Belle Terrace Licensed Practice Nurse (LPN) in Tecumseh, Nebraska
we are looking for qualified candidates to work 6A-6P also we have an opening for 6P-6A.
EDUCATIONAL AND EXPERIENCES: High school diploma or equivalent. A current nursing license from the State of Nebraska.
SKILLS AND REQUIREMENTS:
DEMONSTRATED ABILITY TO: effectively communicate verbally, lift at least 50 pounds unassisted, *perform necessary physical activities (standing, bending, kneeling); *follow verbal or written instructions to perform routine duties and operate equipment/machinery.
PURPOSE OF YOUR JOB POSITION:
The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. 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 or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times.
DELEGATION OF AUTHORITY:
As LPN Charge Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties within the scope of your practice.
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 then from the position if the work is similar, related, or is an essential function of the position.
Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility and their respective job descriptions.
The LPN Charge Nurse is responsible for direction and monitoring of Medication Aides under the supervision of the Registered nurse or Physician.
Periodically review the department’s policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.
Meet with your assigned nursing staff, as well as support personnel, in planning the shifts’ services, programs, and activities.
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 concerning the activities of your shift as required.
Cooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.
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 may be requested.
Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan as required.
Assist in planning the nursing services portion of the resident’s discharge plan as necessary.
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.
Write resident charge slips and forward to the Business Office.
Maintain the Daily Census Report and submit to the Business Office as required.
Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
CHARTING AND DOCUMENTATION:
Complete and file required recordkeeping forms. Charts upon the resident’s admission, transfer, and/or discharge.
Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established procedures.
Receive telephone orders from physicians and record on the Physicians’ Order Form.
Transcribe physician’s orders to resident charts, cardex, medication cards, treatment/care plans, as required.
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.
Fill out and complete accident/incident reports. Submit to Director as required.
Chart all reports of accidents/incidents involving residents. Follow established procedures.
Record new/changed diet orders. Forward information to the Dietary Department.
Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Director of Nursing.
Fill out and complete transfer forms in accordance with established procedures.
Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.
Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
Sign and date all entries made in the resident’s medical record.
DRUG ADMINISTRATION FUNCTIONS:
Prepare and administer medications as ordered by the physician.
Verify the identity of the resident before administering the medication/treatment.
Ensure that prescribed medication for one resident is not administered to another.
Ensure that adequate supplies and equipment is on hand to meet the nursing needs of the residents. Report needs to the Director of Nursing.
Order prescribed medications, supplies, and equipment a necessary, and in accordance with established policies.
Ensure that narcotic records are accurate for your shift.
Notify the Director of Nursing of all drug and narcotic discrepancies noted on your shift.
Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.
Notify the attending physician of automatic stop orders prior to the last dosage being administered.
Dispose of drugs and narcotics as required, and in accordance with established procedures.
Accurately and safely prepare, administer, and document the oral and/or topical medications that are commonly used in this facility and that may be ordered for resident use by the attending physician or the Medical Director.
Verify that any medications brought into the facility by a newly admitted resident are examined and identified by the attending physician or the facility pharmacy or pharmacist.
Follow the labeling policies and practices of the facility
Ensure that all medications administered are properly labeled.
Assist with medication charting as directed by the Nurse Supervisor/Charge Nurse.
Follow facility procedures in regard to charting of medications.
Follow facility policies and procedures regarding the destroying of medications; assist in carrying out these rules under the direction of the facility pharmacist or Director of Nursing Services, including the documentation requirements.
Assist in documenting and removing medications that are discontinued by the attending physician.
Follow facility procedures governing drug receipt errors, including notifying the delivery source and the Director of Nursing Services.
Ensure that medication is returned and reordered except emergency drugs.
Ensure that documentation of the drug receipt error includes a written error report, signed by an observer/witness and you.
Follow facility procedures in holding medications for residents who are transferred from the facility or when a medication is discontinued by the attending physician.
Accurately measure, record, and report the vital signs if residents.
Observe and verify that medication is administered as directed. Document any instance where prescribed medication is not administered, including reason(s) for refusal.
Promptly notify the Charge Nurse or Director of Nursing Services of any errors or reactions to medications by residents.
Ensure that no medication is administered without a written, signed, dated order from an attending licensed physician.
Follow the facility procedure for recording the order in the resident’s clinical record, including the type, route, dosage, frequency and strength of each medication.
Verify the identity of the resident before administering the medication treatment.
Follow the facility’s procedures allowing residents to self-administer their medication.
Assist the Nurse Supervisor/Charge Nurse in monitoring and documenting all aspects of such self-administering.
Promptly notify the Nurse Supervisor/Charge Nurse of any failure of a resident to properly take any “self-administered” medications.
Follow established guidelines concerning the storage of drugs and biologicals.
Be familiar with the meaning and usage of common medical abbreviations, symbols, and terms relative to the administration of medications as use by the facility, pharmacists, and physicians.
Participate in the development and implementation of the resident’s comprehensive assessment as necessary.
Note and report errors in the administration of medications.
