A Brief Overview Coordinates data collection for the Resident Assessment Instrument (RAI), including the MDS, CAAS, Multidisciplinary Care Plan, manage and oversee restorative program, responsible for weekly skin assessments. Assist in absence of RN Manager/DON. Provide high quality care to the following patient populations: Adult, Geriatric. What you will do Develop comprehensive assessments of each resident to create individualized plan of care upon admission, significant change, and quarterly. Completion of the MDS, CAAS and Care Plans are done by required completion dates. Submission of MDS/RUGS are completed in a timely manner. Evaluate nursing and clinical intervention outcomes, conferring with other health care team members as necessary. Monitor resident’s medications, usage, and results. Monitor and assess resident’s alteration in skin, document changes and communicate with providers. Assist in scheduling individual care conferences. Directs Care Conferences with Residents and families. Participates in other necessary team conferences. Interview residents as designated, and review documentation related to medical conditions, such as adverse reactions to medication or treatment, condition change, or progress or lack of progress with interventions. Work as part of a health care team to assess resident needs, plan and modify care and implement interventions as appropriate. Oversee, review, and document on resident's restorative plans monthly. Provide guidance to restorative aid. Supervise resident care and manage staff in absence of Director of Nursing. LTC Call Rotation Required. Assist with maintaining a full schedule, assist with working on the floor when absences occur. Ensure compliance with state, and federal regulations. Participates in state survey and inspections by government agencies. Assist with implementation of plans of corrections to correct deficiencies. Help hire, train and monitor nursing staff. Ensure staff follow departmental policy and procedures. Assist with facilitating QAPI program within the facility. Reports at QAPI regarding quality measures. Readily accepts and responds effectively to changes in work processes, new technology or other changes. Communicate with Director of Nursing any changes in conditions, skin issues, and any other pertinent information. Assessment Demonstrates the ability to obtain information needed to complete the MDS and entire RAI process. Differentiates variations of normal and abnormal assessment findings Analyzes and prioritizes abnormal findings. Communicates information to the appropriate care provider or nursing leader. Anticipates actual or potential problems or health concerns in the hospital and/or home setting and communications with the care team. Demonstrates ongoing assessment of patient’s psychosocial, physiological, and educational process per unit policy. Anticipates, recognizes, and documents subtle changes in patient’s physical and mental status. Integrates analysis of diagnostic information in patient assessment and care Analyzes ongoing assessments to determine patient’s and/or significant others learning and discharge needs. Diagnosis Integrates assessment data and formulates an individual MDS, CAA’s as necessary. Planning Formulates an individualized plan of care including discharge planning based on standards of care, policies, and procedures. Participate in activities aimed at professional growth and development including conferences or continuing education activities. Participate in treatment team conferences regarding diagnosis or outcomes. Collaborates with assigned RN to refer patients requiring more specialized or complex treatment to psychiatrists, primary care physicians, or other medical specialists. Regular and reliable attendance. Must have current knowledge of the entire RAI process and current regulatory requirements related to this process and implement.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
251-500 employees