WEO Charge Nurse 6A to 6P

Department: Nursing

Reports To: Assistant Director of Nursing, Director of Nursing

Position Summary

The Charge Nurse is responsible for providing skilled nursing care to residents in accordance with physician orders, individualized care plans, accepted standards of nursing practice, facility policies, and all applicable federal, state, and local regulations. The Charge Nurse provides clinical leadership by directing, supervising, and supporting licensed nurses, certified nursing assistants, medication aides, and other nursing personnel to ensure the delivery of safe, high-quality, resident-centered care.

Accountability: Assistant Director of Nursing, Director of Nursing

Essential Duties and Responsibilities

• Provide nursing care to residents as prescribed by the attending physician and in accordance with physician orders, individualized care plans, accepted standards of nursing practice, facility policies, and applicable federal, state, and local regulations.
• Assess the overall status of residents and accurately document findings in the medical record.
• Monitor resident conditions and provide nursing care in accordance with physician orders, care plans, facility policies, and regulatory requirements.
• Coordinate, prepare for, and assist with resident admissions, transfers, discharges, and readmissions to ensure continuity of care.
• Communicate effectively with residents, family members, physicians, consultants, interdisciplinary team members, and other healthcare professionals regarding resident condition, treatment plans, and changes in status.
• Lead, direct, supervise, and monitor licensed nurses, certified nursing assistants, medication aides, and other professional and non-professional staff in the delivery of resident care.
• Assign and coordinate daily job assignments, staffing responsibilities, and nursing duties to ensure appropriate resident care coverage.
• Supervise, evaluate, coach, counsel, and recommend disciplinary action regarding the performance of nursing staff in accordance with facility policies.
• Assist with the planning, coordination, and presentation of orientation programs, in-service education, competency validation, and continuing education for facility staff.
• Monitor the care environment and staff practices to ensure compliance with fire safety, disaster preparedness, infection prevention, bloodborne pathogen standards, OSHA requirements, and facility safety programs.
• Assist with developing, implementing, reviewing, and updating individualized resident care plans in collaboration with the interdisciplinary team.
• Delegate nursing duties and responsibilities appropriately based on staff qualifications, competency, resident acuity, and scope of practice.
• Complete or assist with performance evaluations and competency assessments of nursing personnel.
• Report occupational exposures, workplace injuries, and safety incidents in accordance with established facility policies and OSHA requirements.
• Make daily rounds to all resident care areas to observe nursing staff performing assigned duties, assess resident care, provide guidance and coaching, and ensure compliance with facility policies and accepted standards of nursing practice.
• Demonstrate knowledge of and actively promote resident rights, dignity, privacy, confidentiality, and person-centered care.
• Recognize, prevent, and immediately report suspected abuse, neglect, exploitation, or mistreatment of residents in accordance with facility policies and applicable regulations.
• Promote and maintain a safe, clean, organized, and therapeutic environment for residents, visitors, and staff.
• Review the Twenty-Four Hour Report daily to remain informed of changes in resident condition, physician orders, admissions, incidents, and treatment plan updates.
• Participate in the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) assessment process, interdisciplinary care plan meetings, and Total Care Plan conferences as indicated.
• Assist with direct resident care and provide floor nursing support as needed to ensure resident care needs are met.
• Make physician rounds as assigned, communicate resident concerns, obtain and implement new physician orders, and ensure appropriate follow-up.
• Review laboratory orders daily, monitor pending laboratory work, follow up on laboratory results, promptly notify the physician of abnormal findings, and ensure appropriate documentation and interventions are completed.
• Review Medication Administration Records (MARs) daily to ensure accuracy, completeness, physician order reconciliation, and regulatory compliance.
• Monitor resident weights, identify significant weight changes, notify the physician, family, Registered Dietitian, and appropriate interdisciplinary team members as indicated, and ensure required documentation and follow-up are completed.
• Audit resident medical records for documentation accuracy, including physician physicals, code status, advance directives, physician orders, required assessments, and other regulatory documentation, ensuring deficiencies are corrected promptly.
• Respond to and manage acute resident situations, providing clinical leadership and assistance to nursing staff while ensuring appropriate interventions, physician notification, family communication, documentation, and follow-up care.
• Update resident care lists, assignment sheets, communication logs, and other clinical tracking tools as needed to ensure accurate communication and continuity of care.
• Maintain accurate, timely, and complete clinical documentation in accordance with CMS regulations, HIPAA requirements, accepted nursing standards, and facility policies.
• Collaborate with the interdisciplinary team to promote positive resident outcomes and continuity of care.
• Attend required facility meetings, department meetings, in-service education, quality improvement activities, and continuing education programs.
• Assist with survey preparation, regulatory compliance activities, implementation of Plans of Correction, and Quality Assurance and Performance Improvement (QAPI) initiatives as assigned.
• Serve as an active member of the interdisciplinary team by placing residents' safety, dignity, quality of life, and well-being as the highest priority.
• Perform all other duties and responsibilities as assigned by the Director of Nursing or designee.

Requirements

PHYSICAL REQUIREMENTS

• Hold/handle
• Lift
• Carry
• Reach – at and below shoulder height
• Push/pull
• Grasp and handle – pens, paperwork and small equipment
• Sit, stand and walk
• Twist, bend, stoop, kneel and squat
• Fine hand motor coordination
• Ability to read and write legibly
• Ability to comprehend and follow instructions

COGNITIVE AND SENSORY REQUIREMENTS:

Talking: Communicating with residents, families, physicians, visitors and staff

Hearing: Taking instructions from the Administrator, To respond to resident complaints and requests, To respond appropriately to disaster instructions and pages

Sight: For performing job effectively and correctly

Smell: For accurate detection and maintenance of facility odors

Touch: In order to detect changes in temperature

LICENSURE REQUIREMENTS:

Must be a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.) currently licensed and in good standing with the Board of Nursing in the State in which the facility is located.

SUMMARY OF OCCUPATIONAL EXPOSURE:

Tasks and procedures performed by the employee involve risks classified by C.D.C. as Category I. (Direct contact with blood or other bodily fluids to which universal precautions apply.)

Other Considerations and Requirements:

Must be able to tolerate a high pace as typical for a nursing facility. Must be able to take and give instructions well and enjoy working with the elderly. Although employee is required to sit for prolonged periods of time, he/she must also be able to tolerate prolonged standing and walking.