RN PM Shift

PURPOSE: The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants, LPNs, and nursing support staff. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern Markesan Resident Home, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. DELEGATION OF AUTHORITY: As Charge Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. When assuming the position of charge nurse in a nursing home as defined in s.50.04 (2)(b), the RN shall: Follow written protocols and procedures; Manage and direct nursing care and other activities of LPNs and nursing support personnel under the general supervision of an RN; and Accept the charge nurse position only if prepared to completely perform this assignment based on nursing education or active involvement in education or training for responsibilities not included in the basic LPN curriculum. JOB FUNCTIONS: Every effort has been made to identify the essential functions of this position. However, in no way does this job description state or imply that these are the only duties you will be required to perform. The omission of specific statements or duties does not exclude them from this position if the work is similar, related, or is an essential function of the position. ADMINISTRATIVE FUNCTIONS Direct the day-to-day functions of the nursing assistants, LPNs, nursing support staff including med techs and nurse techs in accordance with current rules regulations, and guidelines that govern the long-term care facility. Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility. Periodically review the department's policies, procedure manuals, job descriptions, etc. Make recommendations for revisions. Meet with your assigned nursing staff, as well as support personnel, in planning the shifts services, programs, and activities. Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual. Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained. Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing service department. Assist in planning the nursing services portion of the resident's discharge plan as necessary. Admit, transfer, and discharge residents as required. Complete accident/incident reports as necessary. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. Update administrative staff in the event of fire, tornado warning, exiting of wandering resident(s), workplace violence issues and/or staffing issues. Discipline, coach, train LPN and nurse support staff as needed. Oversee situations that may arise at North Terrace which require nursing interventions. CHARTING AND DOCUMENTATION Complete and file required record keeping forms/charts upon the resident's admission, transfer, and/or discharge. Encourage attending physicians to review treatment plans, record and sign their orders, progress note, etc., in accordance with established policies. Receive telephone orders from physicians and record on the Physicians' Order Form. Transcribe physician's orders to resident charts, Medex, treatment/care plans, as required. (If Unit Coordinator present, Licensed Nurse reviews and signs) Chart nurses' notes in an informative, objective, and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Complete all accident/incident documentation, following established procedures. Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the DON or RN on call. Complete transfer forms in accordance with established procedures. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. Sign and date all entries made in the resident's medical record. DRUG ADMINISTRATION FUNCTIONS Prepare and administer medications as ordered by the physician. Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies. Ensure that scheduled medication records are accurate for you shift. Notify the DON or RN on call of all drug and narcotic discrepancies noted on your shift. Dispose of drugs and narcotics as required and in accordance with established procedures . PERSONNEL FUNCTIONS Participate in employee performance evaluations, making recommendations to the Director of Nursing concerning employee merits, dismissals, etc. Report absentee call-ins to the Nurse Supervisor. Review and evaluate your assigned work force and make recommendations to the RN on call. Provide leadership to nursing personnel assigned to your unit. Make frequent rounds of your unit to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the residents. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift. Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the DON or RN on call as required or as may be necessary. Follow facility's established procedures. Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures governing accidents and incidents . NURSING CARE FUNCTIONS Inform nursing personnel of new admissions, their expected time of arrival, room assignment, etc., ensuring that rooms are ready for new admissions. Greet newly admitted residents upon admission. Participate in the orientation of new residents/family members to the facility. Complete rounds with physicians on your assigned unit. Arrange for diagnostic and therapeutic services, as ordered by the physician in the absence of the Unit Coordinator. Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary. Implement and maintain established nursing objectives and standards. Make periodic checks to ensure that certified nursing assistants are properly administering prescribed treatments and to evaluate the resident's physical and emotional status. Cooperate with and coordinate social and activity programs with nursing service schedules. Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition. Ensure that restorative and rehabilitative programs are carried out to include self-help and care. Administer professional services such as; catheterization, tube feedings, suction, applying and changing dressings, packs, colostomy, and drainage bags, IV's, etc. Obtain sputum, urine and other specimens as ordered for lab tests. Check foods brought into the facility by the resident's family/visitors to ensure that it is within the resident's dietary allowances. Report problem areas to th