Job Description

PurposeThe primary purpose of this position is to provide high quality, holistic nursing care in accordance with nursing practice standards and health care regulations which govern the practice of professional nursing. Lead or direct licensed and non-professional staff in the delivery of direct resident care and support functions.Essential Job Functions Duties and ResponsibilitiesNursing Care Functions * Conduct the daily nursing functions in accordance with current rules, regulations, and guidelines that govern the long term care facility.

• Ensure that all nursing personnel assigned to you comply with the written policies and procedures including the safety program.
• Admit, transfer, and discharge residents with documentation regarding care and service provided.
• Participate in the orientation of new residents/family members to the facility.
• Make rounds with health care provider.
• Utilize nursing personnel qualifications according to the resident\xe2\x80\x99s care plan, wishes, and health care provider orders.
• Complete daily clinical and environmental rounds to evaluate resident care being provided and report significant events.
• Meet and resolve issues with residents and/or family members. Report significant issues to the supervisor.
• Participate in facility surveys (inspections) as requested by management.
• May be responsible for clinical programs as directed, e.g. dementia, wound care, quality assurance, infection control, admissions.

Communication/Documentation Functions * Complete an initial assessment and develop interim care plan.

• Update, review, and transcribe the care plan that identifies the goals, problems, approaches, and revisions based on nursing needs and new health care provider orders.
• Communicate with health care provider to review treatment plans, complete orders, progress notes, etc., in accordance with established policies.
• Review the resident\xe2\x80\x99s medical record for specific treatments, medication orders, diets, labs etc., as for implementation and follow up.
• Requisition and arrange for diagnostic and therapeutic services, as ordered by the health care provider, and in accordance with our established procedures.
• Communicate the department\xe2\x80\x99s policies and procedures to personnel, residents, and visitors.
• Communicate with written (24 hour report) and oral reports/recommendations concerning any changes in resident condition and other activities of your shift to nursing management.
• Fill out and complete accident/incidents involving residents or staff and submit to Director of Nursing.
• Complete and file assessments and all other medical record documentation as required to provide care services.
• Provide resident and family information for care conferences or other meetings.
• Report all discrepancies noted concerning physician\xe2\x80\x99s orders, diet change, charting error, etc., to the supervisor.
• Complete clinically accurate documentation according to policy.
• Review the resident medical documentation and progress notes from the interdisciplinary team to determine if the care plan is being followed. Report any concerns to your supervisor.
• Inform nursing personnel of new admissions and the resident\xe2\x80\x99s care needs. Ensure that rooms are ready for new admissions. Greet newly admitted residents upon admission.
• Notify the resident\xe2\x80\x99s attending health care practitioner and family when there is a change in the resident\xe2\x80\x99s condition.
• Meet with your assigned support personnel (Housekeeping, Dining Services, Nursing Assistants, etc.) to plan the shift\xe2\x80\x99s services, programs, and activities and monitor tasks are completed as directed.
• Coordinate services with other members of the disciplinary team (Housekeeping, Dining Services, Nursing, etc.) to ensure that the resident\xe2\x80\x99s total regimen of care is maintained.
• Assist in arranging transportation for residents and other third party services.

Medication Administration Functions * Prepare and administer medications ordered by the health care provider.

• Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the supervisor.
• Review medication administration record for completeness of information, accuracy in the transcription of the health care provider\xe2\x80\x99s order. Report concerns to your supervisor.
• Dispose of drugs and narcotics as required, and in accordance with established procedures.

Personnel Functions * Assist with adjusting the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents.

• Assist to develop work assignments, schedule duty hours, and assist and supervise nursing staff to ensure that all personnel are performing their work assignments in accordance with acceptable nursing standards.
• Assist in staff development. Formally and informally monitor performance of personnel and ensure adjustments/corrections are made by using coaching, counseling, and discipline methods.
• Work with the Director of Nursing to resolve staff performance issues including those that may lead to termination.
• Review complaints and grievances, complete investigations, and work with the Director of Nursing for a plan of action and resolution..
• Participate in the planning, conducting and scheduling of timely in service and orientation training classes that meet state and federal requirements.

Safety and Sanitation Functions * Supply and make available protective equipment for staff.

• Maintain nursing service work areas (i.e., nurses\' stations, medicine preparation rooms, etc.), resident rooms, and treatment areas in a clean and sanitary manner.
• Recommend to the Director of Nursing the equipment and supply needs of the nursing department. Ensure that a stock level of medications, medical supplies, equipment, etc., is maintained on the premise at all times to adequately meet the needs of the residents.

Required Knowledge, Skills and AbilitiesMust possess the ability to make independent decisions, follow instructions, and accept constructive criticism. Must be able to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public. Must be able to work with ill, disabled, elderly, and emotionally upset people within the facility. Must be able to speak, write and understand English in a manner that is sufficient for effective communication with supervisors, employees, residents, and families.Education and ExperiencePrefer to have experience in nursing in a long-term care facility or similar experience.Licensing/CertificationsMust possess a current and active license to practice as an LPN/LVN in this state.Physical RequirementsAll requirements are subject to possible modification to reasonably accommodate individuals with disabilities. Individuals who pose a direct threat or significant risk to the health and safety of themselves or others in the work place will not be considered qualified for employment if physical requirements cannot be eliminated or reduced by reasonable accommodation.Essential functions are carried out in a variety of positions including standing and sitting. To meet residents\xe2\x80\x99 needs, all positions require the ability to move freely through the building. Other physical demands are required as described below.TaskRequirementFrequency (Place X in approp. box)ConstantlyFrequentlyOccasionallyRarelySeeingXHearingXTactile SenseXTalkingMust convey detailed and important spoken instructions to other workers accuratelyXClimbingXBalancingXStoopingXKneelingXCrouchingXPulling30 lbs.50 lbs.75 lbsPushing30 lbs.50 lbs.75 lbsStandingXWalkingXReachingXFine MotorXGraspingXTwistingXRepetitive MotionsXLifting30 lbs.50 lbs.75 lbsCrawlingXStatic PositionXCarrying30 lbs.50 lbs.75 lbsOtherEquipment and ToolsList equipment and tools operated and the frequency of use:Equipment: Computer and personal communication devices, office equipment; Medical and safety equipment within scope of practiceWorking ConditionsCheck which working conditions the employee is subject to:Physical Conditions:\xe2\x98\x90 Extreme temperatures \xe2\x98\x90 Noise \xe2\x98\x92 Wet and/or humid \xe2\x98\x90 VibrationWorkplace Hazards:\xe2\x98\x92 Blood, body fluids and/or infectious disease \xe2\x98\x90 Hot Water\xe2\x98\x90 Mechanical \xe2\x98\x90 Electrical\xe2\x98\x92 Chemical \xe2\x98\x92 Gasses \xe2\x98\x90Other:

Innovative Staffing Montana