Work Unit Overview: A Registered Nurse (RN) or Licensed Practical Nurse (LPN) provides nursing and nursing related services to residents consistent with each resident's comprehensive assessment and plan of care. All resident care is provided in a manner that meets the resident's physical, mental, psychosocial needs and enables the individual to attain or maintain the highest practicable level of functioning. The charge nurse provides supervision of health care personnel in maintaining a "homelike” environment for the residents, protects and promotes resident rights, assists the resident to maintain independence and control over one’s health to the greatest extent possible.
Job Summary: RN/LPN assesses resident health concerns and needs, develops and implements nursing care plans, and maintains necessary medical records. Duties include administering nursing care and medication management to ill, injured, convalescent, Skilled or disabled patients. May also advise residents on health maintenance and disease prevention or provide case management. An RN/LPN oversees the work of other health care personnel as required by the facility.
- Direct and supervise nursing assistants/residential aides and other healthcare personnel to ensure proper performance of duties according to health care standards, state operations manual, departmental policies as well as county policy.
- Manages admissions and discharges according to facility policy.
- Ensures proper staffing ratios based on acuity and daily needs. Takes necessary steps to acquire needed staff on a shift to shift basis.
- Consult and coordinate with healthcare team members to assess, plan, implement, or evaluate patient care plans and modifies treatment plans as indicated by residents' responses and conditions.
- Order, interpret, and evaluate diagnostic tests to identify and assess resident's condition. Monitor all aspects of resident care, including mental, emotional and physical activity. Communicate changes in resident condition with Providers on a regular basis.
- Monitor, record, and report symptoms or changes in residents' conditions. Maintain accurate, detailed reports and records, and record all medical information, behaviors and changes in condition in progress notes. Notify families of all significant changes for better or worse.
- Instruct individuals, families, or other groups on topics such as health education, disease prevention and contribute to developing ongoing health improvement programs.
Administer prescribed medications: noting times and amounts on residents’ charts; take and records temperatures, pulses, respiration, and blood pressure readings; transcribe written physicians' orders to medication and treatment records; observe and report resident's symptoms to a Provider.
- Observe residents, charting and reporting changes in conditions, such as adverse reactions to medication, vaccines or treatment, and taking any necessary action.
- Provide basic resident care or treatments, such as changing/treating wounds, treating pressure injuries, giving enemas/suppositories, massage or performing catheterizations. Sterilize equipment and supplies appropriately.
- Assist physicians or other nurses in examinations or special procedures, provides general resident care; such as bathing, feeding, turning, and transporting patients; assist with or applies and/or changes dressings; may assist in orthopedic care as needed.
- Answer resident call lights and determine how to assist residents in a timely fashion.
- Measure and record residents' vital signs, such as height, weight, temperature, blood pressure, pulse, and respiration.
Work as part of a health care team to assess resident needs, plan and modify care, and implement interventions on an ongoing basis.
Collect samples, such as urine, stool or sputum from resident, and perform basic laboratory tests on samples if indicated.
Communicate with other health care facilities or ancillary services regarding resident care needs. Prepare residents and assist with administering or explaining examinations, tests, or treatments and procedures.
- Strong clinical skills for resident population. Assemble and use equipment, such as respiratory needs and oxygen supplies.
- Comply with established department/facility policy and procedure objectives, quality assurance, safety, supply inventory and utilization regulations, environmental and infection control.
- Monitor and manage all screening at the front door as well as COVID compliance issues and policies within the facility.
- Perform RAPID/STATE COVID testing and monitor testing on staff, residents, vendors, visitors and volunteers.
- Stay current on facility policies and procedures.
- Able to express self adequately, accurately in written and/or oral communications, (including clinical records) with direct care staff, interdisciplinary team members, administration, government officials.
- Knowledge of emergency and disaster procedures of the facility. Able to locate emergency exits, fire doors, EOP and perinate valve shut offs. Able to lead incident command operations as needed or until Leadership team arrives.
- Provide excellent customer service to residents, families, providers, volunteers and vendors.
- Reports relevant information to DON and/ or proper chain of command.
- Provides expert, day to day guidance, consultation and leadership. Bringing the nursing team together with good communication and clear expectations.
- Performs other duties as assigned.
Must be a graduate from an accredited nursing school and have at least one year of experience in LTC care setting (preferred.) Possession of a valid Montana license as a RN/LPN.
Current CPR certification required.
Must maintain a good citizen court record free of abusing, neglecting or mistreating individuals in a health care related setting.
The job requires freedom from illegal use of drugs and freedom from use and effects of drugs and alcohol in the workplace.
Persons who have been found guilty by a court of law of abusing, neglecting or mistreating individuals in a health care setting are ineligible for employment in this position.
Must pass a background check.
This job requires knowledge of RN/LPN nursing theory and practice, LTC rules, regulations and procedures; medical vocabulary commonly used in conveying instructions and orders between doctors, nurses, and para-professional nursing employees; and medical supplies and equipment, their care and use.
This job requires knowledge of patient rights and confidentiality requirements of patient information and established communications codes; basic communicable disease; infection control practices and procedures; basic emergency care including cardiopulmonary resuscitation (CPR); the use, administration, and effects of narcotics and medicines, as well as behavioral patterns of suspected alcoholic, narcotic, and emotionally disturbed individuals. This job requires the ability to perform physical assessments; take health histories; assess and review lab results; provide primary nursing care; detect suicidal behavior; follow oral and written directions of nursing technical and professional nature; work as part of a team; deal with patients sympathetically and tactfully; maintain and interpret medical records and reports; learn procedures to start; stand and walk for long periods and work under mental and physical strain; establish and maintain effective working relationships with people on the job cooperate with other personnel to achieve departmental objectives and maintain effective employee, interdepartmental and public relations; maintain patient rights and confidentiality of patients information and abide by established communications codes.