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Greater Washington Area Chapter of AACN

RN/LPN New

Boonsboro, MD

Details

Positions Available

Full Time

No recruiters please


Position Description

SUMMARY

The purpose of this position is to delivery daily quality nursing care to the residents.  The Staff Nurse has the responsibility of monitoring the CMA's and GNA's assigned to her floor to ensure the residents are receiving the quality care and that they are following the policies and procedures of the facility and those mandated by the Federal and State Agencies.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

Makes rounds at the beginning and end of duty with on/off shift.

2.    Perform Admission Assessment on new admission and re-admission.

3.    Makes round with the physician when the Patient Care Coordinator is not available.

4.    Consults with the resident's physician in providing the resident's care, treatment, and rehabilitation as necessary.

5.    Requisition and arrange for diagnostic and therapeutic services as ordered by the physician.

6.    Assist the Patient Care Coordinator in assessing residents, gathering data and establishing an accurate and appropriate care plan.

7.    Make referrals to the Dietitian when the resident experiences a weight loss or there is an observed change in the resident's oral intake or when other nutritional problems are noted.

8.    Make referrals to the Rehabilitation Department when there is a change noted in the resident's physical functional status.

9.    Review the resident's chart for specific treatments, medication orders, diets, etc. as necessary.

10.  Review lab reports and notify physician of results ascertain appropriate follow up has been done.

11.  Notify the attending physician when the resident has been in an accident or incident or when there is a change in the resident's condition.  Provide the physician with an accurate assessment of the resident's condition.

12.  Notify the resident's family and/or responsible party when the resident has been in an accident or incident or when there is a change in the resident's condition.

13.  Administer professional services such as medication administration, catheterization, tube feeding, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, taking vital signs, transferring residents, feeding, toileting, etc. as required; document the provision of services accurately and on a timely basis.

14.  Obtain sputum, urine, stool and other specimens for lab tests as ordered.

15.  Monitor seriously ill residents as necessary.

16.  Ensure that the use of restraints is per established policies and guidelines. Participate in restraint rounds with therapy/restorative staff.

17.  Institute and maintain preventative measures for skin breakdown.

18.  Assess resident's skin for signs of breakdown and take immediate action for treatment when indicated.

19.  Ensure that residents with decubitus ulcers receive appropriate treatment such as daily inspection of wounds, turning and positioning, nutritional support and maintaining a clean dry bed.

20.  Participate in wound rounds when indicated.

21.  Review weights obtained by CNAs and verify accuracy; obtain reweigh and monitor when indicated.

22.  Cooperate with and coordinate social and activity programming with nursing services schedules.

23.  Ensure that the nursing assistants and certified medicine assistants are providing direct care to the residents and are providing such care in accordance with the resident's care plan and wishes.

24.  Meet with residents, and/or family members as necessary.  Report problems to Patient Care Coordinator.

25.  Inform the family member of the death of a resident; contact the funeral home when requested by the family; follows facility policy for postmortem care.

MEDICATION ADMINISTRATION FUNCTIONS

1.    Prepare and administer medications as ordered by the physician within the specified time frames and according to established facility policy.

2.    Document acceptance and/or refusal of medications per facility policy.

3.    Administer medications orally, topically, by feeding tube, intramuscularly, subcutaneously, or rectally as  specified per physician's order.

4.    Administer all physician ordered nourishments.

5.    Assess and observe resident for drug interactions and adverse reactions.

6.    Assess need for prn medications; assess and record effectiveness of administered dose.

7.    Verify the identity of the residents before administering the medication.

8.    Ensure that prescribed medication for one resident is not administered to another.

9.    Ensure that an adequate supply of medications for assigned residents, floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents.  Report needs to the Patient Care Coordinator.

10.  Maintain medicine cart in a neat, clean and orderly manner.

11.  Order prescribed medications, supplies and equipment as necessary and in accordance with facility and pharmacy policies.

12.  Count narcotics accurately for the shift and document.  Notify the Patient Care Coordinator for any discrepancies.

13.  Dispose of drugs and narcotics as required and in accordance with established procedures.

TREATMENT ADMINISTRATION FUNCTIONS

1.  Perform sterile and clean dressing changes as ordered and per facility policy; label, date and initial dressings.

2.  Assess wound appearance, stage, drainage, size, and document on skin grid per facility policy.

3.  Administer tube feedings per physicians order (continuous or bolus) and flushes per physicians order and facility policy.

4.    Insert/change urinary catheters (Foley and suprapubic) per physicians orders and facility policy.

5.    Irrigate Foley catheters per physicians orders and facility policy.

6.    Insert/change Nasogastric and gastric tubes per physicians orders and facility policy.

7.    Administer oxygen and respiratory treatments.

8.    Change oxygen tubing and other respiratory equipment per facility policy.

9.    Perform Colostomy Care as ordered.

10.  Administer douches and enemas as ordered.

11.  Assess and document resident's response to treatments and procedures.

CHARTING AND DOCUMENTATION

1.  Complete and file required forms upon resident's admission, transfer and discharge.

2.  Ensure that attending physician's review, record and sign their progress notes and orders in accordance with facility policies.

3.  Receive telephone orders from physicians and record accurately.

4.  Transcribe physician's orders to resident's charts, MAR, TAR, ADL and Lab books accurately.

5.  Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident as well as the resident's response to care.  Review previous nurses notes to assure continuity and follow up.

6.  Date, time and sign all entries in the clinical record.

7.  Write legibly in blue or black ink.

8.  Use only authorized abbreviations established by this facility when recording information.

9.    Chart all reports of accidents, incidents and change

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