Makes daily rounds on assigned unit at least at beginning and at end of shift to observe, examine or interview residents, to verify information from ongoing shift, to monitor regulatory compliance and to determine staff assignments.
Develops and distributes resident care assignments to direct care staff. Assignments match resident needs with skills of direct care staff, and maintain consistency to the extent practicable. Adjusts assignments according to availability of qualified staff. Changes assignments if necessary during shift to meet resident needs.
Provides orientation to unit and unit routines to new staff members or staff from temporary agencies.
Describes care plan goals and approaches to direct care staff so that care plan is consistently implemented on all shifts by all caregivers. Seeks input from nurses’ aides 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 and that work of direct care to residents on unit according to physician orders and in compliance with facility policies and procedures.
Performs physical assessment of new admissions and current residents as indicated by change in condition or as required by regulation.
Coordinates care and delivery of services to assist each resident to attain or maintain highest practicable physical, mental and psychosocial well-being. Consults with and refers relevant resident care issues to attention of interdisciplinary care team members.
Give pertinent information to care plan team to accommodate resident needs and preferences, to manage risk factors for functional decline and to improve functional abilities.
Respect 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 DON and Social Worker if unsure of proper course of action that respects resident’s rights, complies with facility policies and procedures and that is consistent with state and federal laws and regulations.
Trains and develops staff by conducting skills observations of nurses’ aides identifying learning needs and taking advantage of opportunities to teach on the unit. Reports information to DON as part of staff performance evaluations.
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.
Completes written 24-hour facility report. Gives and listens to taped shift report making special note of significant changes in condition, admissions, transfers, discharges, initiation or use of physical or chemical restraints, unnecessary use of any drug, incidents, unexplained injuries, medication errors, loss of resident property or evidence of resident or family dissatisfaction.
Informs the resident in advance about care and treatment and any changes to the plan of care.
Immediately informs the resident, consults with the residents’ physician and notifies the designated family member and/or the resident’s legal representative when there is an accident involving an injury which has potential for requiring 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 the resident from the facility. Promptly notifies the resident, designated family member and/or resident’s legal representative when there is a change in room or roommate.
Reports relevant information to the DON 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, staff behavior (positive and negative), staffing needs, equipment and supply needs, opportunities to revise policies procedures, improve quality.
Monitors staff for compliance with OSHA mandates on work place safety including hazard communication and blood borne pathogens. In cases of work place exposure, provides immediate first aide and refers employee to appropriate facility staff member for post-exposure follow up.
Reports all injuries to self or others to supervisor immediately.
Takes job actions with staff members under appropriate circumstances. Applies facility policies about progressive discipline correctly. Removes staff member from unit if necessary to avoid endangerment to health or safety of residents or other staff members. Reports all job actions taken to DON promptly.
Attends in-service education programs as assigned. Applies information to job tasks.
Assists DON with preparation for long-term care survey. Attends survey training, interacts with state surveyors as instructed by supervisor.
LPN’s will take and transcribe physician’s telephone or verbal orders after proper instruction and in-service from DON and SDC.
