Job DetailsJob Location: Ponte Vedra Beach, FL 32082JOB SUMMARY
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 to ensure that the highest degree of function, self-care and independence of the resident is maintained.
ESSENTIAL DUTIES & RESPONSIBILITIES
1. To provide direct resident care according to established standards of care.
2. Assumes charge position, directs the functions of the nursing assistants. Ensures that the nursing service policies and procedures manuals are used in rendering nursing care.
3. Performs routine charting duties as required and in accordance with our established charting and documentation policies and procedures.
4. Orders prescribed medications from the pharmacy. Prepares and administers medications as ordered by the physician following all Local, State and Federal guidelines.
5. Identifies problems and implements planned changes to improve nursing care on the unit. Informs Director of Nursing of staffing needs, develops work assignments for CNAs.
6. Makes rounds with physicians, informs nursing personnel of admissions, discharges, transfers, condition changes, and can make independent decisions concerning nursing care.
7. Participates in the maintenance of infection control programs, and quality assurance programs. Ensures that assigned personnel follow all established infection control policies and procedures.
8. Assures that the stock level of medications, medical supplies, equipment, etc., is always maintained on that unit, and that supplies are used in an efficient manner to avoid waste.
9. Participates in the development of resident care plans, updates, and provided revisions as needed. Keeps nursing assistants informed of goals and approaches.
10. Monitors nursing care to assure that all residents' rights are adhered to. Ensures that all nursing service personnel are knowledgeable of each resident's rights.
11. Perform any other related duties as required or assigned.QualificationsSkills, Abilities & Competencies:
MINIMUM QUALIFICATIONS:
1. Must possess a valid and current R.N. or L.P.N. License in the State of Florida.
2. Must be able to write, read, and speak the English language.
PHYSICAL REQUIREMENTS:
1. Must be able to move intermittently throughout the workday.
2. Must be able to speak the English language is an understandable manner.
3. Must be able to cope with the mental and emotional stress of the position.
4. Must be able to see and hear or use prosthetics that will enable these senses to function adequately to assure that the requirements of this position are fully met.
5. Must function independently, have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
6. Must be in good general health and demonstrate emotional stability.
7. Must be able to relate to work with the ill, disabled, elderly, emotional upset, and at times, hostile people within the facility.
8. Must be able to lift a minimum of 50 pounds.
9. Must be free of communicable diseases.
EXPERIENCE:
1. Previous long-term care is preferred.
2. Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long term care.
3. Must possess leadership and supervisory ability and the willingness to work harmoniously with professional and non-professional personnel.
USE OF COMPUTER FOR DOCUMENTATION OF MEDICAL RECORDS:
To define the relationship between computerized medical records and printed medical records.
Computerized medical records are maintained on the Electronic Chart System (ECS) for each resident. These records are updated to reflect the status of the resident. Staff have access to information contained within the system, using unique assigned access codes. Information contained on ECS is printed and placed on individual resident records on a regular basis. There are times when information is located on ECS but has not yet been printed. Staff have access to this information for review and may print information at intervals other than as needed. Information contained in ECS is considered part of the resident record and is maintained in a confidential manner.
ELECTRONIC SIGNATURES:
1. Each employee utilizing the computer system will be issued a unique entry to the system. This code is to be kept confidential at all times. The code becomes the equivalent of a written signature. Under no circumstances is computer entry to be done under another person's code. Disciplinary action will result if violations occur.
2. A list of computer codes is maintained in the system's databases. Access to this list is limited to the System Supervisor and employees holding the following positions: Administrator and Director of Nursing. If a User feels that their code confidentiality has been compromised, they may request that the System Supervisor assign a new code.
3. Printouts and/or information viewed on the computer screen contain the date and time of the entry and the initials of the user who made the entry. These initials are comprised of a set of three letters, which are unique to the User who made the entry. The date, time, and initials will appear at the beginning of documentation and are associated with all subsequent entries, until either the date, time or initials change, at which point the new information would appear.
4. To ensure accuracy of documentation, the user is to review information on the screen prior to saving the information. If subsequent errors are noted, the Edit process is to be used to note errors. This process will save the original record, as well as the correction, indicating the date, time, and initials of the original entry, as well as the edited copy.
5. The person dictating, using the Edit/Add process, to indicate agreement, or to note any changes at the end of the entries will verify dictated information. The date, time and initials of the person reviewing the information will be noted electronically.
Licensed Nurses (i.e. Charge Nurses, Staff Nurses, Clinic Manager, Supervisors, Director of Nurses) who are assigned to the Health Center are placed in Category I due to their direct contact with bodily fluids in accordance with their assigned duties as follows:
1. Catharizing residents, obtaining and handling laboratory specimens of urine, feces, sputum drainage, blood etc.
2. Giving injections with the potential for accidental needle sticks.
3. Starting intravenous infusion lines and maintaining I.V. lines.
4. Performing various wound care type treatments.
5. Handling of urine, feces, vomitus, mucus, and drainage, from wounds, while performing hygiene care for the residents.
6. Emptying and cleaning urinals, bedpans, emesis basins, drainage receptacles.
7. Inserting changing and irrigating catheters, nasal gastric tubes and gastrostomy tubes, irrigating intravenous tubing's, INT type needles.
PHYSICAL DEMANDS
While performing the essential functions of this job, the employee is regularly required to stand, walk, sit, talk hear, and occasionally required to reach with hands and arms, stoop, kneel, and crouch. Employee must have excellent balance and be able to climb a ladder and walk around a roof. The employee must occasionally lift and/or move up to 30 pounds and be able to work at heights. Specific vision abilities required by the job include close, distance, and peripheral vision, depth perception and the ability to adjust focus as well as work on a computer for extended periods of time. The employee must be able to communicate verbally with other on the phone or in person.
