attain the highest practical level of functioning and to coordinate total nursing care for the

residents as illustrated by the following:

a. Assesses residents who have had an accident or incident that results in

injury or any unusual event. Documents findings as per Resident Care

Manual Policy.

b. Thoroughly investigates allegations of alleged abuse / neglect or

misappropriation of property and notifies appropriate parties as per

policy.

c. Makes daily rounds in areas of nursing care under his/her supervision,

visiting each unit to evaluate overall unit performance, and to receive

comments relating to the residents needs and problems, and implement

necessary changes.

d. Delegates responsibility to nursing personnel through work

assignments, etc. for direct nursing and non-nursing care of patients

during the shift.

e. Assists in assessing level and number of personnel assigned to the unit.

Makes recommendations regarding such personnel where indicated for

better patient care and utilization of such personnel.

f. Supervises and evaluates the performance of nursing personnel under

his/her direct supervision.

g. Instructs nursing personnel on new policies and procedures and

treatments to allow for the most effective use of nursing time.

h. Reports status of nursing personnel and other supervisory matters to the

Assistant Director of Nursing Services and/or Director of Nursing

Services, on a daily basis.i. Makes recommendations for hiring, disciplining, evaluating and the

termination of personnel through written reports and verbal

communication.

j. Completes appropriate evaluation summaries and assists with those

completed by Unit Managers and/or Charge Nurses, as needed.

k. Assists in the scheduling of personnel to adequately cover all nursing

shifts.

l. Assists with the preparation of the nursing department budget and

adheres to that budget as approved by the Executive Director.

m. Assesses, monitors, and treats specific patient care conditions pursuant

to physician orders.

n. Maintains open line of communication with attending physician

regarding patient care and/or treatment issues.

o. Verifies the coordination of nursing care with other departments and

disciplines within the Facility to best meet resident care objectives.

p. Conducts periodic rounds to observe Facility appearance and safety,

and makes recommendations or assignments for nursing personnel in

regard to these concerns and/or report these concerns to the appropriate

personnel.

q. Coordinates the resolution of resident activity, social service, and

nutritional problems observed by nursing personnel.

2. Establishes and maintains resident care systems per standardized procedure that

are consistent throughout the Facility. These include:

a. Unit Management System for group assignments and nursing assistant

responsibilities.

b. Restraint Reduction System to verify restraints are at a minimum, and that

restraints are released at least every two hours, or per Care Plan. Restraint

releases are to occur on the unit at the same time or per Care Plan, and be

observed by a licensed staff member.

c. Turning and Positioning System to verify schedules are followed every

two hours or per Care Plan.

d. Resident Ambulation System to verify effectiveness and adherence to

resident ambulation program.

e. Scheduling System to verify scheduling for nurses and cna’s is completed

in a fair and consistent manner.

f. Nourishment/Supplements System to verify nourishments/supplements are

passed according to developed schedule.

g. Cleanliness System to verify that environment is clean, orderly and

organized. Reviews written cleaning schedules.h. Infection Control System to verify residents are not at risk for infection.

i. Pharmacy System to verify correct meds are received timely, meds are

discarded timely and properly and costs are appropriate for resident payer

sources; and med room and med carts are monitored for policy

compliance.

j. Lab System to verify labs are drawn timely, and in accordance with

doctors orders.

2. Partners with the Medical Director, Executive Director and Director of Nursing

to develop, implement, and evaluate annual infection prevention goals and plan.

3. Oversees the Infection Prevention and Control Program including surveillance of

healthcare acquired and community acquired infections

4. Conducts infection surveillance and reports routinely to the Quality Assurance

Committee

5. Directs and assists in preparing reports, statistical data, and trend identification

for the QA committee.

6. Works with facility for problem solving when needs arise in areas such as:

a. Monitoring resident care delivery systems

b. Performing chart reviews

c. Checking Physician Orders as needed

7. Provides education and training regarding infection prevention and control

practices to all staff. Includes evidence-based infection control practices and

isolation precautions.

8. Assists with infection risk assessment, prevention, and control strategies.

9. Works with facility committees on policies and procedures, program

development and in-servicing.

10. Keeps current and is knowledgeable of new regulations, directives, and

infection prevention and control material in order to accurately interpret and

relay the information.

11. Assists with new program development as requested

12. Conducts rounds, discussing and monitoring infection control practices with staff; investigates and collects infection data from departments.

13. Maintains a record of incidents of infection and corrective actions related to

infections.

14. Provides education on Antibiotic Stewardship program.

15. Maintains certification in Infection Prevention and Control.

16. Assists with communicable disease notification per state directive.

attain the highest practical level of functioning and to coordinate total nursing care for

the residents which may include:

a. Verifies that a sufficient number of qualified supervisory and supportive

nursing personnel are assigned for each unit/shift to meet the resident

needs.

b. Assists the DNS in the planning of staff development programs that will

enhance staff knowledge of quality resident care.

c. Makes focused rounds daily with supervisors and charge nurses as

appropriate.

d. Participates in coordination of resident services through departmental and

appropriate staff committee meetings, according to the Resident Care

Policies and Procedures Manual

e. Conducts periodic review to verify that the nursing requirements of each

resident admitted to the Facility are reviewed and that the physician is

consulted in planning resident care.

f. Maintains and evaluates statistics for pressure sores, resident Accident and

Incidents, N/G tubes, Foley catheters, resident census, and resident and

employee infections.

g. Reviews closed charts of expired residents for the presence of appropriate

documentation and discharge orders.

h. Conducts periodic reviews of Care Plans to verify they are

interdisciplinary and updated as changes occur.

i. Checks periodically for documentation for residents on 24-Hour Report.

j. Checks periodically for skilled documentation for Medicare services.

k. Checks periodically on each unit for completed MARS, TARS, and flow

forms.

l. Reviews Accidents and Incidents (A/I) and develops an appropriate plan

to prevent future accidents and incidents. Conducts periodic reviews of

documentation for inconsistencies on each unit.

m. Reviews medical record documentation on referrals and advises Executive

Director on whether nursing requirements can be met.

n. Reviews change of condition/24-Hour Report daily and deletes residents

from the report as needed.

