Job Description

Job Description: Registered Nurse

Job Summary

Under direction of a supervisory registered nurse assumes responsibility as a member of the treatment team; works with residents, their families’ other disciplines, and community agencies, and provides assistance, counseling, and instruction to residents; carries out therapeutic and medical orders authorized by a registered nurse, licensed physician, or other supervisor; does related work as required.

Examples Of Work: Organizes assigned professional nursing work and develops effective work methods. Assists physicians with examinations of residents and notifies supervisors of any changes made by physicians. Carries out medical and therapeutic orders by physician. Carries out the principles, and techniques of professional nursing. Has knowledge of immunization, and diagnostic procedures, bedside nursing methods. 

License: Possession of a valid license as a Professional Nurse in the State of New Jersey.

Duties Includes:

·        Monitor, record, and report symptoms or changes in patients’ conditions. Notifies physician and family.

·         Communicates to family, resident, and physician change in condition

·         Maintain accurate, detailed reports and records and communicates resident condition from shift to shift.

·         Prepare reports and analyze data.

·         Assists in preparing accurate and complete records.

·         Keeps records of narcotics on hand and used-performs shift to shift inventory of accountable drugs.

·         Maintains records and files.

·         Prepares and maintains daily medical records of residents including records of medication and treatments ordered and given.

·         Record patients’ medical information and vital signs.

·         Follow physician Order, interpret, and evaluate diagnostic tests to identify and assess patient’s condition.

·         Assessment of resident for changes in condition.

·         Modify patient treatment plans as indicated by patients’ responses and conditions.

·         Direct or supervise less-skilled nursing or healthcare personnel or supervise a particular unit. Provide teaching and education to staff as needed.

·         Consult and coordinate with healthcare team members to assess, plan, implement, or evaluate patient care plans.

·         Monitor all aspects of patient care, including diet and physical activity and psychosocial needs.

·         Instruct individuals, families, or other proups on topics such as health education, disease prevention.

·         Prepare patients for and assist with examinations or treatments.

·         Explains the condition of the illness to the resident and family.

·         Counsels’ residents concerning their medication by utilizing medication fact sheets.

·         Collects specimens to be used in laboratory analyses and monitors abnormality of results and reports to physician.

·         Provides first aid.

·         Carries out routine prophylactic procedures including immunization activities.

·         Provides bedside nursing care.

·         Makes appointments for residents with consulting physicians, arranges transportation, and notifies appropriate personnel.

·         Assumes responsibility of unit in absence of nursing supervisor.

·         Pronouncement of residents upon death.

·         Reconstitute medications.

·         Contributes as a member of the health care team in the determination of treatment goals and participates and involves client in goal planning sessions.

·         Work as part of a healthcare team to assess patient needs, plan, and modify care, and implement interventions.

NOTE: The examples of work for this title are for illustrative purposes only. A particular position using this title may not perform all duties listed in this job specification. Conversely, all duties performed on the job may not be listed.

Will be required to learn to utilize various types of electronic and/or manual recording and information systems used by the facility.

Job Responsibilities:

Responsibilities include but are not limited to:

·         MDS: Keep MDS and Care Plan documentation up to date.

·         Sigma Care: “Dashboard”. Ensure completion of documentation for each resident, daily. Ensure all overdue tasks are complete, daily.

·         Admissions: Perform assessment of new admissions/re-admissions; Enter information into Sigma Care.

·         Med Pass: In accordance with Orders and within acceptable time limitations.

·         Wound Care: Provide to resident as directed by physician order.

·         Charting/Documentation: Complete all required documentation during shift.

·         Orders: Take Physician Orders and enter into SigmaCare.

·         Care Plans: Update as required.

·         Rounds: Completes rounds throughout shift.

·         Feeding: Assists with feeding of residents, if necessary

·         CNA Assignments: Monitors CAN assignments

·         Supervisor: Acts as charge person on occasion.

·         Discharge: Prepares, teaches family and residents with discharge information.

·         Care Directives: Update as required; communicates to staff changes made to resident’s plan of care.

These Duties are in addition to the job description for Registered Nurse

Registered Nurse Physical Duties:

·         Medication Pass: Must be able to push/pull medication and wound cart daily. Approximately for 4-6 hours per day.

·         Toileting: Must have the ability to assist resident onto toilet by supporting resident’s weight during transfer and/or helping resident lift themselves. Must have the ability to assist resident onto a bedpan involves assisting resident to turn on his/her side to get onto the bedpan and get off the bedpan. A Pushing force of approximately 50lbs.

·         Transferring: Must have the ability to assist resident from a bed into wheelchair; wheelchair to bed, etc.. Must be able to support a resident during this transfer. The CNA must have the ability to turn at the waist during pivot transfers. Must have the ability to push a resident in a wheelchair or geri chair to and from various locations. The wheelchairs weight Approximately 25 lbs without the residents’ weight. Must have the ability to maneuver wheelchairs and/ or geri chairs to and from various locations. Approximately 25lbs without the resident’s weight. Must have the ability to support resident while walking and to prevent resident from falling. Presently our residents weigh approx.. 85lbs to 375lbs.

·         Positioning: Must have the ability to turn residents in their bed. Must have the ability to reposition residents in their wheelchair and/or bed. Use of both upper extremities to grasp the gait belt or pad the resident is sitting on, to scoot them up and back in a upright siting position. Must have the ability to tun resident int their bed. Push approximately 50lbs.

·         Meal Trays: Must have the ability to carry meal trays (approx.. 10lbs each) to resident tables. Must have the ability to push a food service cart holding approximately 20 trays or approximately 200lbs. Must have the ability to pick up trays after meal service and deliver back to food service cart (cart trays approx.. 12ft) Must have the ability to bend to the floor approximately 6 inches to retrieve trays from lower rack of food service cart.

·         Bathing: Must have the ability to assist resident from wheelchair into tub/ shower by supporting resident’s wight. Must be able to reach to wash resident in tub. Bend over at the waist and reach into tub to wash the resident completely.

·         Dressing: Must have the ability to extend her/his arm to shoulder lever and possibility above her/his head to undress/dress the resident. Must have the ability to or kneel or squat to the floor to put shoes on resident.

·         Miscellaneous: Must have the ability to be on their feet and move continuously during and 8 hour shift. Must have the ability to lift up to 50lbs. Must have the ability to bend at the waist and at the knees. Must have the ability to support weight of a resident. Must have the ability to maintain a workload exerting up to 100lbs of force occasionally and /up to 50lbs of force frequently and/or up to 20lbs of force constantly to move objects. Must be able to preform proper body mechanics. Must be able to respond quickly to resident responses for safety purposes (safety)

·         Lift: Ability to physically lift, move, and position clients as needed.

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