Job Description

Reports to: Director of Nursing

Department: Nursing

Description of Position: 

The primary purpose of your job is to provide direct nursing care to the residents including medication management and skin care treatments, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and facility policies and procedures and as may be required by the Station Manager, RN Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. 

Delegation of Authority

As the Charge Nurse, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Duties and Responsibilities

Administrative Functions

• Direct the day-to day functions of the nursing assistants 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 established by this facility.
• Meet with your assigned nursing staff, as well as support personnel, in planning the shifts’ services, programs, and activities.
• Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this facility.
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual and in compliance with their respective job descriptions.
• Make written and oral report/recommendations concerning the activities of your shift as required.
• Cooperate with other resident services when coordinating nursing services to ensure that the residents’ total regimen of care is maintained.
• Participate in the development, maintenance, and implementation of the facility’s quality assurance program for the nursing service department.
• Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
• Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan as required.
• Assist in planning the nursing services portion of the resident’s discharge plan as necessary.
• Admit, transfer, and discharge residents as required.
• Complete accident/incident reports as necessary.
• Write resident charge slips for supplies and forward to the Business Office.
• Maintain the Daily Census Report and submit to the Business Office as required.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. (i.e. 24 hour reports, care plans, weekly summaries) as necessary.

Charting and Documentation

• Complete and file required recordkeeping forms/charts upon the resident’s admission, transfer, and/or discharge.
• Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
• Receive telephone orders from physicians and record on the Physicians’ Order Form and as otherwise required. Notify Responsible Party.
• Transcribe physician orders to resident charts, medication administration records, treatment/care plans, as required.
• Chart nurses’ notes in an informative, descriptive and legible 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 Director as required.
• Chart all reports of accidents/incidents involving residents. Submit reports to the Accident/Incident Coordinator. Update care plans with new interventions as needed. Follow established procedures.
• 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 Station Manager/ RN Nurse Supervisor.
• Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.
• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
• Sign and date/time all entries made in the resident’s records.

Drug Administration & Treatment Functions

• Prepare and administer medications as ordered by the physician.
• Verify the identity of the resident before administering the medication/treatment.

• Ensure that prescribed medication for one resident is not administered to another.
• 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 Station Manager/ RN Nurse Supervisor.
• Order prescribed medications, supplies, and equipment as necessary and in accordance wit established policies.
• Ensure that narcotic records are accurate for your shift.
• Notify the Station Manager, RN Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
• Review medication administration records for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage being administered.
• Dispose of drugs and narcotics as required, and in accordance with established procedures.

Personnel Functions

• Assist the Station Manager, RN Nurse Supervisor in determining the staffing needs of the nursing service department.
• Ensure that a sufficient number of certified nursing assistants are available for each tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident.
• Develop work assignments and schedule duty hours, and/or assist nursing supervisory staff in completing and performing such tasks.
• Make daily rounds of your assigned station to ensure that all certified nursing assistants are performing their work assignments in accordance with acceptable nursing standards.
• Monitor absenteeism to ensure that an adequate number of nursing care personnel are on duty at all times. Report problem areas to the Station Manager, RN Nurse Supervisor.
• Review complaints and grievances made or filed by department personnel. Make appropriate reports to the Nurse Supervisor as required or as may be necessary.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis as well as a calm environment throughout your station and shift.
• Meet with your CNAs on a regularly scheduled basis to assist in identifying and correcting problem areas and or to assist in the improvement of services.
• Review and evaluate your CNAs.
• Report occupational exposures to blood, body fluid, infectious materials and hazardous chemicals in accordance with the facilities policies and procedures governing accidents and incidents.

Nursing Care Functions

• Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc. Ensure that rooms are ready for new admissions. Greet newly admitted residents upon admission. Escort them to their rooms as necessary.
• Review nurses’ notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident’s response to the care, and that such care is provided in accordance with the resident’s wishes. Schedule daily rounds to observe residents and to determine if nursing needs are being met. Report problem areas to the Station Manager, RN Nurse Supervisor. Assist in developing and implementing corrective action.
• Notify the resident’s attending physician and Responsible Party when there is a change in the resident’s condition.
• Visit residents on a daily basis in order to observe and evaluate each resident’s physical and emotional status.
• Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled. Report medication errors to the Station Manager, RN Nurse Supervisor.
• Provide direct nursing care as necessary.
• Start IVs, obtain sputum, urine and other specimens for lab tests as ordered.
• Take TPRs, blood pressures, etc., as necessary.
• Ensure that residents who are unable to call for help are checked frequently.
• Respond to emergency situations as needed.
• Assist in arranging transportation for discharged residents as necessary.
• Inform family members of the death of the residents.
• Call funeral homes when requested by the family.

