2-10 Monday-Friday

POSITION DESCRIPTION Job Title: Registered Nurse Effective Date: 2015 Revised Date: 11/2019 Summary Description: To deliver nursing care to patients requiring long-term acute care and/or rehab care. Essential Functions and Responsibilities: Works under direct supervision in accordance with the state-specific Nurse Practice Act, facility Policies and Procedures and nursing judgment. Delivers nursing care to patients/residents requiring long-term or rehabilitative care. Collects patient/resident data, makes observations, and reports pertinent information related to the care of the patient/resident. According to state-specific regulations, implements the patient/resident plan of care and evaluates the patient/resident response. In accordance with state-specific regulations, directs and supervises care given by other nursing personnel in selected situations. Maintains knowledge of necessary documentation requirements. Maintains knowledge of equipment set-up, maintenance and use, i.e., monitors, infusion devices, drain devices, etc. Maintains confidentiality and patient/resident rights, regarding all patient/resident/personnel information. Provides patient/resident/family/caregiver education as directed. Conducts self in a professional manner in compliance with unit and facility policies. Works rotating shifts, holiday and weekends as scheduled. Initiates emergency support measures (i.e. CPR, protects patients/residents from injury). Data Collection Admission and routine patient/resident observations/transfer notes are complete and accurately reflect the patient’s/resident’s status. Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures. Nursing history is present in the medical record for all patients/ residents. Changes in patient’s/resident’s physical/psychological condition (i.e. changes in lab data, vital signs, mental status), are reported appropriately. Planning of Care: Contributions to the formulation/review of nursing care plans are made as appropriate, under the direct supervision or delegation of an RN. Pertinent nursing problems are identified. Goals are stated Appropriate nursing orders are recommended Evaluation of Care Observations related to the effectiveness of nursing interventions, medications, etc., are reported as appropriate and documented in the progress notes. Care Plans: Evaluation of care plan is noted monthly or as indicated. Contributions to care plan revision are made as indicated by the patient’s/resident’s status. General Patient/Resident Care Patient/resident is approached in a kind/gentle and friendly manner. Respect for the patient’s/resident’s dignity and privacy is consistently provided. Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided. Independence by the patient/resident in activities of daily living is fully encouraged possible. Treatments are completed as indicated. Safety concerns are identified, and appropriate actions are taken to maintain a safe environment. Side-rails and height of bed are adjusted. Patient/resident call light and equipment is within reach. Rooms are neat and orderly. Functional assignments are completed. Emergency situations are recognized, and appropriate action is instituted. All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, AED, crash cart, fire extinguisher, etc.) Patient/Resident Education/Discharge Panning Patient/Resident/Family teaching is conducted according to the nursing care plan. Explanations are given to the patient/resident prior to interventions. Discharge/death summaries are complete and accurate. Transfer forms are complete and accurate. Active participation in patient/resident care management is evident. Adherence to Facility Procedures Facility Policy and Procedure Manu