Nurse - Winter Garden - Traditions Management

Description

SUMMARY OF POSITION FUNCTIONS The Nurse assumes, responsibility, and accountability for
resident care of a designated shift and in accordance with Federal and State regulations and
company/community policies, procedures and Personal Service Plans.

ESSENTIAL POSITION FUNCTIONS

• Coordinates patient care and non-patient care (cleaning, etc.) by developing and distributing written

nursing assignments for each employee which outlines residents to be cared for and other duties to
be executed during the shift. Assignments and rotations are provided with consideration that
resident needs are matched with the skills of individual staff members, while maintaining
consistency to the extent practicable.

• Describes personal service plan and approaches to direct care staff so that plan is consistently

implemented on all shifts by all caregivers. Seeks input from personal care assistants about resident
condition, functional abilities, preferences, and alternative approaches to care.

• Monitors delivery of care and services throughout shift to ensure needs are met, tasks are

completed, including complete and accurate resident documentation, and that work of direct care
staff is of acceptable quality and quantity. Insures compliance on unit with resident rights.

• Makes daily rounds on assignment at least at beginning and end of shift to observe, examine, or

interview residents to verify information from ongoing shift, to monitor regulatory compliance, and
to determine or rotate staff assignments and make adjustments according to qualified staff
availability and resident needs.

• Provides orientation, trains, and develops staff by identifying learning needs while taking

opportunities to teach on the unit. Updates employees regarding changes in resident needs.
Instructs personnel on use of equipment.

• Coaches and monitors staff performance providing praise and redirection when applicable. Issues

disciplinary actions to staff, when needed, in a fair and consistent manner in conjunction with
federal and state laws and company policies and procedures.

• When necessary, schedules employees to work and replaces call-ins for the following shift. Ensures

correct number of staff on duty, schedules lunch and rest breaks, approves or denies requests to
leave early.

• Monitors and trains staff and corrects deficiencies for compliance with OSHA mandates on

workplace safety including hazard communication, blood borne pathogens, and infection control
procedures. In cases of work place exposure, coordinates immediate first aid, insures proper
documentation and refers employee for post-exposure treatment.

• Monitors restorative measures provided by staff in daily care of residents (i.e. range of motion, self-help skills, positioning and body mechanics).
• Performs duties as assigned in Community Fire and Disaster Plan that may include taking charge of

evacuation, drills, and transportation of residents.

• Receives, investigates and responds to employee problems and complaints.
• Complies with the community's privacy and confidentiality practices and procedures related to

resident and employee records and all state/federal privacy laws.

Administrative:

• Completes required documentation of care and services delivered during shift including subjective

findings, objective symptoms, interventions, and resident responses to interventions. Completes
required documentation of special circumstances including accident/incident reports in compliance
with state and federal laws and regulations.

• Writes comprehensive weekly/monthly summaries reflective of patient's status, abilities/disabilities,

and specifically addressing problems identified on the patient Personal Service Plan. Initiates and
updates patient Personal Service Plans as needed with appropriate problems, resident-oriented
goals, and approaches based on resident needs.

• Completes written 24-hour community report. Gives and listens to verbal shift report making

special note of significant changes in condition, admissions, transfers, discharges, unnecessary use
of any drug, incidents, unexplained injuries, medication errors, loss of resident property, or evidence
of resident or family dissatisfaction.

• Reports relevant information to Wellness Director including interdisciplinary team functioning and

communication, regulatory compliance issues, resident risk factors, sudden changes in resident
behavior, expressed dissatisfaction by resident or family, refusals of treatment, unexplained injuries,
positive or negative staff behavior, staffing needs, equipment and supply needs, and opportunities
to revise policies or procedures and improve quality.

• Ensures delivery of compassionate quality care evidenced by adequate services and staff coverage

on unit, appropriateness of staff, absence of odors, cleanliness, absence of pressure wounds, and
apparent maintenance of optimal physical, mental, and psychosocial function.

• Updates daily census, completes admission/discharge documentation, assures documentation of

vital and neurological signs and weights, and notifies physician of significant weight loss/gain.

• Actively participates and positively supports the community quality improvement process which

may include monthly meetings. Communicates action team recommendations, outcomes, and
changes to subordinates and peers on other shifts not present at the meeting.

