Macon Rehabilitation and Healthcare Centerposted 3 days ago
Macon, GA
Ambulatory Health Care Services

About the position

The position involves providing direct nursing care to residents and supervising the day-to-day nursing activities performed by nursing assistants. This supervision must adhere to current Federal, State, and Local standards, guidelines, and regulations governing the facility, as required by the Director of Nursing to maintain the highest degree of quality care at all times.

Responsibilities

  • Direct the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the long-term care industry.
  • Confirm that all nursing personnel assigned comply with the written policies and procedures established by the facility.
  • Meet with assigned nursing staff and support personnel to plan the shift's services, programs, and activities.
  • Verify compliance of nursing personnel with the Nursing Policies and Procedures Manual.
  • Make written and oral reports/recommendations concerning shift activities as required.
  • Cooperate with other resident services to ensure the resident's total regimen of care is maintained.
  • Verify compliance of nursing service personnel with their respective job descriptions.
  • Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing department.
  • Participate in surveys (inspections) made by authorized government agencies.
  • Periodically review and update the resident's written discharge plan as required.
  • Assist in planning the nursing portion of the resident's discharge plan as necessary.
  • Admit, transfer, and discharge residents as required.
  • Complete accident/incident reports as necessary.
  • Complete and file required forms/charts upon resident's admission, transfer, and/or discharge.
  • Encourage attending physicians to review treatment plans and record their orders and progress notes.
  • Receive and record telephone orders from physicians on the Physicians' Order Form.
  • Transcribe physician's orders to resident charts, cardex, medication cards, and treatment/care plans as required.
  • Chart nurses' notes in an informative and descriptive manner reflecting the care provided and the resident's response.
  • Record new/changed diet orders and forward information to the Dietary Department.
  • Report discrepancies concerning physician's orders, diet changes, charting errors, etc., to the Nurse Supervisor.
  • Fill out and complete transfer forms in accordance with established procedures.
  • Enter documentation concerning unauthorized discharges in the resident's medical record.
  • Perform routine charting duties as required and in accordance with established policies.
  • Sign and date all entries made in the resident's medical record.
  • Write nurses' notes to reflect adherence to the care plan when administering nursing care or treatment.
  • Prepare and administer medication as ordered by the physician.
  • Verify the identity of the resident before administering medication/treatment.
  • Ensure prescribed medication for one resident is not administered to another.
  • Verify adequate supply of medications, supplies, and equipment is on hand and report needs to the Nurse Supervisor.
  • Order prescribed medications, supplies, and equipment as necessary.
  • Verify accuracy of narcotic records for the shift.
  • Notify the Nurse Supervisor of drug and narcotic discrepancies noted on the shift.
  • Review medication cards for completeness and accuracy.
  • Notify the attending physician of automatic stop orders prior to the last dosage being administered.
  • Immediately notify the Nurse Supervisor and attending physician of any medication administration errors.
  • Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.
  • Promptly respond to call lights and other resident needs.
  • Make rounds with physicians as necessary.
  • Consult with the resident's physician in providing care, treatment, rehabilitation, etc.
  • Review the resident's chart for specific treatments, medication orders, diets, etc.
  • Make periodic checks to confirm prescribed treatments are being properly administered by CNAs.
  • Notify the resident's attending physician when the resident is involved in an accident or incident.
  • Notify the resident's attending physician and responsible party of any change in the resident's condition.
  • Administer professional services such as catheterization, tube feedings, suction, applying and changing dressings, etc.
  • Monitor seriously ill residents as necessary.
  • Review care plans daily to confirm appropriate care is being rendered.
  • Ensure CNAs are aware of the resident care plans and verify they refer to them prior to administering care.
  • Attend in-service education programs to meet facility educational requirements.
  • Be familiar with Standard Precautions, Exposure Control Plan, Fire Drill and Evacuation Procedures.
  • Maintain confidentiality of resident and facility records/information.
  • Protect residents from neglect, mistreatment, and abuse.
  • Protect the personal property of the residents of the facility.
  • Perform other duties as directed by the supervisor or administrator.

Requirements

  • Licensed Practical Nurse with current state license.
  • Excellent technical, assessment, and documentation skills.
  • Good leadership qualities.
  • Organized and detailed in work performance.
  • Good communication skills with excellent self-discipline and patience.
  • Genuine caring for and interest in elderly and disabled people in a nursing facility.
  • Comply with the Residents Rights and Facility Policies and Procedures.
  • Perform work tasks within the physical demand requirements.
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