Registered Nurse - Skilled Nursing Facility

JOB SUMMARY:

Assists in maintaining a positive physical, social, and psychological environment in accordance with resident’s needs and facility philosophy. Responsible to the Director of Nursing for the planning, directing, supervision and delivery of resident care. Responsible for maintaining accurate and complete medical records on each resident.

(Other duties may be assigned.)

§Provides nursing care according to physicians’ orders and in conformance with the nurse practice act, established standards, and administrative policies. In the nurse practice act, “practice of professional nursing” means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to:

1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.

2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments.

3. The supervision and teaching of other personnel in the theory and performance of any of the above acts.

§The professional nurse shall be responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.

§Assists with evaluation of the nursing process on the unit, and provides input regarding needed or desired changes.

§Supervises daily functions of the nursing unit, from LPN and CNA supervision to delivery of resident care.

§Gives/receives nursing report upon reporting in and ending shift duty hours.

§Communicates immediately to supervisor/nursing administration on call any problem requiring immediate attention.

§Administers personal hygienic, preventative, therapeutic and rehabilitative services to residents and assists in the coordination of nursing care with care rendered by other disciplines.

§Admits new residents by assessing their needs and reviewing physician orders.

§Orders prescribed medications, supplies and equipment as necessary, in accordance with established policies.

§Requisition s and arranges for diagnostic and therapeutic services as ordered by resident’s physician.

§Assembles resident’s chart, attaching required forms.

§Administers medications, performs procedures and treatments and provides resident care.

§Maintains documentation, which accurately and completely records data pertaining to resident’s care, condition and treatment.

§Participates as a member in the interdisciplinary resident care conferences in developing a total plan of care, and in communicating that plan to nursing staff caring for the resident.

§Coordinates with Social Services and assists in scheduling appointments and arrangements for transportation of residents to other departments or facilities and clinics for diagnostic, therapeutic, dental or medical services.

§Confers with the Director of Nursing, as necessary, to provide input regarding resident care needs, staffing requirements, and nursing supply needs for the units.

§Makes rounds with physicians, assists in examination and/or treatment of residents and carry out orders.

§Discharges or transfers residents and completes necessary forms per facility policy, re: giving discharge instructions to the resident or responsible party; completing discharge nurses summary; and following return policy procedure for meds to pharmacy.

§Notifies, when necessary, the attending physician and resident’s responsible party in the event of a change in the resident’s condition.

§Maintains a professional attitude at all times on the unit and a professional approach towards nursing care and personnel.

§Attends and participates in in-service classes and on‑job programs as scheduled and directed.

§Assures that established infection control and universal precautions are maintained when performing duties.

§Administers…