Charge Nurse (RN/LPN Weekend Doubles w/Baylor)

Job description

Primary Purpose of this Position The primary purpose of this position is to provide direct nursing care to the residents while supervising the nursing activities for the assigned shift. Duties and Responsibilities Administrative Functions • Ensure the facility meets the minimum staffing levels for nurses and nurse aides; complete required posting of nursing staff data as required. • Ensure that each resident who experiences a significant change in status is assessed using the Resident Assessment Instrument (RAI)process. • Ensure that all resident rooms, common areas, treatment areas and nurse's stations are maintained in a clean, safe and sanitary manner. • Assist to develop a dementia care program involving an interdisciplinary approach with a holistic focus on the needs of the resident living with dementia. • Verify resident census accuracy and report new admissions, discharges, leaves of absence and bed-holds per facility policies; document census as established for billing and clinical purposes. • Assist with safe and orderly resident transfers and discharges in accordance with facility policies. • Coordinate pre-certifications and recertifications in accordance with facility policies for Medicare Advantage and commercial insurance payers. • Interpret the department's policies and procedures to personnel, residents, visitors and government agencies as required. • Participate in developing, maintaining and updating written facility policies and procedures that govern the day-to-day functions of the nursing services department. • Participate in facility surveys (inspections) made by authorized government agencies as requested. • Audit nursing documentation in the clinical record for appropriate and relevant entries. • Attend and contribute in facility "triple check" process for reviewing coding for accuracy. • Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. • Periodically review the department's policies and procedures manuals, job descriptions, etc., and make recommendations for revisions to the Director of Nursing. • Coordinate the completion of resident billable charge sheets in accordance with billing policies. Duties and Responsibilities • Carry out restorative and rehabilitative programs including restorative nursing, activities of daily living (ADLs)teaching, bowel and bladder retraining and education for self-help as appropriate. • Provide pain management for residents in accordance with established pain management protocols. • Complete accident/incident reports as necessary. • Assist the interdisciplinary team (IDT)with establishing nutrition, hydration and body weight parameters for residents; help facilitate the responsibilities of the food and nutrition services department. • Keep the Director of Nursing informed of the status of residents and other related matters through written/oral reports; document reportable events and notifications in accordance with facility policies. • Cooperate with and coordinate social and activity programs with nursing services schedules. • Periodically review the resident's written discharge plan; participate in updating the resident's written discharge plan as required. • Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident including regular re-evaluation to identify changes that require modifications. • Make periodic checks to ensure that Certified Nursing Assistants(CNAs)are properly administering prescribed treatments and to evaluate the resident's physical, psychosocial and emotional status. • Report problem areas to the Director of Nursing; assist in developing and implementing corrective action. • Arrange for diagnostic and therapeutic services as ordered by the physician and in accordance with established facility procedures. • Provide information to the QAPI Committee as requested. • Coordinate transfer or discharge of residents including arranging transportation, compiling the discharge summary, reconciling medication and reviewing upcoming appointments with resident in a language understood by the resident with the goal of a safe discharge. • Ensure that discharged residents are escorted to the pick-up area. Charting and Documentation Functions • Complete and file required recordkeeping forms/charts upon the resident's admission, transfer and/or discharge; provide notifications to the ombudsman and responsible party per requirements. • Document reports of accidents/incidents involving residents; follow established procedures. • Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. Duties and Responsibilities • Audit clinical record for appropriate consents and assessments including advance directives, living wills and other documents required for the delivery of person-centered care with respect to rights and choices. • Record verbal and telephone orders from practitioners on order sheets or in electronic health record (EHR) per facility policies. Medication Administration Functions • Review the controlled substance and drug disposal records for accuracy and notify the Director of Nursing and pharmacy of discrepancies. • Monitor medication administration process and provide appropriate feedback or changes to prevent medication errors. • Ensure that the medication carts and medication rooms are clean, sanitary and well stocked • Assess residents for appropriate self-administration of medication