MDS Nurse

General Purpose

The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times.

Essential Duties

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Administrative Functions

• Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.

• Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.

• Periodically review the department’s policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.

• Meet with your assigned nursing staff, as well as support personnel, in planning the shifts’ services, programs, and activities.

• Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this facility.

• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual.

• Make written and oral reports/recommendations concerning the activities of your shift as required.

• Cooperate with other resident services when coordinating nursing services to ensure that the resident’s total regimen of care is maintained.

• Ensure that all nursing service personnel are in compliance with their respective job descriptions.

• Participate in the development, maintenance, and implementation of the facility’s quality assurance program for the nursing service department.

• Participate in facility surveys (inspections) made by authorized government agencies as may be requested.

• Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan as required.

• Assist in planning the nursing services portion of the resident’s discharge plan as necessary.

• Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.

• Admit, transfer, and discharge residents as required.

• Complete accident/incident reports as necessary.

• Write resident charge slips and forward to the Business Office.

• Maintain the Daily Census Report and submit to the Business Office as required.

• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.

• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.

• Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.

• Report any known or suspected unauthorized attempt to access facility’s information system.  

Charting and Documentation  

• Complete and file required recordkeeping forms/charts upon the resident’s admission, transfer, and/or discharge.

• Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.

• Receive telephone orders from physicians and record on the Physicians’ Order Form.

• Transcribe physician’s orders to resident charts, cardex, medication cards, treatment/care plans, as required.

• Chart nurses’ notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident’s response to the care.  

• Fill out and complete accident/incident reports. Submit to Director as required.

• Chart all reports of accidents/incidents involving residents. Follow established procedures.

• Record new/changed diet orders. Forward information to the Food Services Department.

• Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Nurse Supervisor.

• Fill out and complete transfer forms in accordance with established procedures.

• Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.

• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.

• Sign and date all entries made in the resident’s medical record.  

Drug Administration Functions

• Prepare and administer medications as ordered by the physician.

• Verify the identity of the resident before administering the medication/treatment.

• Ensure that prescribed medication for one resident is not administered to another.

• Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the Nurse Supervisor.

• Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.

• Ensure that narcotic records are accurate for your shift.

• Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.

• Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.

• Notify the attending physician of automatic stop orders prior to the last dosage being administered.

• Dispose of drugs and narcotics as required, and in accordance with established procedures.  

Personnel Functions

• Participate in employee performance evaluations, determining your shift’s staffing requirements, and making recommendations to the Nurse Supervisor concerning employee dismissals, transfers, etc.

• Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work.

• Report absentee call-ins to the Nurse Supervisor.

• Review and evaluate your department’s work force and make recommendations to the Nurse Supervisor.

• Develop work assignments and/or assist in completing and performing such assignments.

• Provide leadership to nursing personnel assigned to your unit/shift.

• Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Nurse Supervisor.

• Ensure that all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program.

• Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.

• Meet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services.

• Ensure that department personnel, residents, and visitors follow the department’s established policies and procedures at all times.

• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the residents.

• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.

• Review complaints and grievances made or filed by your assigned personnel. Make appropriate reports to the Nurse Supervisor as required or as may be necessary. Follow facility’s established procedures.

• Ensure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital status.

• Receive/give the nursing report upon reporting in and ending shift duty hours.

• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility’s policies and procedures governing accidents and incidents.

• Report known or suspected incidents of fraud to the Administrator. • Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.  

Nursing Care Functions

• Inform nursing personnel of new admissions, their expected time of arrival, room assignment, etc.

• Ensure that rooms are ready for new admissions.

• Greet newly admitted residents upon admission. Escort them to their rooms as necessary.

• Participate in the orientation of new residents/family members to the facility.

• Make rounds with physicians as necessary.

• Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.

• Consult with the resident’s physician in providing the resident’s care, treatment, rehabilitation, etc., as necessary.

• Review the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.

• Implement and maintain established nursing objectives and standards.

• Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident’s physical and emotional status.

• Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and/or a nurse aide trainee qualified to perform the procedure.

• Cooperate with and coordinate social and activity programs with nursing service schedules.

• Notify the resident’s attending physician when the resident is involved in an accident or incident.

• Notify the resident’s attending physician and next-of-kin when there is a change in the resident’s condition.

• Carry out restorative and rehabilitative programs, to include self-help and care.

• Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.

• Administer professional services such as; catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required.

• Use restraints when necessary and in accordance with established policies and procedures.

• Obtain sputum, urine and other specimens for lab tests as ordered

• Take and record TPRs, blood pressures, etc., as necessary.

• Monitor seriously ill residents as necessary.

• Check foods brought into the facility by the resident’s family/visitors to ensure that it is within the resident’s dietary allowances. Report problem areas to the Nurse Supervisor and Dietary Supervisor.

• Ensure that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.

• Ensure that residents who are unable to call for help are checked frequently.

• Meet with residents, and/or family members, as necessary. Report problem areas to the Nurse Supervisor

• Admit, transfer and discharge residents as necessary.

• Assist in arranging transportation for discharged residents as necessary.

• Ensure that discharged residents are escorted to the pick-up area.

• Inform family members of the death of the resident.

• Call funeral homes when requested by the family. Ensure that established post-mortem procedures are followed.

