Job Description

PURPOSE OF YOUR JOB POSITION:

The primary purpose of your job position is to supervise the day-to-day nursing activities of the facility during your tour of duty. 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 Services, to assure that the highest degree of quality care is maintained at all times.

DELEGATION OF AUTHORITY:

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

JOB FUNCTIONS:

Every effort has been made to keep your job description as complete as possible. However, it in no way states or implies that they are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

MAJOR DUTIES AND RESPONSIBILITIES:

ADMINISTRATIVE FUNCTIONS:

• Direct the day-to-day functions of the nursing activities in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
• Ensure that the Nursing Service Procedures Manual is followed by nursing service personnel, and that it reflects the day-to-day nursing care procedures used by this facility.
• Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the resident’s total regimen of care.
• Ensure that all nursing service personnel are following their respective job descriptions.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
• Recommend written material that will assist the nursing service department in meeting the day-to-day needs of the residents.
• Participate in the implementation of the facility’s quality assurance program for the nursing service department.
• Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan as required.
• Assist the Director in planning the nursing services portion of the resident’s discharge plan as necessary.
• Participate in survey (inspections) made by authorized government agencies. 
• Make written and oral reports/recommendations to the Director as necessary/required, concerning the operation of the Nursing Services Department.
• Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.
• Admit, transfer, and discharge residents as required.
• Complete accident/incident reports as necessary.
• Make written and oral reports/recommendations concerning the activities of your shift as required.
• Meet with your assigned nursing staff, as well as support personnel, in planning the shifts services, programs and activities.
• Write resident charge slips and forward to the Business Office.
• Maintain the Daily Census Report and submit to the Business Office as required.

CHARTING AND DOCUMENTATION:

• Fill out and complete accident/incident reports. Submit to Director as required.
• Chart all accidents/incidents involving the resident. Follow established procedures.
• Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.
• 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.
• Complete and file required record keeping forms/carts upon the resident’s admission, transfer, and/or discharge.
• Receive telephone orders from physicians and record on the Physicians’ Order Form.
• Record new/changed diet orders. Forward information to the Dietary Department.
• Transcribe physician’s orders to resident charts, medications cards, treatment/care plans, as required.
• Assure that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.
• Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the DON or assistant.
• Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures.
• Sign and date all entries made in the resident’s medical record.
• Fill out and complete Transfer Forms in accordance with our established procedures.

DRUG ADMINISTRATION FUNCTIONS:

• Prepare and administer medications as ordered by the physician.
• Assure that prescribed medication for one resident is not administered to another.
• Verify the identity of the resident before administering the medication/treatment.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies.
• Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hard to meet the nursing needs of the residents. Report needs to DON or his/her designee.
• Ensure that narcotic records are accurate for your shift.
• Dispose of drugs and narcotics as required, and in accordance with our established procedures.
• Notify the attending physician of automatic stop orders prior to the last dosage being administered.
• Review medication records for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.
• Notify the DON or assistant of all drug and narcotic discrepancies notes on your shift.

PERSONNEL FUNCTIONS:

• Inform the DON or assistant of staffing needs when assigned personnel fail to report for work.
• Develop work assignments, and/or assist in completing and performing such tasks.
• Make daily rounds of your unit to ensure that nursing services personnel are performing their work assignments in accordance with acceptable nursing standards.
• Report absentee call-ins to the DON or assistant.
• Review complaints and grievances made or filed by your assigned personnel. Make appropriate report to the DON or assistant as required or as may be necessary.
• Ensure that disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility to assure that nursing services and activities can be adequately maintained to meet the needs of the residents.
• Assure that department personnel, residents, and visitors follow the department’s established policies and procedures at all times.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.
• Meet with your shift’s nursing personnel, on a regularly scheduled basis, assist in identifying and correcting problem areas, and/or the improvement of services.
• Review and evaluate your department’s work force and make recommendations to the DON or assistant.
• Participate in determining your shifts staffing requirement, employee performance evaluations, and making recommendations to the DON or assistant concerning employee dismissal, transfers, etc.
• Give/receive the nursing report upon reporting in and ending shift duty hours.
• Provide supervision and leadership to nursing personnel assigned to your unit/shift.

