RCM - RN

Job description

Registered Nurse (RN) General Purpose The primary responsibility 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 accordance with current federal, state, and local standards, guidelines and regulations that govern the facility and may be required by the Director of Nursing (DON)and or/Assistant Director of Nursing (ADON) when applicable, to ensure that the highest degree of quality care is maintained at all times. Essential Duties Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these 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 an essential function of the position. Administrative Functions • Assist the Director of Nursing Services in directing the day-to-day functions of the nursing activities in accordance with current rules, regulations, and guidelines that govern the long-term care facility. • Participate in developing, maintaining, and updating written policies and procedures that govern the day-to-day functions of the nursing service department. • Ensure that reference material (i.e., PDR’S, regulations, professional standards of practice, etc.) maintained at the nurses’ stations is current. Recommend written material that will assist the nursing service department in meeting the day-to-day needs of the resident. • Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this facility. • Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual. • Make written and oral reports/recommendations to the Director as necessary/required, concerning the operation of the nursing service department. • Periodically review the department’s policies, procedure manuals, job descriptions, etc. Make recommendations for revisions to the Director. • Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the residents’ total regimen of care. • Ensure that all nursing service personnel are in compliance with their respective job descriptions. • Participate in the development, maintenance and implementation of the facility’s quality assurance program for the nursing service department. • Participate in facility surveys (inspections) made by authorized government agencies as requested by the Administrator or Director of Nursing Services. • 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. • Meet with the nursing staff, as well as support personnel, in planning the department’s services, programs, and activities. • Admit, transfer, and discharge residents as required. • Complete accident/incident reports as necessary. • Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required. • Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., asnecessary. • Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator. • Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator. • Report any known or suspected unauthorized attempt to access facility’s information system. Committee Functions • Attend various committee meetings of the facility (i.e., Infection Control, Policy Advisory, Pharmaceutical, Quality Assessment, etc.) as required. • Assist in preparing written and/or oral reports of the nursing service programs and activities to submit to such committee(s) as directed. • Provide information to the Quality Assurance and Assessment Committee as requested. • Participate in developing the agenda for the Care Plan Committee meetings as necessary. • Participate in regularly scheduled reviews of the discharge plans and make such plans available to the Care Plan Committee as required or as may be necessary. • Implement recommendations from established committees as instructed by the Director. Personnel Functions • Ensure that a sufficient number of licensed practical and/or registered nurses are available for your tour of duty to ensure that quality care is maintained. • Ensure that a sufficient number of certified nursing assistants are available for your tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident. • Develop work assignments, and/or assist in completing and performing such tasks. • Delegate to each Charge Nurse the administrative authority, responsibility, and accountability necessary to perform his/her assigned duties. • Ensure that all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program. • Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse. • Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report findings to the Director. • Monitor absenteeism to ensure that an adequate number of nursing care personnel are on duty at all times. Report problem areas to the Director. • Ensure that established policies and procedures, including dress codes, are followed by all departmental personnel. • Review complaints and grievances made or filed by department personnel. Make appropriate reports to the Director as required or as may be necessary. • Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the residents. • 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 on a regularly scheduled basis to assist in identifying and correcting problem areas and/or to assist in the improvement of services. • Review and evaluate your department’s work force and make recommendations to the Director. • Participate in employee performance evaluations, determining your shift’s staffing requirements, and making recommendations to the Director concerning employee dismissals, transfers, etc. • Ensure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status. • Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility’s policies and procedures governing accidents and incidents. • Report known or suspected incidents of fraud to the Administrator. • Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines. Nursing Care Functions • Inform nursing service 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 them to their rooms as necessary • Make rounds with physicians as necessary. • Encourage attending physicians to record and sign progress notes, physicians’ orders, etc., on a timely basis and in accordance with current regulations. • Inform the Director when physician visits are not made in a timely manner. • Consult with the resident, his/her family, and the resident’s physician in planning 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. • Visit residents on a daily basis in order to observe and evaluate each resident’s physical and emotional status. • Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and/or a nurse aide trainee qualified to perform the procedure. • Review nurses’ notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident’s response to the care, and that such care is provided in accordance with the resident’s wishes. • Provide direct nursing care as necessary. • Start IVs, obtain sputum, urine and other specimens for lab tests as ordered. • Take TPRs, blood pressures, etc., as necessary. • Admit, transfer and discharge residents as necessary. • Report problem areas to the Director. Assist in developing and implementing corrective action. • Keep the Director informed of the status of residents and other related matters through written/oral reports. • Assist the Charge Nurse in monitoring seriously ill residents. • Authorize the use of restraints when necessary and in accordance with our facilities policies and procedures. • Ensure that all RNs and LPNs on your shift comply with written procedures for the administration, storage, and control of medications and supplies. • Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled. • Review medication cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies. • Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner. • Ensure that residents who are unable to call for help are checked frequently. • Meet with residents, and/or family members, as necessary. Report problems to the Director. • Assist in arranging transportation for discharged residents as necessary. • Inform family members of the death of the resident. • Call funeral homes when requested by the family. Staff Development • Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on “how to do the job,” and ensure a well-educated nursing service department. • Assist the In-service Director/Educator in developing annual facility in-service training