The RN on each shift shall be the licensed nurse who assumes responsibility for and supervises all activities to be completed on their shift. He/She is accountable to and works under his/her immediate supervisor, the Director of Nurses. He/She performs selected acts in the care of the residents, administers selected treatments and medications prescribed by the physician or a licensed dentist.
MAJOR RESPONSIBILITIES
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Supervising care delegated to other staff members working his/her shift. Assisting the attending physician and family members. Administration of selected medications and treatments not allowed to be performed by medication aides.
Carrying out prescribed nursing regimens and constantly evaluating them for accuracy and effectiveness. Providing for the physical, psychological, and social aspects of the residents. Practicing safe and informed nursing within a changing health care system.
Complete monthly assessments on residents assigned for the month. Complete initial assessments of newly admitted residents. Completing assessments and informing physicians, family members and the Director of Nurses of the condition changes on all residents.
Supervision and Responsibility of medication ordering and reordering. Make sure the lab is posted and up to date – contact the doctor with lab results and file in the chart. One copy is sent to the physician.
Documenting all nursing procedures, routing medications, medication prescribed PRN with follow up on results, which occur on your shift. Documenting and reporting to the Director of Nurses and the Administrator all accidents and/or incidents as soon as possible. Make rounds to evaluate resident care and ensure that good nursing procedures are being performed correctly.
See that residents are clean and dry. Assure proper nursing staff conducts good patient care during your shift. Assure the narcotic count is correct and is documented as such.
Any discrepancy is to be traced and reported to the Director of Nurses before leaving the facility. Responsible for noting and carrying out physician orders. Any other nursing responsibility assigned by the Director of Nurses on a continuing or a one-time basis.
Is responsible during the shift, for the total nursing care of residents in his/her assigned unit or units. Can recognize significant changes in the condition of residents and take necessary action. Supervise direct patient care personnel in the unit.
Ensures that the individual nursing care plan is followed to meet the resident’s needs according to accepted nursing practices within the State of Texas. Administers or supervises the preparation and administration of prescribed medications. Administers or supervises prescribed treatments.
Supervises serving of prescribed diets and fluid intake (it is acceptable to document only deviations from normal) and reports persistent and unresolved problems to the physician, the Director of Nurses, and the Dietary consultant. Ensures that all medications and treatments are charted “after the fact” by the person administering the medication or completing the treatment on his assigned shift. Supervises the preparation of incident and accident reports.
Directs charting on his/her shift including vital signs. Ensures that a copy of the medical records or an abstract of them is forwarded with the transfer of resident. Ensures that drugs covered by the Controlled Substances Act are verifiable by inventory.
Monitor chemical control drugs and behavior monitoring sheets. Is responsible for the detection and correction of situations that have a high probability of causing accidents or injuries to residents and staff. Ensures continuing promotion of the resident’s physical and emotional health by assisting and teaching him/her.
If a resident refuses to follow instructions, the LVN must document the refusal in the resident’s chart. Participating in the resident care plan progress. Night RN responsible for ensuring that medications received match MAR and physician’s orders.
Night RN responsible for daily census recording. Continuing education through such methods as reading nursing literature, attending conferences, and taking formal course work to keep current with new developments in the health field. Maintain facility care and/or meet all requirements of the City- County Health Department and the State Health Department and the State Health Department for employment.
Participates in regular staff meetings and in-services. Miscellaneous Duties and
Completes other duties as assigned Maintains confidentiality of sensitive information. Documents work processes as required by HCH policies and department policies and procedures. ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE HCHD PERFORMANCE STANDARDS JOB REQUIREMENTS Education Minimum High School Diploma or GED equivalent.
Graduate from an approved school of professional nursing. Possess a current unrestricted Registered Nurse in the State of Texas Preferred Work Experience Minimum Previous experience in direct patient care. Preferred Licenses & Certifications Minimum Maintain BLS certification as a condition of employment Maintain RN Licensure as a condition of employment Preferred
, Knowledge, and Abilities Consistent availability to work twelve-hour shifts as scheduled as a regular full-time, non-exempt employee. Excellent command of the English language (reading, writing, and speaking) is essential. Demonstrated computer skills appropriate for the position Demonstrated critical thinking, ability to analyze complex situations, and ability to read and apply policy and procedures.
Ability to maintain accurate records Excellent organizational and interpersonal communication skills Demonstrated ability to manage multiple priorities Ability to communicate information effectively and to respond adequately to questions from family members, coworkers, supervisors, and others as required. Must participate in ongoing in-service programs and training as required by State Standards. Other
Must convey a professional demeanor Must be able to act calmly and efficiently in a busy or stressful situation Adheres to all policies and procedures, including standards for safety, attendance, punctuality, and personal appearance Must be able to establish and maintain positive working relationships with managers and peers Attendance at mandatory staff meetings is a condition of employment. Must report any suspected abuse to the Abuse Coordinator or direct supervisor immediately.