The Practical Nurse or Registered Nurse has an overall responsibility for resident care in the facility. All of the following duties are essential unless otherwise noted:
- Must report to work on schedule. Dependability, regular attendance and punctuality are essential job requirements.
- Evaluate resident needs, conditions, and care, and assist in developing nursing care plans for individual residents, including rehabilitative and restorative activities and instruction in self-help.
- Communicate with family members regarding the condition and progress of the resident, including in-person discussion and answering of telephone inquiries.
- Assist the physicians in rounds when needed, reviewing physicians’ orders, ordering medications, maintaining residents’ charts, and transcribing physicians’ orders.
- Assist Nurse Managers with orientation and training programs for new employees in the department, as required.
- Assist the Director of Nursing/Nurse Managers with implementation of guidelines and procedures for the department.
- Make daily rounds to evaluate emotional and physical needs of residents during the tour of duty.
- Notify the physician and family of incidents or changes in the condition of a resident.
- Participate in all in-service meetings and CEU’s as required.
- Carry out and follow all facility personnel guidelines.
- Model behaviors that reflect continued personal and professional growth.
- Supervise Nursing Assistants, Nourishment Aides, and Aide Helpers.
- Give correct medication to the right resident, according to the amount, time, and route of administration as ordered by the physician. Ensure that prescribed medication for one resident is not administered to another. Verify the identity of the resident before administering the medication/treatment.
- Perform other duties as assigned by the Nurse Manager/Director of Nursing.
Safety
- Follow established infection control procedures at all times.
- Follow established procedures in the use and disposal of personal protective equipment.
- Report hazardous conditions or equipment to the Charge Nurse.
- Report missing/illegible labels and MSDSs to the Charge Nurse.
Charting and documentation
- Receive telephone orders from physicians and record on the Physician’s Order Form.
- 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 the care.
- Fill out and complete accident/incident reports. Submit to the Safety Manager. Chart all reports of accidents/ incidents involving residents.
- Record new/changed diet orders. Forward information to the Dietary Department.
- Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc. to the Charge Nurse.
- Fill out and complete transfer forms in accordance with established procedures.
- Transcribe physician’s orders to resident charts, cardex, medication cards, treatment/care plans, as required.
- Ensure that appropriate documentation concerning unauthorized discharges is entered into he resident’s record in accordance with established procedures.
- Sign and date all entries made in the resident’s medical record.
- Perform routine charting duties as required an in accordance with established charging and documentation policies and procedures.
- Ensure that narcotic records are accurate for your shift.
Drug administration
- Give correct medication to the right resident, according to the amount, time, and route of administration as ordered by the physician. Ensure that prescribed medication for one resident is not administered to another. Verify the identity of the resident before administering the medication/treatment.
- Dispose of drugs and narcotics as required, and in accordance with established procedures.
- Notify the attending physician of automatic stop orders prior to the last dosage being administered.
- Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.
- Notify the Nurse Manager of all drug and narcotic discrepancies noted on your shift.
- Ensure that an adequate supply of floor, stock medications, emergency medications, supplies and equipment is on hand to meet the nursing needs of the residents. Report needs to the Unit Secretary. Requisition prescribed medications, supplies, and equipment as necessary.
Nursing care
- Carry out restorative and rehabilitative programs, to include self-help and care.
- Administer professional services including, but not limited to: catheterization, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required.
- Obtain sputum, urine and other specimens for lab tests as ordered.
- Take and record TPRs, blood pressures, etc., as necessary.
- Monitor seriously ill residents.
- Perform other duties as assigned by the Director of Nursing or designee.
Resident Rights
- Maintain the confidentiality of all resident care information.
- Treat all residents fairly, and with kindness, dignity, and respect.
- Provide nursing care in privacy and knock before entering the resident’s room.
- Be familiar with resident rights and responsibilities.
- Assure complaints and grievances made by the residents are reported either in writing, or orally, using the facility procedure.
- Report all allegations of resident abuse and/or misappropriation of resident property, using facility procedure.
- Notify the Charge Nurse of any change in a resident’s condition.
Qualifications
Must be a graduate of an accredited school of nursing and must possess and be responsible for all actions necessary to maintain a current license with the Iowa State Board of Nursing.
Additional Information
All your information will be kept confidential according to EEO guidelines.