2. Establishes and maintains resident care systems per standardized procedure that are

consistent throughout the Facility. These include:

a. Unit Management System for group assignments and nursing assistant

responsibilities.

b. Restraint Reduction System to verify restraints are at a minimum, and that

restraints are released at least every two hours, or per Care Plan. Restraint

releases are to occur on the unit at the same time or per Care Plan, and be

observed by a licensed staff member.

c. Turning and Positioning System to verify schedules are followed every

two hours or per Care Plan.

d. Resident Ambulation System to verify effectiveness and adherence to

resident ambulation program.

e. Scheduling System to verify scheduling for nurses and CNA’s is

completed in a fair and consistent manner.

f. Nourishment Supplements System to verify nourishments/supplements are

passed according to developed schedule.

g. Cleanliness System to verify that environment is clean, orderly and

organized. Reviews written cleaning schedules.

h. Infection Control System to verify residents are not at risk for infection.

i. Pharmacy System to verify correct meds are received timely, meds are

discarded timely and properly and costs are appropriate for resident payer

sources; and med room and med carts are monitored for policy

compliance.

j. Lab System to verify labs are drawn timely, and in accordance to doctors

orders.

2. Develops and updates instant and comprehensive Care Plans as needed.

3. Transcribes, clarifies, and implements physician’s orders.

4. Administers and monitors resident medications and treatments per physician’s

orders. Maintains accurate medication administration records and treatment

administration records. Verifies medication cart is secure and clean. Secures

narcotics per Facility policy and state regulations.

5. Communicates status of residents to incoming licensed personnel according to

established procedures at shift change. Performs medication inventory at the

beginning and end of the shift with another licensed nurse and immediately

notifies supervisor of discrepancies.

6. Documents residents change in condition; develops, documents, and implements

appropriate nursing interventions; and notifies physician and appropriate persons

as needed.

7. Updates and maintains accurate resident clinical files.

8. Conducts personal physical examination of residents for skin breakdown upon

admission and as assigned.

9. Supervises, trains, and delegates job tasks to certified nursing assistants and unit

clerks.

10. Communicates status of residents, new admissions, scheduled appointments,

assigned baths, restorative instructions, changes in specialized diets, and other

individualized patient instructions to certified nursing assistant staff at shift

change.

rooms, offices, and common areas; polishes and removes items; checks that

resident rooms are safe, comfortable, and maintained in an attractive manner.

2. Demonstrates ability to adjust to changes in shift assignments to meet Facility

needs.

3. Cleans and sanitizes areas of responsibility according to Facility policy and

procedure.

4. Moves and arranges resident’s furniture and equipment as directed by the

supervisor.

5. Cleans resident dining areas at the completion of meal service and adheres to

weekly cleaning schedule of the dining area.

6. Cleans and sanitizes resident bathrooms and common bath areas.

7. Cleans and maintains windows and walls in resident rooms and common areas.

8. Complies with weekly departmental cleaning schedule.

9. Adheres to all cleaning chemical hazards as indicated on supplies.

10. Demonstrates ability to locate emergency equipment (i.e. fire extinguisher).

11. Demonstrates ability to identify / respond appropriately to potential behavioral

outbursts.

12. Complies with Material Safety Data Sheets (MSDS) guidelines for chemical use.

13. Participates as assigned in the orientation of new staff and demonstrates a

positive, helpful, and enthusiastic attitude.

14. Performs Laundry Aide duties as needed.

Care Plan which includes communicating, assistance with grooming, bathing, oral

hygiene, turning, incontinent care, toileting, colostomy care, prosthetic

appliances, transferring, ambulation, and range of motion, as appropriate.

2. Observes and reports changes in resident conditions to Supervisor.

3. Performs tasks assigned by Supervisor including vital signs, residents’ weights,

applying non-prescription creams/ointments, and collecting specimens..

4. Escorts residents to dining room, assists with feeding, and verifies meal

consumption.

5. Passes supplements, snacks, and fluids to residents per protocol and schedule and

verifies consumption.

6. Maintains clean, neat and organized work environment.

7. Protects the personal belongings of each resident including eyeglasses, dentures,

hearing aids, furnishings, jewelry, clothing, memorabilia, etc. Promptly reports

missing items to Supervisor per protocol.

8. Answers resident call lights promptly and courteously.

9. Assists with orienting residents and their families to the nursing home upon

admission.

10. Escorts residents to appointments, including beauty shop, activities, church

services, and participates in activities and functions as directed.

11. Completes certified nursing assistant electronic records, documenting care

provided and other information in accordance with Facility policy and procedures.

12. Participates in the training and orientation of new staff by demonstrating a

positive, helpful, and enthusiastic attitude.

13. Identifies and appropriately responds to potential and/or actual behavioral

outbursts