Clinical:

• Provides direct patient care, administers medications and specialized treatments and diet as

prescribed to residents on unit according to physician orders and in compliance with community
policies and procedures. Receives and gives a comprehensive report on all residents.

• Makes rounds with physicians, schedules lab, x-ray, and appointments as ordered, reviews lab test

results, and notifies physician of the same.

• Performs physical assessment of new admissions and current residents as indicated by change in

condition or as required by regulation. Completes assigned sections of resident assessment
instruments used in the community.

• With participation members and resident, to the extent practicable, develops, implements,

evaluates, and revises service plans with timetables to assist each resident to attain or maintain
highest practical physical, mental, and psychosocial well-being. Modifies approaches in service plan
to accommodate resident needs and preferences to manage risk factors for functional decline and
to improve functional abilities. Coordinates care and delivery of services with all disciplines.
Consults with and refers relevant resident care issues to the Wellness Director.

• Respects rights of residents regarding freedom of choice, consent for care and services, refusals of

treatment and implementation of advance directives if any. Promptly consults with Wellness
Director if unsure of proper course of action that respects resident's rights, complies with
company/community policies and procedures and provides consistency with federal and state laws
and regulations.

• Immediately informs the resident, consults with physician, and notifies the designated family

member and/or legal representative when there is an accident involving an injury which has
potential for physician intervention; a significant change in the resident's physical, mental, or
psychosocial status; a need to alter treatment significantly or a decision to transfer or discharge
from the community or change room of the resident.

• Uses good judgment to prepare, administer and immediately document medications and treatments

as ordered by physicians. Maintains awareness of prominent medication interactions and side
effects, monitors resident for occurrence of such and notifies physician as needed. Orders timely
medications to ensure continuity of administration.

• Keeps medication rooms and carts locked when unattended and is responsible for the security of

the keys and correct reconciliation of controlled substances during shift. Counts all drugs on
Individual Control Drug Records with on-coming charge person at change of shifts. Keeps
medication room and cart clean and organized. Insures proper storage of drugs and biological items.

• Informs resident in advance about care and treatment and any changes to the Personal Service Plan.
• Attends in-service education programs and applies information to job tasks.

Note:
The essential functions of this job may be revised or updated as community needs dictate.
NON-
ESSENTIAL POSITION FUNCTIONS

• Other duties as assigned.

SUPERVISORY RESPONSIBILITIES

• Directly supervises P.C.A. employees. Carries out supervisory responsibilities in accordance with the

organization's policies and applicable laws. Responsibilities include training employees; planning,
assigning, and directing work; input on appraisal performance; rewarding and disciplining
employees; addressing complaints and resolving problems.

SPECIAL REQUIREMENTS

• Must be able to work overtime.

EDUCATION & QUALIFICATIONS
To perform this position successfully, an individual must be able to perform each essential duty
satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to
perform the essential functions.

• Graduate of an accredited school of nursing.
• One-year providing direct care to residents in long-term care, acute care, restorative or geriatric

nursing setting preferred.

• Prior experience as a Nurse or similar supervisory experience preferred.

KNOWLEDGE, SKILLS, ABILITIES

• Knowledge of federal/state regulations.
• Ability to interpret and apply knowledge of regulations and policy to direct care staff to insure

compliance while maintaining consistency and fairness

• Ability to coordinate numerous activities at any given time and make sound judgments and judicious

decision quickly, often under pressure.

• Ability to read, analyze, professional journals, technical procedures, or governmental regulations.

Ability to write reports. Ability to effectively present information and respond to questions from
groups of managers, clients, staff, and the general public.

• Ability to add and subtract two digit numbers and to multiply and divide with 10's and 100's. Ability

to perform these operations using units of American money and weight measurement, volume, and
distance.

• Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to

interpret an extensive variety of technical instructions in mathematical or diagram form and deal
with several abstract and concrete variables.
CERTIFICATES, LICENSES, REGISTRATIONS

• Current active Florida Registered Nurse or Licensed Practical Nurse.
• CPR Certification

About Florida Care Provider Background Screening Clearinghouse (Clearinghouse):
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.