The Registered Nurse is accountable for the delivery of safe and therapeutic resident care from admission through discharge in collaboration with the physician, family and other members of the multi-disciplinary health care team. Delivery of quality nursing care is assured through utilization of the nursing process. The goal of resident care shall be toward restoring and maintaining each resident’s capabilities at their maximum mental and physical level. Registered Nurses serve as a positive clinical role model for staff as well as a resource person and support the philosophy, mission and core values of St. Leonard.
Reports to: Unit Manager
Essential Job Specific Duties/Responsibilities
- Performs activities related to the nursing care needs of residents.
- Gives and received a thorough shift report to/from oncoming nurse.
- Monitors work performance of nurse assistants. Makes frequent rounds throughout the shift.
- Suggests appropriate ways to solve problems and make improvements on the unit(s).
- Provides hands-on direct care; including ADLs and treatments as necessary. Able to delegate specific nursing tasks appropriately.
- Makes rounds with physicians. Utilizes physician file appropriately.
- Performs activities related to medications and treatments in accordance with facility policies and processes.
- Safely administers medication and treatments ordered by the physician.
- Maintains control of scheduled drugs and all drugs in medicine cart; monitors for discrepancies and reports promptly to RN Unit Manager.
- Keeps medication cart key-locked when not within eye view of nurse.
- Appropriately records and orders medications from the pharmacy.
- Monitors for and reports Adverse Drug Reactions appropriately.
- Documents in accordance with nursing policies and procedures.
- Monitors and documents accurately all nursing actions implemented as well as effectiveness of implementation in nursing notes and resident plan of care.
- Accurately records assessments of physiological and mental dimensions of residents, including pain assessment.
- Documentation in EMR is accurate and timely.
- Monthly summary completed accurately and timely utilizing resident plan of care. Plan of Care and Resident Care Card updated/revised monthly and as necessary.
- Skin Integrity reviews accurately reflect resident and are completed weekly.
- Documents, at time of services, all medication and treatments administered.
- Documents resident response to non-pharmacological strategies to promotes pain relief and resident response to analgesics.
- Maintains effective communication with residents, families, staff and physicians.
- Responsible for daily shift documentation including head to tow assessment of skilled residents.
- Functions in a calm, positive manner in an emergency or crisis situation.
- Communicates consistently with the RN Unit Manager; reports pertinent concerns/issues to RN Unit Manager.
- Places necessary calls to families and physicians. Demonstrates appropriateness of faxing vs. phone calls to physicians.
- Communicates appropriately with physicians; makes rounds with physicians in absences of RN Unit Manager or as delegated by RN Unit Manager.
- Reviews and teaches resident and family about pain management, including pain-rating scales and goal setting; importance of aggressive, preventative pain treatment; analgesic misconceptions; and plan for pain management.
- Participates in resident/family teaching, and initiates discharge planning in a timely manner.
In addition to the essential job specific duties listed above, the Registered Nurse shall be required to perform all duties (essential and non-essential) in a manner consistent with the mission statement and core values (reverence, service and stewardship) of St. Leonard and will be evaluated on such basis. Furthermore, every employee must abide by all campus, departmental and safety policies, rules and regulations.
St. Leonard has the right to change the job specific duties and specifications required for the position of Registered Nurse from time to time without prior notice.