programs (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.). • Assist the Director in planning clinical supervision for nurse aide trainees. • Attend and participate in continuing education 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 • Assist the Safety Officer in developing safety standards for the nursing service department as necessary. • Assist the Director and/or Infection Control Coordinator in identifying, evaluating, and classifying routine and jobrelated functions to ensure that tasks in which there is potential exposure to blood/body fluids are properly identified and recorded. • Ensure that all personnel performing tasks that involve potential exposure to blood/body fluids participate in appropriate in-service training programs prior to performing such tasks. • Ensure that an adequate supply of personal protective equipment is on hand and readily available to personnel who perform procedures that involve exposure to blood or body fluids. • Ensure that personnel follow established procedures for the use and disposal of personal protective equipment. • Monitor your shift’s personnel to ensure that they are following established safety regulations in the use of equipment and supplies. • Ensure that all nursing service personnel comply with established departmental policies and procedures. • Ensure that nursing service work areas (i.e., nurses’ stations, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner. • Ensure that all resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner. • Ensure that nursing service personnel follow established handwashing and hand hygiene procedures. • Ensure that nursing service personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner. • Participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel. • Ensure that nursing service personnel follow established infection control procedures when isolation precautions become necessary. • Participate in the development, implementation and maintenance of the procedures for reporting hazardous conditions or equipment. • Ensure that all personnel wear and/or use safety equipment and supplies (e.g., back brace, mechanical lifts, etc.) when lifting or moving residents. • Report missing/illegible labels and MSDSs to the safety officer or other designated person. Equipment and Supply Functions • Recommend to the Director the equipment and supply needs of the department. • Ensure that an adequate stock level of medications, medical supplies, equipment, etc., is maintained on premises at all times to meet the needs of the resident. • Assist the Maintenance Director in developing a preventive maintenance program for maintaining the nursing service department’s equipment and supplies in a safe and operable manner. • Participate in the development and implementation of the procedures for the safe operation of all nursing service equipment. • Ensure that only trained and authorized personnel operate the nursing service department’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. • Ensure that appropriate MSDSs are on file for hazardous chemicals used in the nursing service department. Care Plan and Assessment Functions • Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident as necessary. • Participate in the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care. • Encourage the resident to participate in the development and review of his/her care plan. • Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. • Ensure that all personnel involved in providing care to the resident are aware of the resident’s care plan. Ensure that nursing personnel refer to the resident’s care plan prior to administering daily care to the resident. • Review nurses’ notes to determine if the care plan is being followed. • Assist the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising the MDS, including the implementation of RAPs and Triggers. • Review resident’s medical and nursing treatments to ensure that they are provided in accordance with the resident’s care plan and wishes. Budget and Planning Functions • Keep abreast of economic conditions/situations, and recommend to the Director adjustments in nursing services that ensure the continued ability to provide quality care. • Recommend to the Director the equipment needs of the nursing service department. • Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc. Supervisory Requirements Assist with the overall supervision of and management of the nursing staff. As RN, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Qualification Education and/or Experience Must posess, as a minimum, a Nursing Degree an accredited college or university. Must have training in rehabilitative and restorative nursing practices. 2 years or more experience preferably in a long-term care facility. Language Skills Must be able to read, write, speak, and understand the English language. Ability to read technical procedures. Ability to read and comprehend policy and procedure manuals. Ability to effectively present information and respond to questions from managers and employees. Mathematical Skills Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations. Reasoning Ability Must possess • the ability to make independent decisions when circumstances warrant such action with the ability to solve practical problems. • the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public. • leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel. • the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care. Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Be a supportive team member, contribute to and be an example of team work and team concept. Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities. Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents. Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices. Must be able to relate information concerning a resident’s condition. Must not pose a direct threat to the health or safety of other individuals in the workplace. Certificates, Licenses, Registrations Must possess a current, unencumbered, active license to practice as an RN in this state. Current CPR certification. Knowledge and experience with PCC preferred. Must maintain all required continuing education/licensing. Must remain in good standing with the State Board of Nursing at all times. Physical Demands Must be able to move intermittently throughout the workday. Must be able to speak and write the English language in an understandable manner. Must be able to cope with the mental and emotional stress of the position. Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met. Must function independently, and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies. Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination. Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility. Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet. May be necessary to assist in the evacuation of residents during emergency situations. Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.). Moves intermittently during working hours. Is subject to frequent interruptions. Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances. Is subject to hostile and emotionally upset residents, family members, personnel, and visitors. Communicates with the medical staff, nursing personnel, and other department directors. Works beyond normal working hours and on weekends and holidays when necessary. Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.). Is involved in community/civic health matters/projects as appropriate. Attends and participates in continuing educational programs. Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminants. Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses. May be subject to the handling of and exposure to hazardous chemicals. Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs. Additional Information Note: Nothing in this job specification restricts management’s right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons. The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position. We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.