Staff Development

• Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on “how to do the job,” and ensure a well-educated nursing service department.

• Implement and maintain an effective orientation program that orients the new employee to your shift, its policies and procedures, and to his/her job position and duties.

• Assist in standardizing the methods in which work will be accomplished.

• Assist in training department personnel in identifying tasks that involve potential exposure to blood/body fluids.

• Assist the Director in planning clinical supervision for nurse aide trainees.

• Attend and participate in outside training programs.

• Attend and participate in annual facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.).

• Attend and participate in advance directive in-service training programs for the staff and community.

• Attend and participate in continuing education programs designed to keep you abreast of changes in your profession, as well as to maintain your license on a current status.  

Safety and Sanitation

• Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies.

• Ensure that established departmental policies and procedures, including dress codes, are followed by your assigned nursing personnel.

• Assist the Director and/or Infection Control Coordinator in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks in which there is potential exposure to blood/body fluids are properly identified and recorded.

• Ensure that all personnel performing tasks that involve potential exposure to blood/body fluids participate in appropriate in-service training programs prior to performing such tasks.

• Ensure that an adequate supply of personal protective equipment are on hand and are readily available to personnel who perform procedures that involve exposure to blood or body fluids.

• Ensure that your assigned work areas (i.e., nurses’ stations, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner.

• Ensure that your unit’s resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner.

• Ensure that your assigned personnel follow established handwashing and hand hygiene technique in the administering of nursing care procedures.

• Ensure that your assigned personnel participate in and conduct all fire safety and disaster preparedness drills in a safe and professional manner.

• Participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel.

• Ensure that your assigned personnel follow established infection control procedures when isolation precautions become necessary.

• Ensure that nursing personnel follow established procedures in the use and disposal of personal protective equipment.

• Participate in the development, implementation and maintenance of the procedures for reporting hazardous conditions or equipment.

• Ensure that all personnel wear and/or use safety equipment and supplies (e.g., back brace, mechanical lifts, etc.) when lifting or moving residents.

• Report missing/illegible labels and MSDSs to the safety officer or other designated person.  

Equipment and Supply Functions

• Recommend to the Nurse Supervisor the equipment and supply needs of your unit/shift.

• Ensure that an adequate stock level of medications, medical supplies, equipment, etc., is maintained on your unit/shift at all times to meet the needs of the residents.

• Participate in the development and implementation of the procedures for the safe operation of all nursing service equipment.

• Ensure that only trained and authorized personnel operate your unit/shift’s equipment.

• Ensure that all personnel operate nursing service equipment in a safe manner.

• Monitor nursing procedures to ensure that nursing service supplies are used in an efficient manner to avoid waste.

• Ensure that appropriate MSDSs are on file for hazardous chemicals used in the nursing service department.  

Care Plan and Assessment Functions

• Review care plans daily to ensure that appropriate care is being rendered.

• Inform the Nurse Supervisor of any changes that need to be made on the care plan.

• Ensure that your nurses’ notes reflect that the care plan is being followed when administering nursing care or treatment.

• Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.

• Ensure that your assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNAs refer to the resident’s care plan prior to administering daily care to the resident.

• Assist the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising the MDS, including the implementation of RAPs and Triggers.  

Budget and Planning Functions

• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.  

Miscellaneous

• Provide data to the Quality Assurance & Assessment Committee as requested.  

Supervisory Requirements

As LPN / LVN you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Qualification

Education and/or Experience

Must possess, as a minimum, a Nursing Degree from an accredited college or university, or be a graduate of an approved LPN/LVN program.

Must possess a current, unencumbered, active license to practice as an LPN/LVN in this state.

Language Skills

Must be able to read, write, speak, and understand the English language.

Ability to read technical procedures.  

Ability to read and comprehend policy and procedure manuals.  

Ability to effectively present information and respond to questions from managers and employees.

Must be able to relate information concerning a resident’s condition.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability

Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.

Must be a supportive team member, contribute to and be an example of team work and team concept.

Must possess the ability to make independent decisions when circumstances warrant such action.

Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.

Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.

Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.

Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.

Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.

Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.

Must not pose a direct threat to the health or safety of other individuals in the workplace.

Certificates, Licenses, Registrations

Must possess a current, unencumbered, active license to practice as an LPN/LVN in this state.

Current CPR certification.

Knowledge and experience with PCC preferred.  

Must maintain all required continuing education/licensing.  

Must remain in good standing with the State Board of Nursing at all times.

Physical Demands

Must be able to move intermittently throughout the workday.

Must be able to speak and write the English language in an understandable manner.

Must be able to cope with the mental and emotional stress of the position.

Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.

Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.

Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination.

Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.

Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.

May be necessary to assist in the evacuation of residents during emergency situations.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.). Moves intermittently during working hours. Is subject to frequent interruptions. Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances. Is subject to hostile and emotionally upset residents, family members, personnel, and visitors. Communicates with the medical staff, nursing personnel, and other department directors. Works beyond normal working hours, and in other positions temporarily, when necessary. Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.). Attends and participates in continuing educational programs. Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants. Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses. May be subject to the handling of and exposure to hazardous chemicals. Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.

Additional Information

Note: Nothing in this job specification restricts management’s right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons.  The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position. 

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.