Job Description

Summary of Position

The Registered Nurse (RN) plays an integral role in the success of our team, our community and creating a place our residents are proud to call home. The primary purpose of this position is to provide high quality, holistic nursing care in accordance with nursing practice standards and health care regulations which govern the practice of professional nursing. Lead or direct licensed and non-professional staff in the delivery of direct resident care and support functions.

Essential Job Functions

Nursing Care Functions

Conduct the daily nursing functions in accordance with current rules, regulations, and guidelines that govern the long-term care facility/assisted living communities.
Ensure that all nursing personnel assigned to you comply with the written policies and procedures including the safety program.
Admit, transfer, and discharge residents with documentation regarding care and service provided.
Participate in the orientation of new residents/family members to the facility.
Make rounds with health care provider as needed.
Utilize nursing personnel qualifications according to the resident's care plan, service plans and health care provider orders.

Communication/Documentation Functions

Complete daily clinical and environmental rounds to evaluate resident care being provided and report significant events.
Meet and resolve issues with residents and/or family members. Report significant issues to the supervisor.
Participate in facility surveys (inspections) as requested by management.
May be responsible for clinical programs as directed, e.g., dementia, wound care, quality assurance, infection control, admissions.
Complete an initial assessment and assist or develop interim care plan/service plans.
Update, review, and transcribe the care plan that identifies the goals, problems, approaches, and revisions based on nursing needs and new health care provider orders.
Assist with service plans as directed by the Director of Nursing.
Communicate with health care provider to review treatment plans, complete orders, progress notes, etc., in accordance with established policies.
Review the resident's medical record for specific treatments, medication orders, diets, labs etc., as for implementation and follow up.
Requisition and arrange for diagnostic and therapeutic services, as ordered by the health care provider, and in accordance with our established procedures.
Communicate the department's policies and procedures to personnel, residents, and visitors.
Communicate with written (24-hour report) and oral reports/recommendations concerning any changes in resident condition and other activities of your shift to nursing management.
Fill out and complete accident/incident reports involving residents and submit to Director of Nursing.
Complete assessments and all other medical record documentation as required to provide care services.
Provide resident and family information for care conferences or other meetings.
Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the supervisor.
Complete clinically accurate documentation according to policy.
Review the resident medical documentation and progress notes from the interdisciplinary team to determine if the care plan/service plans are being followed. Report any concerns to your supervisor.
Inform nursing personnel of new admissions and the resident's care needs. Ensure that rooms are ready for new admissions. Greet newly admitted residents upon admission.
Notify the resident's attending health care practitioner and family when there is a change in the resident's condition.
Assist in arranging transportation for residents and other third-party services.

Medication Administration Functions

Prepare and administer medications ordered by the health care provider.
Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the supervisor.
Review medication administration record for completeness of information, accuracy in the transcription of the health care provider's order. Report concerns to your supervisor.
Dispose of drugs and narcotics as required, and in accordance with established procedures.

Personnel Functions

Supervise your nursing unit to ensure that all personnel are performing their work assignments in accordance with acceptable nursing standards.
Work with the Director of Nursing to resolve staff performance issues including those that may lead to termination.
Review complaints and grievances, and work with the Director of Nursing for a plan of action and resolution.

Safety and Sanitation Functions

Assure and make available protective equipment for staff.
Maintain nursing service work areas (i.e., nurses' stations, medicine preparation rooms, etc.), resident rooms, and treatment areas in a clean and sanitary manner.
Recommend to the Director of Nursing the equipment and supply needs of the nursing department. Ensure that a stock level of medications, medical supplies, equipment, etc., is maintained on the premise at all times to adequately meet the needs of the residents.
Perform other job-related duties as assigned.

Knowledge and Critical Skills

Be able to make independent decisions and follow instructions.
Deal tactfully with personnel, prospects, residents, family members, visitors, government agencies/personnel, and the public.
Capable of working with ill, disabled, elderly, and emotionally upset people within the facility.
Communicate effectively in a manner that is sufficient for effective communication with supervisors, team members, prospects, residents, and families.

Education and Experience

Must meet all applicable state and federal requirements for this position.
Must possess a current, unencumbered, active license to practice as an RN in applicable state, in good standing throughout employment with no disciplinary action in effect against professional license.
Prefer one year of experience in nursing in a home care, assisted living, or long-term care facility.

Supervisory Responsibility

This position requires the RN to ensure resident care is provided per standards of practice following policies and procedures of the facility by CNAs/Caregivers but the CNAs/Caregivers do not directly report to them.

Working Conditions and Physical Demands

Tasks assigned to this position may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals.

Physical Requirements - The Physical activities of this position involve:

Walk long distances
Stand for extended periods of time
Sustain repetitive movement (CPR compressions, bagging, etc.)
Maintain physical tolerance (stand/walk/work on your feet for 8-12 hours at a time with minimal breaks)
Be able to lift up to 50 pounds at times
Be able to push and pull up to 50 pounds at times

Cognitive Requirements - The Cognitive activities with or without prosthetics of this position are:

Executes tasks independently
Ability to express yourself clearly and effectively
General computer literacy

Environmental Requirements - An individual in this position may be exposed to:

Ambient room temperatures and lighting

Other Requirements -

May be required to work nights, weekends and holidays

Platinum Service®

Platinum Service® is characterized by a high level of responsiveness delivered in a competent, timely and caring way. Employees commit to providing courteous, responsive, and quality service to our residents by following the principles of our Platinum Service® program.

Conclusion

All employees are expected to follow all policies and procedures. These policies and procedures can be found in the employee handbook, department policy and procedure manuals and with your supervisor. This job description is intended to convey information essential to understanding the scope of the position and it is not intended to be an exhaustive list of skills, efforts, duties, responsibilities or working conditions associated with the position. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities at any time.

West Hills Health and Rehabilitation

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