatments. Monitor and document resident’s physical and emotional response during and after procedures as necessary. Transcribe new physician orders correctly. Ensure physician’s orders are carried out. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Accurately monitor resident’s needs and initiate appropriate intervention. Observe and monitor residents at regular intervals. Notify physicians, DON, Administrator and other departments of resident’s conditions that should be brought to his/her attention. Respond promptly to changes in resident’s condition and report to physician/family/DON or Nurse Manager. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Take direct appropriate action in emergency situations. Recognize potential emergencies and take the appropriate action (e.g. shock, respiratory distress, diabetic coma, etc.). Notify DON and/or Administrator of any observed potential or actual emergency. Ensure the coordination of care of any acutely ill residents (e.g. vital signs, feeding, oxygen therapy, charging, transfers to hospital, etc.). Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. C ommunicate clearly and appropriately, both verbally and in writing. C ommunicate with the physician or ensure that the physician is notified regarding resident progress, physical and emotional status, interventions, and family interactions. C ommunicate changes in resident condition to health care provider utilizing a systematic method describing situation, background, appearance and request for orders. Ensure that family is notified of changes in resident’s condition and new orders. Inform nursing assistants of resident’s care plan and special needs. Review all incident reports and medication error forms, documenting follow up in progress notes, plan of care and coordinate action as indicated. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Teach the resident and/or family about his/her illness. Educate staff on general knowledge of resident’s conditions and needs. Document resident and family education. Ensure that nursing staff personnel honor resident’s refusal and treatment requests. Ensure that such requests are in accordance with the facility’s policies and governing advance directives. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating. Demonstrate the knowledge and skill necessary to provide care, based on physical, psycho/social, educational, safety and related criteria for adult and geriatric residents. Rate Resident Care Responsibilities: Identify specific Standards that contribute to Rating.