Job Description

Position Summary:  The purpose of this position is to render professional nursing care to residents; to follow facility policies and procedures to implement treatment orders; to assess resident treatment needs and take appropriate action; to maintain residents’ medical records; and to participate in supervision of care provided to residents.

Essential Functions:

• Attend work as scheduled and follow company’s call-off procedures

• Follow established standards of nursing practices in accordance with National Standards of Practice and the State Practice Act to implement facility policies and procedures.
• Obtain report from nurse being relieved and record sufficient information to implement appropriate follow-up action as necessary relating to the residents’ treatment needs.
• Obtain report from nurse being relieved and record sufficient information related to medication administration to implement accurate changes to medication orders.
• Conduct resident rounds as assigned and report problems to the Nursing Supervisor or Director of Nursing Service, and take necessary follow-up action.
• Administer medications to residents in an accurate, timely manner.
• Monitor residents for effectiveness of drug therapy and occurrence of adverse effects.
• Document resident care related to medication administration, related monitoring, effectiveness of drug therapy and occurrence of adverse effects.
• Notify physician, when necessary, of changes in residents’ conditions, weight, medication errors, medication not available, abnormal laboratory/
  • X-ray results and any other unusual observations.
• Document physician notification and follow up action(s) per facility policy.
• Complete all documentation related to the resident’s medication administration.
• Follow comprehensive care plans related to medication administration based on each resident’s needs and his/her comprehensive assessment as assigned.
• Identify safety hazards and initiate corrective action.
• Assume responsibility for compliance with federal, State and local regulations within the assigned unit.
• Verify accuracy of narcotic count, check emergency kit and exchange keys.
• Order, receive and store medications accurately and appropriately.
• Identify special nursing problems and emergency situations quickly and initiate immediate “life-saving” measures in the absence of a physician.
• Participate in facility educational programs including, but not limited to, orientation, in-service and nursing education.
• Provide clinical supervision to nurses and CNAs. Monitor for completion of assigned duties.
• Attend staff meetings as required.
• Attend all scheduled inservices as assigned.
• Instruct nursing assistants in proper, preventative safety measures and use of adaptive equipment to meet residents’ needs.
• Use and supervise the use of equipment and supplies efficiently and in a cost-effective manner.
• Compile information for facility committees as instructed.
• Administer treatments according to the physician’s order and accurately record treatments administered and weekly progress notes.
• Be responsible for the safety of residents under his/her supervision.
• Document resident care provided and resident’s response or lack of response to treatment provided.
• Assess and report changes in resident’s condition including development of decubitus to physician, Charge Nurse, Nursing Supervisor, Director of Nursing Service and take follow-up action as necessary.
• Assess each resident’s skin condition weekly, and as necessary, including stage, size (measurements), sites, depth, color, drainage and odor of each condition.
• Assist with admission/transfer and discharge of residents as necessary and as assigned by the Director of Nursing Service.
• Complete admission/transfer and discharge documentation.
• Perform basic nursing skills.
• Obtain physicians’ orders and any revisions for treatments as necessary.
• Assess resident needs and initiate development of individualized care plans.
• Review and update resident care plans as necessary and as assigned.
• Provide direct resident care, in addition to treatment, as necessary.
• Give daily instruction to Nursing Assistants regarding care related to treatment.
• Assume Quality Assurance duties as assigned.
• Provide Charge Nurse coming on duty with concise, accurate report.
• Consistently work cooperatively with residents, nursing personnel, physicians, families, consultant personnel, community agencies and ancillary personnel.
• Keep the resident and family informed about nursing care provided.
• Listen to resident, family or physician complaints and initiate corrective action and report special problems to his/her supervisor.
• Render immediate assistance to any resident in need.
• Follow facility Residents’ Rights policies.
• Comply with facility policies and procedures against discrimination and sexual harassment.
• Protect the privacy of resident Protected Health Information.
• Protect the confidentiality and security of all resident and facility information.
  • Non- Essential Job Functions
• Come to work in clean, neat attire and consistently present a professional appearance.

Non-Essential Functions:

• Attends all required training, in-service, and staff meetings.
• Strives to maintain a safe working environment through the prevention of accidents, the preservation of equipment, and the achievement of safe working practices.
• Maintains a positive and professional demeanor toward all associates, customers, vendors, clients.
• Adheres to all policies and procedures of Spring Hills PASL, LLC.
• Performs other duties as assigned.

Experience and Education:

Applied Associate, Diploma or Bachelors degree from an accredited school of nursing or institute; and one year of LTC /Skilled experience.  Must have a Registered Nurse’s License current, with no judgments against it, in the state in which he/she is practicing.  Must be BLS and CPR certified. A minimum of two (2) years of nursing experience, preferably in geriatrics.

Physical Requirements: Standing (1/3-2/3), walking (1/3-2/3), using hands to finger, handle or feel (over 2/3), reach with hands and arms (over 2/3), climb and balance (under 1/3), stoop, kneel (under 1/3), talk or hear (over 2/3), taste or smell (under 1/3). Lifting up to 10 pounds (1/3 - 2/3), Up to 25 pounds (under 1/3); Up to 50 pounds (under 1/3); up to 100 pounds (under 1/3), more than 100 pounds (none)