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Assists in defining, maintaining and interpreting standards of practice.
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Performs required skills (assessment, intervention) according to guidelines, policies and procedures.
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Participates in interdisciplinary committees which influence or determine policies affecting nursing practice.
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Follow facility procedures/protocols for admitting residents transferring to hospitals/clinics/outpatient visits and completion of appropriate documentation based on established guideline.
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Makes rounds on all resident rooms and ensure that the L.P.N.’s, C.N.A.’s and/or others under his/her supervision receive their resident reports, has their assignments and break times scheduled.
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Assist the L.P.N. in establishing routines which facilitate a high level of nursing practice.
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Receives and give reports from and to outgoing and incoming shifts. Count or ensure the counting of controlled drugs with outgoing and incoming shifts.
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Coordinates/Prepares MDS schedules for quarterly, annual and significant change assessments.
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Complete MDS Booklet as per schedule (Nursing Sections).
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Reviews and signs off on all completed MDS and RAP Summary.
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Develops care plan that demonstrate knowledge of criteria to ascertain resident specific needs based on health care problem(s).
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Makes needed revisions and updates to the care plans.
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Ensures that care plan is carried out which demonstrates familiarity with criteria to establish priorities specific to anticipated outcomes.
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Monitors the provision of care for the residents in his/her assigned unit.
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Interprets philosophy and objectives of nursing service to residents, families and others.
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Identifies resident/family learning needs based on the discharge care plan as applicable and carries out appropriate teaching required.
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Demonstrates ability to coordinate and collaborate with resident/family and other members of the comprehensive health care team.
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Monitors the administration and accurate recording of medications used.
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Investigates and follow through on medication errors.
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Notifies physicians of pertinent observations and reactions, incident and abnormal laboratory and x-ray results as required and documents same promptly.
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Transcribes physician orders timely and ensure orders are implemented as appropriate.
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Reports all resident, visitor and work-related accidents/injuries and demonstrates appropriate follow through by investigating, documenting and processing incident reports.
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Accepts guidance, supervision, and criticism if needed.
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Practices in compliance with the Nurse Practice Act and regulatory agencies regulations.
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Assures that a stock level of medications, medical supplies, equipment, etc. are maintained at adequate levels at all times.
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Assume the authority, responsibility and accountability of directing your nursing shifts.
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Other responsibilities as deemed necessary and appropriate or as may be directed by the Director of Nursing Services or Administrator.
