Description
POSITION SUMMARY
The Registered Nurse is responsible to the Unit Manager and is clinically competent; delivers care to residents utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation; and effectively interacts with resident/family/significant other, and other health team members while maintaining standards of professional nursing.
POSITION RESPONSIBILITIES / STANDARDS
• Indicates core responsibility
• Utilize the nursing process by demonstrating appropriate assessment, planning, implementation, and evaluation of the resident's care, as evidenced by resident’s response to care and nursing observation.
o Assess the resident: collect and document the resident's current health status and medical history. Complete and/or review Admission Data Record as defined by policy. Perform accurate and ongoing assessment of resident's status and respond appropriately.
o Plan/Implement: set priorities for nursing action in a logical sequence according to resident's needs and formulate a Plan of Care by the appropriate selection of Nurse Practice Standards. The Plan of Care is initiated on admission based on all aspects of the initial assessment. Plan includes physiological, psychosocial, and environmental factors; resident/family/significant other education and resident discharge planning.
o Evaluate: perform ongoing assessment and revise plan of care as needed based on new data and resident's condition.
o Document accurate and ongoing assessment of resident status. Document resident’s care which reflects nursing intervention, resident’s response to care provided, resident’s needs, problems, capabilities, limitations, and progress toward goals. Documentation includes evidence of appropriate resident/family/significant other teaching, and the understanding of these instructions is noted in the medical record.
o Communicate with the physician regarding resident’s needs, the nursing assessments, and recommendations on a daily basis, and as needed, as evidenced by resident feedback and Director of Nursing observation. Collaborate with other nurses and co-workers to ensure the resident’s well being as evidenced by staff/resident feedback.
• Teach resident/family/significant other appropriate health information in a timely manner and share written informational material as evidenced by resident feedback and observation. Perform direct resident care, utilizing established procedures, policies, and standards as evidenced by resident/staff feedback and observation.
o Administer medications according to policy and procedure.
o Administer IVs according to policy and procedure.
o Observe and document resident's response to prescribed medications.
o Demonstrate ability and appropriate technical skills when administering treatments and procedures in accordance with physician's orders and policy and procedure (done within a timely manner).
o Demonstrate necessary skills and knowledge to provide care for residents according to policy and procedure.
o Demonstrate necessary skills and knowledge to provide care for residents according to unit specific competencies.
o Demonstrate ability to handle emergency situations in a prompt, effective, and professional manner.
o Provide personal resident care to provide comfort and well-being to the resident, acknowledging physiological and psychological needs.
o Perform indirect resident care, utilizing established procedures, policies, and standards as evidenced by resident/staff feedback and observation.
§ Give a thorough, concise report at change of shift.
Communicate pertinent information to the appropriate person in a timely manner.
o Demonstrate accurate and timely documentation according to Form guidelines.
o Accurately transcribes physician orders according to policy and procedure.
· Maintain a clean, neat, and safe environment for resident and staff according to policy and procedure as evidenced by resident/client feedback and observation.
o Ensure that supplies and equipment necessary for patient care are stored in an organized and efficient manner.
o Demonstrate correct and safe technique in the use of equipment according to specific product information.
o Follow appropriate procedure for obtaining and returning or cleaning/disposing of equipment and supplies.
o Participate in economical utilization of supplies and ensure that equipment is maintained in a clean and safe manner.
• Adhere to Administrative & Nursing policies.
o Maintain adequate staffing to provide safe efficient care
o Do not incur excessive overtime.
o Remain conscientious in regard to personal hygiene and comply with specific division/unit regulations.
o Comply with specific facility/unit policy and procedure concerning safety.
o 100% attendance to yearly mandatory skill updates.
RESIDENT SATISFACTION
• Assist residents, family members or other clients with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
• Answer and refer telephone calls or other inquires to facilitate accurate and timely communication.
o Identify yourself and your assigned station in a pleasant and positive manner.
o Take responsibility for helping the caller.
TEAMWORK
• Assist in the orientation/training of new employees; projecting a positive image and attitude.
• Consistently work in a positive and cooperative manner with fellow co-workers.
• Assist other nursing personnel in the performance of their assignments.
o Seek out opportunities to help rather than waiting to be asked.
o Consider the impact of your actions on other employees throughout the facility.
• Recognize the need for variations in staffing and volunteer to fill open shifts.
• Take direction and initiate actions (cross/additional training) that will allow the assumption of cross-functional duties to ensure seamless patient care.
• Demonstrate flexibility to perform duties wherever volume deems it necessary within the facility.
PROBLEM SOLVING
• Demonstrate sound judgment by taking appropriate actions regarding questionable findings or concerns.
o Investigate and follow through on unusual orders or requests for service or information.
o Follow proper reporting procedures for actual or potential accidents and/or incidents so follow-up and/or prevention can occur.
o Record/report the need for service maintenance or repair of equipment and remove any faulty equipment from service.
• Contribute to and participate in Quality Improvement activities utilizing a problem-solving methodology for performance improvement.
• Consistently evaluate work and determine if further steps are needed to meet resident expectations.
o Take initiative to correct inadequate work or finish incomplete work, even if it is not yours.
• Ensure compliance with regulatory standards.
PRODUCTIVITY/EFFICIENCY
• Consistently demonstrate ability to respond to changing situations in a flexible manner in order to meet current needs, such as reprioritizing work as necessary.
• Minimize non-productive time and fill slow periods with activities that will enable you to prepare to meet the future needs of the facility (education, organizing, and housekeeping, assisting others).
• Organize job functions and work area to be able to effectively complete varied assignments within established time frames.
• Consistently demonstrate ability to take the initiative to make decisions/choices without direct supervision.
PERSONAL DEVELOPMENT
• Attend required annual in-service programs.
•Seek and Participate in continuing education to remain current in nursing care delivery.
ADHERENCE TO SYSTEM AND DEPARTMENTAL POLICIES
• Demonstrate knowledge and understanding of all policies and procedures and ability to reference them from appropriate books and manuals.