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JOB PURPOSE: The RN is responsible for providing professional nursing services as defined in their scope of care to patients under the direction and supervision of a Registered Nurse. Scope of work may be modified by State specific rules under the Nurse Practice Act.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
* Participates with members of the interdisciplinary team to plan, coordinate and evaluate residents' care.
* Provides direct care and/or assists with care as directed and consistent with their scope of practice and competency. Initiate the SBAR process and collaborate with the RN for assessment and recommendations.
* Documents the resident's condition and nursing needs accurately and in a timely manner. Reports pertinent observations and reactions regarding residents promptly to RN.
* Provides oncoming shift and supervisors with accurate and complete resident status report. Maintains the 24 hour report book.
* Receives and records physicians' orders
* Develops work assignments for Nurse Aides as directed. Provides feedback to Unit Managers regarding performance of Nurse Aides.
* Reports problems and complaints timely to the Unit Manager or Supervisor.
* Receives and provides accurate and complete resident status report at shift change. Maintains 24 Hr Report Book.
* Assists in data collection for admission, transfer and discharge of residents and provides the information to the Nurse Manager. Completes clinical admission paperwork. Assists with clinical discharge process.
* Serves on and participates in committees as assigned.
* Assures that inventory and supplies are maintained in a clean and safe manner. Communicate needs to housekeeping, maintenance or nutritional services.
* Supports and participates in the center's Performance Improvement initiatives.
* Participates in Survey readiness
* Makes rounds with physicians and other team members as needed. Assist physicians and consultants with special tests or procedures within the scope of state specific nurse practice act and personal clinical competency.
* Participates in resident assessment and care planning activities, reviews and revises residents' assessments and care plans as needed to the extent permitted by state nurse practice act.
* Coordinates residents' care activities and communicates changes to other team members and resident family/significant other.
* Administers treatments
* Reviews, transcribes, communicates and implements physician orders, obtaining RN signature as required by State Regulations.
* Assists with emergencies, administers cardiopulmonary resuscitation.
* Documents care performed and observations of resident status in the clinical record promptly by utilizing standard clinical documentation guidelines as required by Wingate and local, state and federal rules and regulations.
* Monitors completeness and accuracy of own clinical medical record entries and those of assigned RN and Nurse Aides daily.
* Participates in medication management to promote optimal safety and effectiveness for residents by:
* Initiates and assists consultants while providing services. Reviews documentation from consultant visit and follows up on recommendation.
* Assist with follow up on results of qualitative and quantitative medical record audits.
* Communicates and implements pharmacy review/DRR recommendation as assigned.
* Provides individual and/or unit education to residents/families and staff based upon need and within scope of practice.
* Participate in the orientation of new employees.
* Committed to working with residents and families to develop and implement strategies that promote person-centered care.
* Applies "5 Star" customer service approach in all aspects of job.
* Actively supports Wingate's commitment to providing "5 Star" service on all quality objectives, with an emphasis on continual improvement.
* Adheres to all company policies, procedures, and standards of conduct.
* Reports to the appropriate managers any known or suspected violations of policy and procedures, regulations or standards of conduct.
* Performs additional duties as assigned.
* Administering medications as ordered, including next scheduled dose following admission/readmission. Notify Supervisor of medications not available.
* Observing and reporting resident responses to medication
* Identifying and promptly communicating adverse drug reactions
* Maintaining narcotic records accurately within scope of practice
* Responsible for completing medication interchange and insurance prior to authorization as assigned
* Ordering or arranging for ordering of pharmaceuticals
* Notifying physicians of automatic stop orders
* Completes recapitulated physician orders review as assigned
* Notifying supervisors of discrepancies in drug inventories
* Cleans, organizes and replenishes supplies on medication/treatment carts after each use and prior to shift change.
* Licensure as RN in states included in service area.
* Graduate of an accredited school of nursing
* 2 years of current experience a long term care preferred
* CPR certification required
* Must have excellent interpersonal, commmunication and organizational skills and must be able to assume a flexible work schedule.
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled