Description:
PRINCIPAL RESPONSIBILITIES:
A. CLINICAL:
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Performs patient assessments by developing, implementing, and evaluating Patient Care Plans.
- Performs treatments, administers medications, and/or implements other nursing interventions as indicated by the Patient Care Plan and/or Physician Order.
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Provides nursing care in accordance with infection control standards.
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Follows safety policies when performing nursing care.
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Initiates emergency measures according to Center policy and within standards of nursing practice.
B. ADMINISTRATIVE
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Ensures the exchange of essential information necessary for quality patient care.
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Maintains all documentation as required by Federal, State, and Company and policies.
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Maintains inventory of supplies and/or medications to meet patient needs.
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Participates in all assigned meetings and in-services.
C. SUPERVISORY
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Meets unit work goals through assignment of staff to patient care needs.
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Monitors performance through coaching and praising.
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Recognizes effective performance (or) takes direct corrective action after coaching/ counseling as needed
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Evaluates quality and quantity of patient care service accomplished by staff.
D. CONSUMER SERVICE:
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Presents professional image to consumers through dress, behavior, and speech.
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Adheres to Company standards for resolving consumer concerns.
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Ensures that all patient rights are protected.
E. QUALIFICATIONS:
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Current nursing licensure in the state of California required.
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Written and verbal communication skills in English as business necessity.
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Administrative and organizational abilities necessary.
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Current CPR certification required.
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One year of nursing experience preferred.
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Supervisory experience preferred.
Requirements:
STANDARD OF PERFORMANCE
A. CLINICAL:
Activity:
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Participates in Shift Report.
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Performs patient assessments:
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Admission;
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Daily;
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Change of condition; and
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Discharge.
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Conducts comprehensive assessment (MDS) and initiates/updates patient plan of care.
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Performs treatments as prescribed.
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Passes medications as prescribed.
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Follows infection control policies in performing nursing care:
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Hand washing;
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Universal precautions; and
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Linen handling procedures.
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Follows all safety policies in performing nursing care.
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Initiates and conducts emergency measures required to stabilize patient condition.
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Follows Company nursing policies and procedures at all times when delivering resident care.
Measured by:
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Time and Attendance Records and direct observation by Director of Nursing.
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Admission Checklist, rounds by Patient Care Coordinator, and review of Clinical Record Summary discharge notes.
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Results of Quality Assurance Standard review by DON and completion of MDS audits and Plan of Care audits.
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Quality Assurance standards outcome properly documented to Treatment Sheet and direct observation by Patient Care Coordinator.
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Quality Assurance standards documented to Medication Record and direct observation by Patient Care Coordinator.
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Quality Assurance Standards, direct observation by Patient Care Coordinator, and review of Infection Control Report by Patient Care Coordinator.
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Review of Safety Committee Reports.
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Required documentation (i.e., daily nurse's notes).
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Direct observation by the Patient Care Coordinator.
B. ADMINISTRATIVE:
Activity:
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Communicates patient needs and change of condition to appropriate persons, i.e.:
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Other shifts and patient care;
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Coordinator;
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Dietary;
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Activities and social services;
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Physicians;
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Responsible parties (i.e., families, conservator);
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Outside therapies; and
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Maintenance Department.
2. Maintain all documentation (current and complete) including, but not limited to:
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Patient Care Plans;
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Nursing Progress Notes;
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Medication Administration Record;
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Treatment Records;
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Physician Order Sheets;
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Quality Assurance audits;
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Acuity Reports;
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Incident Reports; and
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Restorative Progress Summary.
3. Utilizes nursing supplies as needed.
4. Orders medications as needed and as ordered by physicians:
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Logs ordered and received;
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Removes discounted medications; and
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Reorder emergency medication kit.
5. Participates in all meetings as required.
6. Participates in all in-service as required.
Measured by:
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Direct observation and review by Patient Care Coordinator.
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Review of appropriate documentation by Patient Care Coordinator and Medical Records audit.
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Review of supply inventory and observation of patient bedside units by Patient Care Coordinator.
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Review of medication storage and preparation areas, review of appropriate documentation by Patient Care Coordinator, and review of pharmacy audit.
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Review of minutes, review of attendance records, and direct observation by Patient Care Coordinator.
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Review of in-service records by Director of Staff Development and Patient Care Coordinator.
C. SUPERVISORY:
Activity:
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Assigns staff to meet patient care needs by verbal and/or written Condition Report.
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Assists in providing adequate staffing by seeking replacements for current and oncoming shifts.
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Uses Absentee Report forms appropriately.
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Observes staff performance during patient rounds.
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Coaches staff during rounds for both quality and quantity of work performance and work habits.
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Demonstrates effective work habits to staff during rounds and as needed.
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Praises and recognizes staff for effective performance.
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Participates with Patient Care Coordinator in Progressive coaching and follow-up.
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Monitors patient appearance and comfort.
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Audits documentation by nursing staff.
Measured by:
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Review of completed Daily Assignment Sheet and direct observation by Patient Care Coordinator.
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Review of documentation in Shift Log Book and verbal report.
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Completed Absentee Report on file.
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Resident outcome Quality Assurance tool and direct observation by Patient Care Coordinator.
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Direct observation by Patient Care Coordinator.
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Direct observation by Patient Care Coordinator.
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Positive feedback from staff and direct observation by Patient Care Coordinator.
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Review of documented Progressive Coaching Form.
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Direct observation by Patient Care Coordinator and absence of complaints.
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Medical Records audit.
D. CONSUMER SERVICE:
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Reports for duty in approved uniform and maintains high standards of personal hygiene.
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Refrains from rude and discourteous behavior toward consumers and co-workers. Avoids the use of profanity.
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Limits eating and/or smoking to designated areas.
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Reports to duty promptly as scheduled (and) takes breaks only during assigned times and in designated places.
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Speaks, writes, and understands English for business necessity.
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Follows consumer service standards for:
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Making daily contact with patients;
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Greeting visitors;
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Making initial contact with newly admitted residents;
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Giving information to patients and visitors;
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Getting information from patients and visitors;
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Referring patients and visitors; and
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Handling complaints.
7. Utilizes the telephone in accordance with consumer service standards when:
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Answering phones;
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Placing a caller on hold;
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Transferring a call; and
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Taking a message.
8. Utilizes the paging system effectively.
9. Monitors general patient care to identify and correct any infringement of patient rights.
Measured by:
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Visual inspections by Patient Care Coordinator.
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Absence of complaints.
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Direct observation by Patient Care Coordinator.
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Direct observation by Patient Care Coordinator.
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Direct observation by Patient Care Coordinator.
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A combination of absence of complaints (and) periodic audit of skills by Patient Care Coordinator or other management staff.
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A combination of absence of complaints (and) periodic audit of skills by Patient Care Coordinator or other management staff.
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A combination of absence of complaints and periodic audit of skills by Patient Care Coordinator and other management staff.
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A combination of absence of complaints and periodic audit of skills by Patient Care Coordinator and other management staff.