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POSITION PURPOSE: Organizes and directs assigned unit duties to provide quality nursing care to residents. ESSENTIAL FUNCTIONS OF POSITION: Responsible during the shift for the total nursing care of residents in the assigned unit. Assumes responsibility for compliance with Federal, State, Local, and company regulations. Explains procedures and treatments and care plan to resident. Administers prescribed medications and treatments in accordance with approved nursing techniques. Transcribes physician’s orders. Charts progress notes in an informative, factual manner that reflects the care administered as well as the resident’s response to care. Receives/gives report from/to nurse he/she is relieving/coming on and records sufficient information and implements appropriate follow-up action as necessary Follows established procedures for charting and reporting all reports of incident/accidents for residents and employees. Conducts frequent rounds to evaluate effectiveness of care delivery. Prepares equipment and aids Physician during treatment and examination of resident. Maintains awareness of comfort and safety needs of resident. Observes resident, records significant conditions and reactions, and notifies supervisor or Physician of resident’s condition and reaction to drugs, treatments, and significant incidents. Takes temperature, pulse, blood pressure, and other vital signs to detect deviations from normal and assess condition of resident. Responds to emergency situations based upon nursing standards, policies, procedures, and protocol. Assists in completion of the care plans (acute and long term) and is involved in the care conference as deemed necessary. Participates, reports to DON/ Administrator and conducts (as appropriate) investigations related to any alleged abuse. Ensures that documentation is reflective of the care plan and that the approaches on the care plan are being followed. Assures that assigned CNA’s are aware of the resident care plan, and ensure that the nursing assistant refers to the care plan prior to administering care. Monitors that CNA’s documentation is completed daily. Takes report form CNA’s to facilitate accurate documentation in resident medical record. Follows company policy and procedure in the event a restraint must be utilized. Coordinates residents’ rehabilitation program with therapists to ensure 24 hour rehabilitation needs are met. Identifies residents at risk for nutritional problems and implements preventative measures. Records new/changed diet orders. Forwards information to the Dietary Department. Makes beds, bathes and feeds resident, when necessary. Assures documentation is accurately completed for admission, discharge and transfer. Supervises and evaluates implementation of the “Resident’s Rights”. Participates in department or unit quality improvement activities. Follows facility procedure requesting supplies and charges for items ordered through Central Supply. Participates and attends periodic in-services and staff meetings. Perform additional duties as assigned. EDUCATION / REQUIREMENTS: Current State of L VN/LPN with a minimum of 2 years related experience; or equivalent combination of education and experience. Good standing in the state registry is required.