Summary

The primary purpose of your job position is to assist the Director of Nursing in planning, organizing, developing, and directing the day-to-day functions of the Nursing Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator, the Medical Director,and/or the Director of Nursing, to ensure that the highest degree of quality care is maintained at all times. MDS 3.0 Certification REQUIRED

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation of CAA’s.
• Assist in developing methods for coordinating nursing services with other resident services to ensure that the resident’s total regimen of care is maintained.
• Participate in facility surveys (inspections) made by authorized government agencies as requested by the Administrator or Director of Nursing.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
• 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.
• Track resident Medicare information pertinent to days, assessments, etc.
• Transmit MDS information in an efficient and timely manner.
• Monitor QM’s and assist in audits to assure quality resident care.
• Ensure certification/re-certification of Skilled Services forms are signed timely.
• Serve on, participate in, and attend various committees of the facility (i.e., Infection Control, Policy Advisory, Pharmaceutical, Budget, Quality Assurance and Assessment, etc.) as required, and as appointed by the Administrator and/or Director of Nursing.
• Participate in regularly scheduled Medicare meetings.
• Evaluate and implement recommendations from established committees as they may pertain to the assessment and/or care plan functions of the facility.
• Maintain an effective friendly working relationship with health professionals, physicians, consultants, and governmental agencies that may be involved in the resident assessment/care plan functions of the facility.
• Meet with and solicit advice from department supervisors concerning the resident assessment/care plan functions of the facility.
• Conduct or coordinate the interviewing of each resident for the resident’s assessment.
• 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.
• Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Director of Nursing.
• Provide direct nursing care as necessary.
• Sign and date all entries made in the resident’s medical records.
• Make appropriate reports to the Director of Nursing as required or as may be necessary. Follow facility’s established procedures.
• Assist the In-service Trainer in developing any training activities needed concerning resident assessment/care plan skills.
• Attend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and blood borne pathogens standard.
• Attend and participate in continuing education programs designed to help you keep abreast of changes in your profession, as well as to maintain your license on a current status.
• Ensure that all assigned work areas (i.e., nurses’ stations, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner.
• Ensure that personnel follow established infection control procedures when isolation precautions become necessary.
• 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.
• Participate in the development and implementation of the procedures for the safe operation of all nursing service equipment.
  *Participate in the development of a written care plan (preliminary and comprehensive) for each resident that identifies the problem/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible of each element of care.
• Ensure that an initial resident assessment is completed within fourteen days of the resident’s admission.
• Ensure that a comprehensive care plan is completed within twenty-one days of the resident’s admission.
• Ensure that a complete resident assessment is conducted within fourteen days of a significant change in the resident’s condition.
• Ensure that each portion of the assessment is signed and dated by the person completing that portion of the MDS.
• Meet with residents, and/or family members, as necessary. Report problem areas to the Director of Nursing.
• Sign and date the assessment instrument to certify its completion.
• Maintain the confidentiality of all resident care information.
• Ensure that all residents are treated fairly, and with kindness, dignity, and respect.
• Report all allegations of resident abuse and/or misappropriation of resident property.
• Participate in educational in-service opportunities.
• Other duties may be assigned.
  h2. Skills/Abilities:
• Excellent verbal/written communication skills.
• Excellent organizational skills.

Education/Experience:

• Valid RN license
• MDS 3.0 Certification REQUIRED
• 2 years of experience or more with expertise with PDPM Patient Driven Payment Model and ROP Requirements of Participation

Physical Requirements:

The Americans with Disability Act prohibits discrimination against a qualified individual with a disability. To be qualified for this position an individual must meet the above-mentioned standards and/or be able to perform the essential functions.