Identify, manage, and treat specific skin disorders and primary and secondary lesions, such as skin abrasions, foot problems such as corns and callouses, decubitus ulcers, bacterial, parasitic and viral skin infections, scaling papular diseases, and benign tumors.
Provide assessment and diagnostic services to residents. Perform an assessment evaluation using techniques including observation, inspection, and palpation.
Provide, within established protocols and under the supervision of the physician, treatment for uncomplicated dermatologic disorders as directed by the attending physician or Medical Director.
Ensure that residents with decubitus ulcers receive appropriate prophylaxis and treatment, such as daily inspection, turning and activity, a well-planned diet, and maintaining a clean, dry bed.
Give direct physical and psychological nursing care in emergencies, as well as in the presence of illness or disability in order to maintain life, provide comfort, reduce stress, and enhance the resident’s ability to cope.
Work with other health agencies and family members in the physical and emotional transitions of admission, care, and discharge of residents as necessary,
Assist in resident rehabilitation activities. Where required, perform range of motion, assist in ambulation, provide emotional support. Monitor the results of physical therapy activities.
provide preventative health care services. make recommendations to the resident concerning nutrition, prevention of common skin disorders, etc.
Provide information to resident and family members of prevention techniques and other ways to maintain or improve the general health and psychosocial status of the resident.
Participate in employee performance evaluations, determining your shift’s staffing requirements, and making recommendations to the Director of Nursing Services concerning employee dismissals, transfers, etc.
Inform the Director of Nursing Services of staffing needs when assigned personnel fail to report to work.
Report absentee call-ins to the Director of Nursing Services.
Develop work assignments and/or assist in completing and performing such assignments.
Provide leadership to nursing personnel assigned to your unit/shift.
Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Director of Nursing Services.
Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.
Meet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services.
Ensure that department personnel, residents, and visitors follow the department’s established policies and procedures at all times.
Develop and maintain a good working rapport with inter-departmental personnel, as well as other department 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.
Review complaints and grievances made or filed by your assigned personnel.
Make appropriate reports to the nurse Supervisor as required or as may be necessary. Follow facility’s established procedures.
Ensure that department disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.
Receive/give the nursing report upon reporting in and ending shift duty hours.
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.
NURSING CARE FUNCTIONS:
Inform 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 them to their rooms as necessary.
Participate in the orientation of new residents/family members to the facility.
Make rounds with physicians as necessary.
Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.
Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.
Review the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.
Implement and maintain established nursing objectives and standards.
Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the 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.
Cooperate with and coordinate social and activity programs with nursing service schedules.
Notify the resident’s attending physician when the resident is involved in an accident or incident.
Notify the resident’s attending physician and next-of-kin when there is a change in the resident’s condition.
Carry out restorative and rehabilitative programs, to include self-help and care.
Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.
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 for the dead and dying, etc., as required.
Obtain sputum, urine, and other specimens for lab tests as ordered.
Take and record TPRs, blood pressures, etc., as necessary.
Monitor seriously ill residents as necessary.
Check foods brought into the facility by the resident’s family/visitors to ensure that it is within the resident’s dietary allowances. Report problem areas to the Nurse Supervisor and Dietary Supervisor.
Ensure that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.
Ensure that residents who are unable to call for help are checked frequently.
Meet with residents, and/or family members, as necessary. Report problem areas to the Nurse Supervisor.
Admit, transfer and discharge residents as necessary.
Assist in arranging transportation for discharged residents as necessary.
Ensure that discharged residents are escorted to the pick-up area.
Inform family members of the death of the resident.
Call funeral homes when requested by the family. Ensure that established post-mortem procedures are followed.
Implement and maintain an effective orientation program that orients the new employee to your shift, its policies and procedures, and to his/her job position and duties.
Assist in standardizing the methods in which work will be accomplished.
Assist in training department personnel in identifying tasks that involve potential exposure to blood/body fluids.
Assist the Director in planning clinical supervision for nurse aide trainees.
Attend and participate in outside training programs.
Attend and participate in annual OSHA and CDC in-services training programs for hazard communications, TB management, and bloodborne pathogens standard.
Attend and participate in advance directive in-service training programs for the staff and community.
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:
Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies.
Ensure that established departmental policies and procedures, including dress codes, are followed by your assigned nursing personnel.
Assist the Director and/or Infection Control Coordinator in identifying, evaluating, and classifying routine and job-related 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-services training programs prior to performing such tasks.
Ensure that an adequate supply of personal protective equipment are on hand and are readily available to personnel who perform procedures that involve exposure to blood or body fluids.
Ensure that your assigned work areas (i.e., nurses’ station, 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 personnel follow established handwashing techniques in the administering of nursing care 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 development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel.
Ensure that you assigned personnel follow established infection control procedures when isolation precautions become necessary.
Ensure that nursing personnel follow established procedures in the use and disposal of personal protective equipment.
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 SUPPLIES:
Recommend to the Director of Nursing Services the equipment and supply needs of your unit/shift.
Ensure that an adequate stock level of medications, medical supplies, equipment, etc.. is maintained on your unit/shift at all times to meet the needs of the residents.
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 your unit/shift’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.