Registered Nurse (RN)

• Graduated of an accredited school of nursing and licensed by the state of PA as a RN.

• Current CPR or certified within 90 days of hire

• Other certifications may be required for other areas of the organization

The RN assumes responsibility for a specific unit or area within the organization to include assessment (under the supervision of the DON/ADON), medication distribution, treatment clinical documentation, and supervision of CNA’s and other staff.

• Uses dual identifiers to confirm resident/guest identify prior to medication administration and treatments.

• Practices SBAR (situation, background, assessment, recommendation), the preferred method of communication when interacting with members of healthcare community.

• Encourages resident/guest to be involved in their own care when possible.

• Receives full and detailed report from the outgoing nurses to ensure proper communication and necessary follow-up of resident’s/guest’s care.

• Recognizes and responds competently to changes in resident’s condition and documents appropriately.

• Initiates Plan of Care on admission. Reviews, evaluates & updates plan & interventions as needed.

• Interacts and partners with all multidisciplinary service teams, internal and external, to assure continuum of care.

• Practices Standard Precautions and adheres to infection prevention strategies.

• Demonstrates compliance to Resident’s Rights.

• Refers to Nursing/Administration/IV/Emergency Management Policy and Procedures (Public Folders, Hard Copy manual) to assure standard of care.

• Transcribes physician orders correctly on MAR & TAR.

• Faxes POS to Pharmacy provider to ensure timely delivery and administration.

• Maintains a safe environment for residents/guests and reports unsafe situation for resolution.

• Follows chain of command.

• Adheres to proper hand washing technique.

• Administers medications according to policy and procedure.

• Notifies responsible party of changes in patient’s condition.

• Works closely with Social Worker in trying to resolve residents’/guests/ needs.

• Checks syringes, and counts narcotics at end of shift.

• Orders stock medications and prescription medications; as needed.

• Admits and discharges residents/guests according to facility procedure.

• Reviews report with CNAs prior to their assignment activation.

• Performs assessments related to:

• Skin

• Cardiac

• Respiratory

• GI

• Neurological

• Muscular Skeletal

• Renal

• Pain

• Accurately documents on the following forms:

• Ambulation/Restorative care

• Pyschotropic Monitoring

• Pain Management

• Pressure Ulcer Management/skin assessment

• Fall Prevention Strategies

• Antibiotic documentation

• Incidents/accident

• Nurses Note day 1-5 and day 6 -Discharge Documentation.

• Accurate and timely completion of Nursing assessment and data collection upon admission:

• Fall Risk assessment

• Side Rail screen

• Braden Scale

• Bowel and Bladder

• Elopement Risk Profile

• Pain Evaluation

• Smoking Evaluation

• Data collection

• Immunization Record Sheet

• Contacts physician for admission orders:

• Reconciles medications

• Documents legibly onto POS

• Read back and verifies Telephone Orders

• Make appropriate referrals

• Transcribes all orders.

• Fax back (new admissions)

PART II. FACILITY –WIDE RESPONSIBILITIES & STANDARDS

• Speak English in patient care areas.

• Attend mandatory and scheduled in-services/meetings.

• Arrive to work on time as scheduled

• Demonstrate ability to work with others cooperatively.

• Demonstrate flexibility in assignment to meet resident/family needs.

• Wear ID at all times appropriately when working.

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