RN/LPN

at Bethesda Home in Goessel, Kansas, United States

Job Description

PURPOSE OF YOUR JOB

The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants.  Such supervision must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility, and as may be required by the Director of Nursing or Assistant Director of Nursing to ensure that the highest degree of quality care is maintained at all times.

                                                DELEGATION OF AUTHORITY

As Charge Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

1. ADMINISTRATIVE FUNCTIONS
2. Direct the day-to-day functions of the CNA’s in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
3. Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
4. Periodically review the department’s policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.
5. Meet with your assigned nursing staff, as well as support personnel, in planning the shift’s services, programs and activities.
6. Ensure that the Nursing Procedure manual is current and reflects the day-to-day nursing procedures performed in this facility.
7. Make written and oral reports/recommendations concerning the activities of your shift as required.
8. Cooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.
9. Ensure that all nursing personnel are in compliance with their respective job functions.
10. Participate in the development, maintenance and implementation of the facility’s quality assurance program for the nursing department.
11. Participate in facility surveys made by authorized government agencies as may be requested.
12. Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan as required.
13. Assist in planning the nursing services portion of the resident’s discharge plan as necessary.
14. Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.
15. Admit, transfer and discharge residents, as required.
16. Examine the resident and his/her medical records and charts, and discriminate between normal and abnormal findings, in order to recognize when to refer the resident to a physician for evaluation, supervision or directions.
17. Complete accident/incident reports or Report of Concern as necessary.
18. Maintain the Daily Census Report and submit to the DON at the end of the month.
19. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.

CHARTING AND DOCUMENTATION

1. Complete and file required record keeping forms/charts upon the resident’s admission, transfer and/or discharge.
2. Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
3. Receive telephone orders from physicians and record on the Physicians’ Order Form.
4. Transcribe physician’s orders to resident charts, medications sheets, treatment sheets, as required.
5. Chart nurses notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident’s response to the care.
6. Fill out and complete accident/incident reports. Submit to DON as required.
7. Chart all reports of accidents/incidents involving residents. Follow established procedures.
8. Record new/changed diet orders. Forward information to the Dietary Department.
9. Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc. to the DON.
10. Fill out and complete transfer forms in accordance with established procedures.
11. Ensure that appropriate documentation for Medicare Skilled admissions is entered in the resident’s medical record in accordance with established procedures.
12. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
13. Sign and date all entries made in the resident’s medical record.

III.       DRUG ADMINISTRATION FUNCTIONS

1. Prepare and administer medications as ordered by the physician.
2. Verify the identity of the resident before administering the medications/treatments.
3. Ensure that prescribed medication for one resident is not administered to another.
4. Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the DON.
5. Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.
6. Ensure that narcotic records are accurate for your shift.
7. Notify the DON of all drug and narcotic discrepancies noted on your shift.
8. Review medication sheets for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.
9. Notify the attending physician of automatic stop orders prior to the last dosage being administered.
10. Place discontinued, outdated, or deteriorated drugs in appropriate containers for disposition according to facility policy.

Mennonite Bethesda Society, Inc. recommends COVID-19 and Influenza vaccinations for all employees. Exemption accommodation requests may be sought. Mennonite Bethesda Society, Inc. is not required to approve exemption accommodations if doing so would pose a direct threat to self or others in the workplace or would create an undue hardship for Mennonite Bethesda Society, Inc.