MDS- RN

Overview

MDS- RN Full Time (Healthcare)

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.

• Administer patient assessments, oversee the assessment process, set assessment schedules, and ensure assessments are completed accurately and timely.
• Coordinate the care plan according to regulatory requirements.
• Create schedules for Medicare and Medicaid; start Medicare coverage for newly qualified patients or send out denial letters; stay updated on changes in Medicare coverage; determine documents needed for Medicaid reimbursement.
• Direct daily functions of nursing assistants in accordance with current rules, regulations, and guidelines for the long-term care facility.
• Ensure nursing personnel comply with written policies and procedures; periodically review department policies and manuals; recommend revisions as needed.
• Plan shifts, services, programs, and activities with assigned nursing staff and support personnel; maintain an up-to-date Nursing Service Procedures Manual.
• Provide written and oral reports/recommendations about shift activities; cooperate with other resident services to maintain the resident’s total regimen of care.
• Participate in the development, maintenance, and implementation of the facility's quality assurance program for the nursing service department; participate in facility surveys as requested.
• Review and update the resident discharge plan; assist in planning the nursing services portion of the discharge plan as necessary.
• Interpret department policies to personnel, residents, visitors, and government agencies; admit, transfer, and discharge residents as required.
• Complete accident/incident reports; manage charting and documentation per policies; ensure accuracy and confidentiality of resident information.
• Write resident charge slips and forward to the Business Office; maintain the Daily Census Report.
• Perform administrative duties (forms, reports, evaluations, studies, charting); ensure compliance with privacy and information security requirements.

• Complete and file required recordkeeping forms/charts at admission, transfer, and discharge.
• Encourage physicians to review treatment plans and sign orders; receive and transcribe physician orders to resident charts and related documentation.
• Document nursing notes descriptively; report accidents/incidents; forward reports to the Director as required.
• Record diet orders and discrepancies; coordinate with Food Services; ensure documentation reflects treatments and responses.
• Ensure appropriate documentation for unauthorized discharges and transfer forms; follow charting policies and procedures.
• Sign and date all entries in the resident's medical record.

• Prepare and administer medications as ordered; verify resident identity prior to administration; prevent cross-occasion medication errors.
• Maintain adequate stock of medications, supplies, and equipment; manage narcotic records and report discrepancies.
• Review medication cards for accuracy; notify attending physician of automatic stop orders prior to last dosage; dispose of drugs per procedures.

• Participate in staffing decisions, supervise nursing personnel, and ensure coverage; conduct daily rounds to monitor performance to standards.
• Ensure all nursing assistants are trained and supervised; meet regularly with shift staff to address problems and improve services.
• Promote a respectful, warm, and calm environment; develop good working relationships with interdepartmental staff.
• Handle complaints and grievances; report to Nurse Supervisor as required; follow facility procedures for disciplinary actions.
• Oversee nursing service activities while maintaining safety and regulatory compliance; enforce policies on confidentiality and access control.

• Monitor safety regulations; ensure PPE availability…