NURSING CARE FUNCTIONS:

• I nform nursing personnel of new admissions, their expected time of arrival, room assignment, etc.
• Ensure that rooms are ready for new admissions.
• Greet newly admitted residents upon admission. Escort to room as necessary.
• Make rounds with physicians as necessary.
• Implement and maintain established nursing objectives and standards.
• Cooperate with and coordinate social and activity programs with nursing service schedules.
• Make independent decisions concerning nursing care.
• Notify the resident’s attending physician when the resident is involved in an accident/incident.
• Make periodic checks to assure that care is being properly administered by nursing assistants and to evaluate the resident’s physical and emotional status.
• Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, taking blood, giving massages and range of motion exercises, care of the dead/dying, etc., as required.
• Participate in the orientation of new residents/family members to the facility.
• Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.
• Meet with residents, and/or family members, as necessary. Report problem areas to the DON or assistant.
• Admit, transfer and discharge residents as necessary.
• Assist in arranging transportation for discharged residents as necessary.
• Ensure that discharged residents are escorted to the pickup area.
• Review the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.
• Carry out restorative and rehabilitative programs, to include self-help and care.
• Check foods brought into the facility by the resident’s family/visitors to assure that it is within the resident’s dietary allowances. Report problem areas to the Dietary Supervisor.
• Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.
• Consult with resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.
• Notify the resident’s attending physician and next of kin when there is a change in the resident’s condition.
• Work with the facility’s consultants and implement those changes authorized by DON.
• Call funeral homes when requested by the family. Ensure that established postmortem procedures are followed.
• Use restraints when necessary and in accordance with our facility’s policies and procedures.
• Obtain sputum, urine and other lab tests as ordered.
• Take and record TPRs, blood pressure, etc., as necessary.
• Monitor seriously ill residents as necessary.
• Inform family members of the death of resident as necessary.

STAF DEVELOPMENT:

• Assist in standardizing the methods in which work will be accomplished
• Attend and participate in continuing educational programs designed to keep you abreast of changes in your profession, as well as to maintain your license on a current status.

SAFETY AND SANITATION:

• Monitor your assigned personnel to assure that they are following established safety regulations in the use of equipment and supplies.
• Ensure that your assigned work areas (i.e., nurses’ stations, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner.
• Ensure that your unit’s resident care rooms, treatment areas, etc., are maintained in a clean, safe and sanitary manner.
• Ensure that your assigned nursing personnel follow established departmental policies and procedures.
• Ensure that your assigned personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner.
• Participate in the maintenance of the Infection Control Program and monitoring communicable and/or infectious diseases among the residents and personnel.
• Ensure that your assigned personnel follow established infectious control procedures when isolation precautions become necessary.
• Report hazardous conditions or equipment.
• Ensure that your assigned personnel follow established hand washing techniques in the administering of nursing care procedures.
• Ensure that your assigned personnel follow Universal Precautions.

EQUIPMENT AND SUPPLY FUNCTIONS:

• Recommend to the DON or his/her assistant, the equipment and supply needs of your unit.
• Assure that a stock level of medications, medical supplies, equipment, etc., is maintained on your unit at all times to adequately meet the needs of the residents.
• Ensure that only trained and authorized personnel operate your unit’s equipment.
• Ensure that all personnel operate nursing service equipment in a safe manner.
• Monitor nursing procedures to ensure that nursing service supplies are used in an efficient manner to avoid waste.

CARE PLAN AND ASSESSMENT FUNCTIONS:

• Review care plans daily to ensure that appropriate care is being rendered.
• Update care plans as residents’ conditions change.
• Ensure that your nurse’s notes reflect that the care is being followed.
• Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing need.
• Ensure that your assigned nursing assistants are aware of the resident care plans and that they are used in administering daily care to the resident.

RESIDENTS' RIGHTS FUNCTIONS:

• Maintain the confidentiality of all resident care information.
• Monitor nursing care to assure that all residents are treated fairly, and with kindness, dignity, and respect.
• Ensure that all nursing care is provided in privacy and that nursing service personnel knocks before entering the resident’s room.
• Ensure that all nursing service personnel are knowledgeable of the residents’ rights.
• Review complaints and grievances made by the resident and make a writ/oral report to the DON indicating what action(s) were taken to resolve the complaint or grievance.
• Maintain a written record of the resident’s complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint.

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