The Registered Nurse (RN) is accountable for resident care on the assigned unit. The RN is responsible for performing a variety of duties to provide quality nursing care to residents to maintain or attain the highest practical level of functioning; implementing specific procedures and programs; participating with the charge nurses and the Director of Nursing in establishing specific goals; determining work procedures and expediting work flow; insuring compliance with all operating policies and procedures and Pennsylvania Department of Health regulations and Federal Health Care Administration regulations; promote quality care and service, communicating with and supervising appropriate personnel; providing periodic reports; performing ongoing audits.
Registered Nurse essential duties and responsibilities include, but are not limited to:
-Has responsibility and accountability for resident care, staff and the environment of care.
-Ensures thorough and prompt reporting of incidents with follow-up as necessary to the DON and/or Administrator.
-Encourage each resident’s ability to maintain or attain the highest practical physical, mental, and psychological well being and thus performs various duties to provide quality nursing care to residents and to coordinate total nursing care for the residents.
-Assess residents and analyze obtained information to develop appropriate interventions to prevent decline; record signs of change in condition, notify appropriate staff per facility protocol to evaluate weight loss, decline in ambulation, change in performance of ADL’s, development of skin breakdown, etc.; observe conditions which indicate possible need for restorative nursing programs and then notify appropriate staff per facility protocol of the need for evaluation; inform the physician of changes in assessment when appropriate.
-Assess the resident upon admission and develop interim care plan, contribute to the full care plan, and update the care plan as warranted and as required; attend and participate at the Plan of Care meetings as scheduled.
-Administer medications and treatments to residents as needed; monitor the administration of intravenous fluids as needed; place orders for medications from the pharmacy.
-Respond to emergencies; assess the condition of the resident; decide on the type of medical attention; call appropriate ambulance service when resident is transferred to or admitted to a hospital; notify the physician when there is a change in resident’s condition.
-Confer with residents and their families; make referrals to other departments when appropriate.
-Maintain resident clinical files; keep charts updated; document appropriately.
-Complete employee and incident report forms; complete follow-up investigation forms.
-Make rounds to see each resident daily and as needed.
-Ensure that residents are aware of the services available to them; encourage residents to participate in activities programs and provide staff support to enable residents to get to and from and participate in activities.
-Maintain accountability for controlled substances; inventory medications at the beginning and end of the shift with another licensed nurse; notify supervisor of discrepancies.
-Support the facility’s medical supply system; follow procedures for resident charge items.
-Correlate the accuracy and completeness of documentation and its impact on reimbursement and federal regulations.
-Communicate status of residents to incoming personnel according to established procedures; communicate with physicians; transcribe, clarify, and implement physicians’ orders.
-Evaluate the quality of care provided by the charge nurses, unit clerk, and certified nursing assistants.
-In-service staff related to identified needs.
-Complete job performance counseling and follow-up review for professional and nursing assistant staff.
-Plan, direct, control and monitor all designated units nursing functions; acts as primarily liaison for intra and inter-departmental activities; ability to lead and maintain a team environment.
Related Experience: One year previous experience in Acute Care facility preferred. One year previous experience in a Continuing Care Facility, Long Term Care Facility, or Rehabilitation Facility preferred
Education or Degree Requirements: Graduate of accredited School of Nursing
Licenses, Certifications, Registrations: Current license with the State of Pennsylvania for Registered Nurse. Must maintain current CPR Certification
Media, Pennsylvania , 19063
Wesley Enhanced Living
Jul 31st, 2019