Registered Nurse (RN)

QUALIFICATIONS

• Graduated of an accredited school of nursing and licensed by the state of NJ as a RN.
• Current CPR or certified within 90 days of hire
• Other certifications may be required for other areas of the organization

POSITION SUMMARY

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.

PART I: JOB RESPONSIBILITIES AND STANDARDS

• 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

24.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

EMPLOYEE IS REQUIRED TO

• 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.

#IND123