1. Assumes team leader role, accepting responsibility and accountability for all resident care on designated team, including providing direct physical nursing care, with respect to the following general list of duties:
- Performs resident care and various nursing duties according to policies/procedures and standards as delegated by the NM, CC, RN, or Charge Nurse.
- Demonstrates appropriate knowledge and technical skills when performing resident care.
- Provides for the emotional & physical comfort and safety of the resident and his/her family/caregiver.
- Observes for changes in clinical and/or functional status & reports changes to NM/CC/Supervisor in a timely manner.
- Observes residents for specific signs/symptoms as instructed by Nurse Manager, Clinical Coordinator, or RN.
- Makes rounds to monitor, observe, and evaluate residents’ general condition.
- Assists residents with all aspects of ADL and any special care needs as indicated by the NM, CC, RN, or Charge Nurse for which they are properly educated and trained.
- Assists other staff members with resident care.
- Ensures necessary supplies for resident care are available.
- Recognizes & responds to emergent situations efficiently and effectively by managing self, residents, staff, and others appropriately.
2. Assists in resident care coordination
- Assists with creating daily resident care assignments for the assigned team.
- Provides direction to CNA, giving and taking reports. Demonstrates the ability to delegate duties. Oversees completion of CNA assignments.
- Demonstrates ability to problem solve utilizing resources.
- Collects and documents data relevant to the resident's current health status, medical history, and discharge plan needs.
- Sets priorities for nursing actions according to the resident's needs.
- Completes 24-hour report for assigned team.
- Monitors dining room during mealtime, ensuring residents are safe, fed, and/or encouraged to complete meals.
3. Documents resident care in accordance with Loretto's policies/procedures.
- Participates in completing a portion of the admission paperwork accurately & according to guidelines.
- Documents pertinent nursing observations and actions in the medical record appropriately.
- Completes all unit-specific forms within the LPN role accurately & in a timely manner.
- Transcribes physician orders when needed.
- Ensures CNAs complete required documentation.
4. Prepares, administers, and records medications, treatments, and nursing procedures according to Loretto’s policies/procedures.
- Monitors/documents the resident’s response to medication.
- Performs resident care treatments & procedures according to polices/procedures.
- Documents medication and treatment administration records promptly per policy.
- Possesses a sound knowledge base of medication and treatment administration.
- Provides the resident and/or family instruction on medication as it relates to a resident's diagnosis, status, or plan of treatment.
- Orders and maintains stock supplies and medications.
- Stocks and cleans med carts during and upon completion of medication pass.
- Promotes an environment for the resident that acknowledges & respects the resident's individuality & rights during both treatments & medication administration.
5. Demonstrates ability to function as charge nurse by assuming responsibility and accountability for resident care and entire unit functioning in the absence of NM/CC.
- Creates daily work assignments fairly, utilizing available resources.
- Coordinates unit activities effectively.
- Assures completion of 24-hour report and faxes to supervisor.
- Manages emergency situations effectively - fire safety, resident falls, change/deterioration in resident condition & initiates appropriate follow-up.
- Assists with maintaining the accuracy of the resident care assignment sheets.
- Contacts/interacts with families as needed.
6. Assists in the preparation of the resident for the MD, NP, and PA.
- Observes the health status of residents. Collects and records data from the resident, caregivers/family, health care providers, individuals, and/or agencies in the community and documents appropriately.
- Reviews the resident's medical record to ascertain that pertinent data is in the record and attempts to retrieve any missing information.
- Reviews the resident's medications with the physician at every visit.
7. Communicates effectively, professionally, and appropriately with Health Team Members, residents, and families.
- Communicates information intra/interdepartmentally.
- Keeps supervisors informed of significant changes in residents’ behavior or condition.
- Notifies supervisors promptly of any problems related to any staff members.
- Reinforces resident and family education and training. Observes and reports resident and family compliance with the teaching plan.
- Maintains the highest level of customer service when assisting the resident, the resident’s family, and visitors.
8. Works cooperatively within the health care team.
- Supports the team in planning the resident's care by assisting in the development and implementation of realistic, measurable, time-bound goals.
- Cooperates with leadership staff in implementing planned changes and activities to improve residents' care or overall functioning of the clinical unit.
- Assists other staff members with resident care.
- Supports the orientation process by assigning buddies, if necessary, and following up with staff to ensure the assignment is being completed.
- Welcomes new staff/float to the unit, and assists with orientation of new staff.
- Accepts assignments and adapts to changes in job responsibilities in a professional manner.
- Responds to and handles situations in an appropriate manner following the chain of command for resolution.
9. Complies with all Loretto and departmental policies and procedures:
- Adheres to all infection control and safety policies and procedures.
- Adheres to Resident Rights and confidentiality regulations.
- Completes annual competencies.
- Operates patient care equipment in accordance with policy and procedure. Obtains, cleans, and returns equipment. Takes appropriate action to ensure broken equipment is repaired.
- Adheres to the nursing dress code. Arrives at work on time for assigned shift, prepared to work. Adheres to clocking procedures per protocol.
- Complies with all other facility and management policies, procedures, and requirements.