Staff Development

Assist the Station Manager, RN Supervisor & Director of Staff Development, as needed, in the development, planning, conducting, and scheduling in-service training classes that provide instructions on “how to do the job” and ensure a well-educated nursing service department.

Safety and Sanitation

• Ensure that nursing service personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner.
• Participate in the development, implementation and maintenance of the procedures for reporting hazardous conditions or equipment.
• Monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies.
• Ensure that all personnel wear and/or use safety equipment and supplies (e.g. mechanical lifts, etc.) when moving or lifting a resident.
• Report missing/illegible labels and MSDSs to the safety officer or other designated person.
• Participate in the maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel.
• Assist the Infection Control Coordinator in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks in which there is potential exposure to blood/body fluids are properly identified and recorded.
• Ensure that all personnel performing tasks that involve potential exposure to blood/body fluids participate in appropriate in-service training programs prior to performing such tasks. 
• Ensure that an adequate supply of personal protective equipment is on hand and readily available to personnel who perform procedures that involve exposure to blood or body fluids.
• Ensure that nursing service personnel follow established infection control procedures when isolation precautions become necessary.
• Monitor nursing service work areas (i.e., nurses’ station, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner. Ensure that all resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner.

Equipment and Supply Functions

• Recommend to the Station Manager, RN Nurse Supervisor the equipment and supply needs of the department.
• Ensure that an adequate stock level of medications, medical supplies, equipment, etc., is maintained on premises at all times to adequately meet the needs of the resident.
• Assist the Maintenance Director in developing a preventive maintenance program for maintaining the nursing department’s equipment and supplies in a safe and operable manner.
• Participate in the development and implementation of the procedures for the safe operation of all nursing service equipment.
• Ensure that only trained and authorized personnel operate the department’s equipment. Ensure that all personnel operate nursing service equipment in a safe manner.
• Ensure that appropriate MSDSs are on file for hazardous chemicals used in the nursing department.

Care Plan and Assessment Functions

• Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident.
• Assist the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising the MDS, including the implementation of RAPs and Triggers.
• Participate in the development of a written care plan (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care.
• Encourage the resident to participate in the development and review of his/her care plan.
• Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.
• Ensure that all personnel involved in providing care to the resident are aware of the resident/s care plan. Ensure that nursing personnel refer to the resident’s care plan prior to administering daily care to the resident. Review nurses’ notes to determine if the care plan is being followed.

Resident Rights

• Maintain the confidentiality of all resident care information.
• Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect. Ensure that all nursing care is provided in privacy and that nursing service personnel knock before entering the resident’s room.
• Ensure that all nursing service personnel are knowledgeable of the residents’ responsibilities and rights including the right to refuse treatment.

Working Conditions

• Works in nursing station as well as throughout the nursing service area (i.e. drug rooms, nurses’ stations, resident rooms, etc.).
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
• Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.
• “Communicates with the medical staff, nursing personnel, and other department supervisors.
• Works beyond normal working hours and on weekends and holidays when necessary.
• Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
• Is involved in community/civic health matters/projects as appropriate.
• Attends and participates in continuing educational programs.
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• May be subject to the handling of and exposure to hazardous chemicals.

Qualifications for the Position

Education

• Must possess, as a minimum, a Nursing Degree from an accredited college or university

Experience

• 1 year experience in a skilled nursing facility is preferred, but not required.

Specific Requirements

• Must possess a current, unencumbered, active license to practice as a Nurse in the state.
• Must be able to read, write, speak, and understand the English language
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
• Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
• Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
• Must be able to relate information concerning a resident’s condition.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements (With or Without the Aid of Mechanical Devices)

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write the English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
• Must function independently, and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
• Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination. Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and at time, hostile people within the facility.
• Must be able to push, pull, move, and/or lift a minimum of 50 pound to a minimum height of 3 feet and be able to push, pull, move, and /or carry such weight a minimum distance of 10 feet.
• May be necessary to assist tin the evacuation of residents during emergency situations.

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