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POST DATE 9/1/2016
END DATE 10/28/2016
Lutheran Senior Services
Saint Charles, MO
JOB DESCRIPTIONJOB DESCRIPTION:
Directs, provides nursing care to the residents, and supervises the day-to-day nursing activities performed by nursing staff by performing the following duties. Maintains the Core Values that support the Christian Mission of Lutheran Senior Services, Older Adults Living Life to the Fullest .
* Assess and manage the functions of the nursing staff in accordance with current rules, regulations and guidelines that govern the long-term facility.
* Participate in maintaining our written policies and procedures that govern the day-to-day functions of the Nursing Department.
* Ensure that the Nursing Procedures Manual is followed by nursing personnel, and that it reflects the day-to-day nursing care procedure used by the facility.
* Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the residents total regimen of care.
* Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
* Participate in the maintenance of the facilities quality assurance program for the Nursing Department.
* Participate in survey (inspection) made by authorized agencies.
* Make written and oral reports/recommendations to the Director as required concerning the operation of the Nursing Department.
* Meet with your assigned nursing staff at beginning of each shift to give a resident report, and give nursing assistants and medical technicians their assignments.
* Be familiar with the departments policies and procedures.
* Admit, transfer, and discharge residents as required, with paperwork.
* Complete accident/incident reports as necessary.
* Write resident charge slips and forward to the Business Office.
* Ensure that the written policies and procedures that govern the day-to-day functions of the Nursing Department are followed by all nursing personnel.
* Ensure all nursing personnel are following their respective job description
* Recommend to the DON the equipment and supplies you need for the unit.
CHARTING AND DOCUMENTATION:
* Chart all accidents/incidents involving the resident or employee.
* Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
* Utilize care plan for documentation of nurses notes.
* Chart nurses notes in an informative and descriptive manner that reflects the care provided to the residents as well as the residents response to the care.
* Complete and file required record keeping forms/charts upon the residents admission, transfer, and/or discharge.
* Receive telephone orders from physicians and record on the physicians order form.
* Record new/changed diet orders. Forward information to the Food Service Department.
* Transcribed physicians orders to resident charts, and MAR s treatment/care plans as required.
* Assure the appropriate documentation concerning unauthorized discharges is entered in the residents medical records in accordance with established procedures.
* Report all discrepancies noted to the supervisors concerning physicians orders, diet changes, charting errors and fill out appropriate forms.
* Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures.
* Prepare and administer medications as ordered by the physician and in accordance to our procedures.
* Order prescribed medications, supplies and equipment as necessary, and in accordance with our established policies.
* Ensure that an adequate supply of floor stock medications, supplies and equipment are on hand to meet the nursing needs of the residents. Reports needs to the Supervisor.
* Ensure that narcotic records are accurate for your shift.
* Review medications bubble cards for completeness of information, accuracy in transcription of the physicians orders and adherence to stop order policies.
* Notify Supervisor of all drug and narcotic discrepancies noted on your shift.
* Inform nursing personnel of new admissions, their expected time of arrival, room assignment.
* Ensure that rooms are ready for new admissions.
* Make rounds with physicians as necessary.
* Nursing should cooperate with and coordinate their schedule with social and activity programs and assist in transporting resident in the same.
* Make independent decisions concerning nursing care.
* Notify the residents attending physician when the resident is involved in and accident or incident.
* Make periodic checks to assure that prescribed treatments are being properly administered by nursing assistants and to evaluate the residents physical emotional status.
* Administer professional services such as; cauterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, initiate and maintain IV therapy with doctors orders.
* Participate in the orientations of new residents/family members to the facility.
* Provide teaching and counseling to residents as permitted within regulatory standards and as outlined in resident care plan.
* Requisition and arrange for diagnostic and therapeutic services as ordered by physician.
* Carry out restorative and rehabilitative programs.
* Inspect the Nursing Services Treatment areas daily to ensure that they are maintained in a clean and safe manner.
* Monitor seriously ill residents as necessary and document every shift.
* Meet with residents, and/ or family members as necessary. Report problem to the DON.
* Consult with the resident physician in planning resident care. Treatment, rehab, etc., as necessary.
* Notify the residents attending physician, responsible party and chaplain when there is change in the residents condition.
* Initiate the use of restraints when necessary and in accordance with our facilities emergency restraint policies and procedures.
* Obtain sputum, urine and other lab tests as ordered.
* Take TPRs blood pressure, weights etc., in accordance with our facilities policies and procedures.
* Follow facilities lift free program on all assessed resident transfers unless specific Doctors orders stated otherwise.
* Admit, transfer and discharge residents as necessary.
Participate in a effective orientation program that orients the new employee to your shift, its policies and procedures, and to his/her job duties.
Attend and participate in continuing educational programs designed to keep you abreast of changes in your profession, as well as to maintain your license.
SAFETY AND SANITATION:
* Monitor your shifts personnel to assure that they are followed established safety regulations in the use of equipment and supplies.
* Ensure that your units residents care rooms, treatment areas, etc., are maintained in a clean, safe and sanitary manner.
* Ensure that your nursing employees follow established departmental policies and procedures, including dress codes.
* Ensure that your assigned personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner.
* Participate in the maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel.
* Participate in the maintenance of the procedures for reporting hazardous conditions of equipment.
* Utilize body substance precautions and other infection control guidelines.
* Ensure that nursing service employees follow established hand washing techniques.
CARE PLAN ASSESSMENT:
* Inform supervisor and/or care plan nurse of any changes that need to be made to the care plan.
* Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing care needs during