Position Title: RN                                                                            

Employee Status: Non-Exempt                                   *                Reports to*: Clinical Director and DON

Purpose/Summary Statement:

The purpose of this position is to supervise, provide and coordinate nursing care in compliance with facility policies and procedures and to assess residents' care needs and take appropriate action.

Essential Tasks and Functions:

Obtain report from nurse being relieved and record sufficient information to implement appropriate follow-up action as necessary.

Initiate Team Huddle if Clinical Director is not available.

Take appropriate action to assure adequate staffing to provide resident care.

Count narcotics, check emergency kit and exchange keys.

Has knowledge of HIPAA regulations.

Has knowledge and ability to use the organization's electronic health record system.

Conduct resident rounds daily, reporting problems to Clinical Director and initiating corrective action.

Follows through, as needed, on information given by shift report, resident or family regarding resident concerns.

Consults other departments as appropriate to provide for an interdisciplinary approach to the patient's needs.

Identify resident problems and emergency situation and initiate emergency care and "life-saving" measures in the absence of a physician.

Provide instructions for appropriate nursing care to licensed nurses and Nursing Assistants.

Administers medications, following the five (5) medication rights and reduces the potential for medication errors.

Order, receive and store medications appropriately.

Ability to perform a head-to-toe assessment on all patients and reassessments as per policy. This includes: geriatric and the general patient population.

Ability to adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the resident and family regarding pain management.

Assesses the resident's condition and nursing needs; sets goals; prescribes appropriate nursing action.

Assess residents on admission, during daily routine and when conditions change. Documents appropriately in the Electronic Health Record.

Communicates appropriately and clearly to Clinical Director, co-workers, and physicians and the Rehabilitation Services staff.

Promptly report changes in residents' conditions to the physician, Director of Nursing Service and responsible party, and take follow-up action as necessary.

Documents changes in resident's condition and nursing care on progress notes and plan of care.

Notes and carries out physician's orders in a timely manner

Implements plan of care for the resident based on assessments and goals as established by the interdisciplinary care team.

Ability to revise plan of care as indicated by the patient's response to treatment and evaluate overall plan daily for effectiveness.

Formulates a teaching plan based upon identified learning needs and evaluates effectiveness of learning; family is included in teaching as appropriate.