in coordination with the IDT. • Reconcile medication delivery from pharmacy by verifying the medications, quantity and accuracy. • Collaborate with the IDT to ensure the safe and appropriate use of medications for all residents. • Administer medications in accordance with physician orders, regulations and facility policies. • Support the objectives of the infection prevention and control program including antibiotic stewardship. • Work with the IDT to review unnecessary medications and coordinate gradual dose reductions as appropriate. • Reconcile resident medications (pre/post-discharge) as part of the discharge process. • Order prescribed medications, supplies and equipment as necessary and in accordance with established facility policies. Personnel Functions • Meet with assigned nursing staff as well as support personnel in planning the shifts' services, programs and activities and to assist in identifying and correcting problem areas and/or improving delivery of person-centered care and services. • Assist the Director of Nursing in directing the day-to-day functions of the nursing activities in accordance with current rules, regulations and guidelines that govern the facility. • Direct the day-to-day functions of the CNAs in accordance with current rules, regulations and guidelines that govern the facility. • Coordinate with the scheduler to ensure a Registered Nurse (RN) is on duty at least 8 hours a day/7 days a week and a Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN)is on duty 24 hours a day. Duties and Responsibilities • Ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity; this includes proper licensure or certification if required. • Assess residents for conditions which may be aided by assistive or adaptive devices; recommend/request in accordance with facility policies; monitor for proper utilization and application of assistive devices. • Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse. • Develop positive professional relationships with nursing students, teachers/professors and other visitors. • Prepare and deliver nursing report at change of shift or in situations requiring a coordinated effort. • Assist in the grievance process in coordination with the grievance officer; assist residents with filing grievances, investigating allegations and coordinating an appropriate response; respond to resident or family grievances in accordance with facility policies. • Review complaints and grievances made or filed by your assigned personnel; make appropriate reports to the Charge Nurse/Nurse Supervisor as required or as necessary. Staff Development Functions • Collaborate with the Staff Development Coordinator for team member training, skill development and competencies in accordance with facility policies(e.g.,proper hand-washing techniques, proper operation of Hoyer lift or assistive device); educate in a manner or format understood by the team member. • Assist in training department personnel. • Assist the Director of Nursing in planning clinical supervision for nurse aide trainees, nursing students and newly hired nurses. • Attend continuing education program or training as needed to provide competent nursing care; assist with coaching and training with nursing team members in unit/facility. Safety and Sanitation Functions • Ensure that all nursing services personnel comply with established departmental policies and procedures. • Ensure that all personnel wear and/or use safety equipment and supplies (e.g., back brace, mechanical lifts, etc.) when lifting or moving residents in accordance with plan of care and facility policies; order and stock personal protective equipment (PPE)as necessary. • Ensure that the resident environment remains as free of accent hazards as possible and that each resident receives adequate supervision and assistive devices to prevent accidents. • Ensure that nursing services personnel follow established infection prevention and control procedures. Equipment and Supply Functions • Maintain list(s) of equipment repairs or needs required for resident care. • Recommend to the Charge Nurse/Nurse Supervisor the equipment and supply needs of your unit/shift. • Ensure that appropriate safety data sheets (SDSs)are on file for hazardous chemicals used in the nursing services department. • Participate in the development and implementation of the procedures for the safe operation of all nursing services equipment. Education Must possess, as a minimum, a nursing degree from an accredited college or university, or be a graduate of an approved Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)program. Experience • Must have, as a minimum, one (1) year of experience as a supervisor in a hospital, nursing care facility, or other related health care facility. • Must have training in rehabilitative and restorative nursing practices. Specific Requirements • Must possess a current unencumbered active license to practice as a Registered Nurse(RN)or LPN/LVN in the state. • Must be able to read, write, speak and understand the English language. • Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. • Must be a supportive team member, contribute to and be an example of team work and team concept. • 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 nursing care facilities. • 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, 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.