Job Description
DUTIES AND RESPONSIBILITIES :
Provide an ongoing objective evaluation of the important aspects of patients’ care through daily review of patient charts and identification of variations in care to provide data for use in the correction of potential problems and to meet the requirements of all regulatory agencies. Relate effectively with interdepartmental and intradepartmental personnel, medical staff, patients, patient’s families and outside agencies. Conduct and coordinate the development and completion of the resident assessment in accordance with the requirements of the state and the policies and goals of this facility. Assist with the resolution of grievances, complaints and staff related issues and concerns.
The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures.
Assist the DON and relevant department supervisor in ensuring that all personnel involved in providing care to the resident are aware of the resident’s care plan and that nursing personnel refer to the resident’s care plan prior to administering daily care to the resident.
FUNCTIONS :
- Conduct and coordinate the development and completion of the resident assessment (including the delegation of specific tasks) (MDS) in accordance with current rules, regulations and guidelines that govern the resident assessment, including the implementation of RAPs and Triggers.
- Conduct or coordinate the interviewing of each resident’s assessment.
- Evaluate each resident’s condition and pertinent medical data to determine any need for special assessment activities or a need to amend the admission assessment.
- Develop preliminary and comprehensive assessments of the nursing needs of each resident, utilizing the forms required by current rules or regulations and facility policies.
- Ensure that appropriate health professionals are involved in the assessment.
- Coordinate 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 services is responsible for each element of care.
- Ensure that the care plan includes measurable objectives and timetables to meet the resident’s medical, nursing and mental and psychological needs as identified in the resident’s assessment.
- Ensure that the initial resident assessment and comprehensive care plan is completed within the required time frame of the resident’s admission.
- Develop the schedule of steps required for the resident admission, assessment and plan of care. Insure all assessment for all requirements are complete, i.e. self administration – restraints, infection control. i.e. PPD.
- Ensure that quarterly and annual resident assessments and care plan review are made on a timely basis.
- Ensure that a complete resident assessment is conducted within the required time frame if a significant change in the resident’s condition.
- Coordinate the review and revision of the resident’s care plan by the interdisciplinary team after each quarterly reviews or other assessment, assuring that the care plan is evaluated and revised each time an assessment is done or when there is a change in the resident’s status.
- Ensure that each portion of the assessment is signed and dated by the person completing the portion of the MDS.
- Maintain and periodically update written policies and procedures that govern the development, use and implementation of the resident assessment (MDS) and care plan.
- Perform administrative duties such as completing medical forms, reports, evaluations, studies, etc., as necessary.
- Develop, implement, and maintain an ongoing quality assurance program for the resident assessment/care plans.
- Assist the resident and staff in completing the care plan portion of the resident’s discharge plan.
- Participate in surveys (inspections) made by authorized government agencies.
- Be sensitive to resident families and respond in an appropriate professional manner.
- Perform related duties as assigned or as the situation dictates.
- Ensure that the annual medication post audit and medication room audits are completed.
QUALIFICATIONS :
- License/Registration: Board of Nursing, RN
- Continuing Education : As required.
- Education : Minimum of at least a high school diploma, ability to read, write, and follow written and oral instructions, and successfully complete the prescribed licensed-training program.
- Experience : Clinical nursing experience with background in medical and nursing care practices and procedures preferred.
- Job knowledge: Nursing policies and procedures; administration of medication, federal, and state laws and regulations relative to resident care, facility policies.
- Standards : Professional standards and code of ethics must be adhered to at all times
- Professional Memberships: Not required.
- Other : Excellent human relations and communication skills are needed to maintain good rapport and effective working relationships with nursing staff.
Hybrid part-time
Job Tags
Part time