Coordinates and delivers, on an age and developmentally appropriate basis, direct clinical care per nursing process for adult and geriatric residents/patients. Delivers resident/patient care according to the Scope of Service for the Living Center. Assumes weekend charge nurse responsibilities as follows: acts as a clinical and administrative role model and resource for the Living Center. Contact person for the physicians and other department managers. Manages the care of the residents/patients. Adheres to and practices the SJH Corporate Compliance Program and participates in Performance Improvement activities. Essential Functions Resident Care · Obtains data from resident and/or family using observational, interviewing, interpretation and critical thinking skills for valid assessment of condition upon admission and daily. Data to include: condition of the skin, mobility, sensory impairments, cardiovascular status, respiratory status, nutritional status, reaction to medication, psychosocial and mental status. · Utilizes resident data for problem identification, particularly rehabilitation and restoration of all functions where possible and good supportive care to prevent further deterioration when not possible. · Initiates appropriate nursing interventions that are population specific/developmentally appropriate and allows for resident choice whenever possible. · Identifies changes in resident status and responds appropriately using safe nursing judgment in the notification of a physician and follows chain of command. · Assures all pertinent resident data is communicated through oral and written means appropriately using the change of condition log. · Uses SBAR when communicating resident information. Resident Safety and Plan of Care · Formulates a plan of care that is resident centered and is based on the 10 Eden principles. · Attends care conferences as schedule allows. · Responsible for following resident care plan guidelines as outlined by the Care Coordinators. · Identifies risk factors and provides for resident safety. · Implements measures to prevent injury and provide a safe environment. · Keeps department and hallways clean and orderly. · Demonstrates knowledge and awareness of medication action, side effects and protocols for use. · Gives medications safely and accurately according to policy and procedure. · Completes event reports for all adverse drug reactions. · Consistently implements the current National Patient Safety Goals. · Uses two patient identifiers · Provides clear and concise reports when "handing off" to another provider · Completes medication reconciliation on admission and at discharge · Implements correct hand washing according to the CDC guidelines · Implements interventions to reduce falls and pressure ulcers Resident and Family Education · Addresses resident and family's spiritual needs utilizing a holistic, resident centered approach. · Incorporates teaching/education into all aspects of resident care and nursing practice. · Provides clear information to assist the resident and family to make informed decisions. · Notifies families appropriately regarding resident's needs and/or change in condition. · Documents all resident and family education and pertinent communications.
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Job Type
Full-time
Education Level
Associate degree