The Registered Nurse (RN) is accountable for the delivery of safe and therapeutic resident care from admission through discharge in collaboration with the physician, family and other members of the multi-disciplinary health care team. Delivery of quality nursing care is assured through utilization of the nursing process. The goal of resident care shall be toward restoring and maintaining each resident’s capabilities at their maximum mental and physical level. The Registered Nurse serves as a positive clinical role model for staff as well as a resource person.
Essential Job Specific Duties/Responsibilities
1. Performs activities related to the nursing care needs of residents.
- Gives and received a thorough shift report to/from oncoming nurse.
- Monitors work performance of nursing assistants. Makes frequent rounds throughout the shift.
- Suggests appropriate ways to solve problems and make improvements on the unit(s).
- Provides hands-on direct care, including ADLs and treatments as necessary. Identifies aspects of resident care that require the judgment and skill of an RN and those that can be performed by other staff. Delegates specific nursing tasks appropriately.
- Makes rounds with physicians. Utilizes physician file appropriately.
2. Performs activities related to medications and treatments in accordance with facility policies and processes.
- Safely administers medication and treatments ordered by the physician.
- Maintains control of scheduled drugs and all drugs in medicine cart; monitors for discrepancies and reports promptly to Nurse Manager.
- Keeps medication cart key-locked when not within eye view of nurse.
- Appropriately records and orders medications from the pharmacy.
- Monitors for and reports Adverse Drug Reactions appropriately.
3. Documents in accordance with nursing policies and procedures.
- Monitors and documents accurately all nursing actions implemented as well as effectiveness of implementation in Nursing Notes and Resident Plan of Care.
- Accurately records assessments of physiological and mental dimensions of residents, including pain assessment.
- Documents in EMR accurately, legibly, and timely.
- Completes monthly summary accurately and timely utilizing Resident Plan of Care. Updates Plan of Care and Resident Care Card monthly and as necessary.
- Completes weekly Skin Integrity reviews accurately to reflect resident.
- Documents, at time of services, all medication and treatments administered.
- Documents resident response to non-pharmacological strategies to promotes pain relief and resident response to analgesics.
4. Maintains effective communication with residents, families, staff, and physicians.
- Completes daily shift documentation, including head to toe assessment of skilled residents.
- Functions in a calm, positive manner in an emergency or crisis situation.
- Communicates consistently with the Nurse Manager, reporting pertinent concerns/issues.
- Places necessary calls to families and physicians. Demonstrates appropriateness of faxing vs. phone calls to physicians.
- Communicates appropriately with physicians; makes rounds with physicians in absences of Nurse Manager or as delegated by Nurse Manager.
- Reviews and teaches resident and family about pain management, including pain-rating scales and goal setting; importance of aggressive, preventative pain treatment; analgesic misconceptions; and plan for pain management.
- Participates in resident/family teaching and initiates discharge planning in a timely manner.
5. Satisfies all educational in-service requirements mandated by CHI Living Communities, the department, external accrediting, and regulatory agencies.
- Attends all mandatory in-service programs.
- Adheres to facility policies and procedures.
- Completes yearly online education program by deadline.
- Attends employee meetings on a regular basis.
In addition to the essential job specific duties listed above, the Registered Nurse shall be required to perform all duties (essential and non-essential) in a manner consistent with mission and values (compassion, excellence, inclusion, integrity, collaboration) of CHI Living Communities and will be evaluated on such basis. Furthermore, every employee must abide by all campus, departmental, and safety policies, rules, and regulations.
CHI Living Communities has the right to change the job specific duties and specifications required for the position of Registered Nurse from time to time without prior notice.