Long Term Care
Monday's 6:30a - 6:30p
The Full Time Long Term Care Dayshift Nurse will be responsible for directing the patient care of the residents in long term care during assigned times. Responsible for the completion and coordination of MDS assessments for long term care residents.
DUTIES AND ESSENTIAL JOB FUNCTIONS:
- Attends in-services, staff meetings and care planning to improve and maintain skills and improve the care of the residents.
- Encourages and promotes good interpersonal relationships with team members and provide a team manner of supervision.
- Reviews and abides by code of ethics and supervises others in the same.
- Prepares and passes medications and treatments on hours scheduled with appropriate charting of changes. Administers PRN’s and record with a note if results obtained.
- The nurse in charge, on all shifts, is responsible for knowing the condition of all residents on his/her unit.
- Is responsible for supervising the Certified Nursing Assistants during their shift. This includes all care including feeding, passing trays, nourishment and fresh water, ambulation, ROM, personal care, toileting and bed checks, and any orders on nursing orders specific to the individual residents. Rooms should be tidied including utility areas and equipment.
- Communicates his/her location at all times to LTC nursing staff.
- Performs nursing histories and nursing assessments on all new Residents to include: vital signs, height, weight and an assessment of skin condition. Patient’s Rights will be signed and residents will be given information on Advance Directives. This will be documented on admission progress notes.
- Checks BM list for laxatives needs, on third day if no BM, give laxative.
- Is responsible for reporting changes to medical provider as needed. Notes vital signs and specifics on Progress Notes. Starts Alert charting according to Alert charting Policy, as needed.
- If an incident occurs involving staff, the person must complete an online incident report.
- When accidents occur involving visitors or patients, have involved staff fill out a Quality Assurance Memo and turn it into your supervisor as soon as possible. Family and Physicians are to be notified of all accidents, including falls, skin tears and bruises. Proper documentation will be done according to facility policy.
- When a situation occurs that involves a patient’s condition, the licensed staff on duty must contact the family and document that change immediately.
- The Long Term Care Nurse will be responsible that all patients’ rights are honored under his/her supervision. Review the resident rights on a regular basis. Examples: answering lights promptly, free from abuse, physical or mental and treated with dignity and respect.
- Nailcare for diabetics will be done by licensed staff as needed, or schedules appointment with Podiatry.
- Assist doctors if rounds are made and carry out new orders.
- Drug count of Class II and III drugs at the start and end of each 12 hr. shift.
- Sets up MDS assessments, observation/charting periods to avoid case mix defaults.
- Develops a care plan from the nursing assessment as well as the findings of the Multidisciplinary team. Leads the care planning process including meetings.
- Updates the care plan and care directives as indicated during quarterly review or investigations.
- Develops goals and approaches specific to resident needs.
- Keeps documentation up to date and revised in accordance with state and federal regulations.Teaches and communicates the nursing process including documentation to all staff as indicated.
- Understands case mix reimbursement and reviews facility case mix index. Addresses default issues to assure a balanced reasonable and accurate reimbursement rate.
- Reviews RUGS items on each MDS for accuracy and adequate documentation and assures correction as needed.
- After MDS is inputted into the computer, reviews for accuracy and follows up with documentation and care plan changes.
- Assists CBH to reach maximum reimbursement by assessing for significant changes according to RAI guidelines. Reports according to state and federal guidelines. Documents all findings as investigated.
- Reviews activities of restorative CNA’s for appropriate residents, care given in regard to each individual resident. Documents on a quarterly basis or when changes noted in the care plan as well as progress notes.
- Demonstrates knowledge of infection control standards and adheres to the guidelines for handwashing, standard precautions, and bloodborne pathogens as required by DOSH.
- Maintains confidentiality of all hospital and patient information at all times as observed by peers and management.
- Demonstrates awareness of safe work habits and maintains a safe working environment by adhering to department and hospital policies, including but not limited to, zero lift, SDS, body mechanics and ergonomics.
- Demonstrates compliance to all Human Resources policies, including but not limited to, attendance, dress code, smoking, and name badges.
- Attends department meetings and participates in mandatory education.
- Conducts self in a professional manner and is pleasant, respectful, and courteous in all interactions with patients, families, staff, and other visitors to the hospital.
- Promotes effective working relationships and works cohesively with employees both within and outside of the department.
- Understands and demonstrates the mandatory reporting process for abuse or neglect as required by the Department of Social and Health Services.
Must hold a Washington State license and have completed an approved course for a Registered Nurse or Licensed Practical Nurse. Current CPR Card is required. Basic computer skills are required. Previous nursing home experience and the desire, patience, and compassion to work with the elderly is preferred. Previous experience in a charge/supervisory/leadership role is preferred. Must be able to speak, read, write, follow oral/written instructions in English.
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