PRINCIPAL RESPONSIBILITIES: A.
CLINICAL: Performs patient assessments by developing, implementing, and evaluating Patient Care Plans. •Performs treatments, administers medications, and/or implements other nursing interventions as indicated by the Patient Care Plan and/or Physician Order. Provides nursing care in accordance with infection control standards. Follows safety policies when performing nursing care. Initiates emergency measures according to Center policy and within standards of nursing practice. B.
ADMINISTRATIVE Ensures the exchange of essential information necessary for quality patient care.
Maintains all documentation as required by Federal, State, and Company and policies.
Maintains inventory of supplies and/or medications to meet patient needs.
Participates in all assigned meetings and in-services.
C.
SUPERVISORY Meets unit work goals through assignment of staff to patient care needs.
Monitors performance through coaching and praising.
Recognizes effective performance (or) takes direct corrective action after coaching/ counseling as needed Evaluates quality and quantity of patient care service accomplished by staff.
D.
CONSUMER SERVICE: Presents professional image to consumers through dress, behavior, and speech.
Adheres to Company standards for resolving consumer concerns.
Ensures that all patient rights are protected.
E.
QUALIFICATIONS: Current nursing licensure in the state of California required.
Written and verbal communication skills in English as business necessity.
Administrative and organizational abilities necessary.
Current CPR certification required.
One year of nursing experience preferred.
Supervisory experience preferred.
Requirements
STANDARD OF PERFORMANCE A.
CLINICAL: Activity: Participates in Shift Report.
Performs patient assessments: Admission; Daily; Change of condition; and Discharge.
Conducts comprehensive assessment (MDS) and initiates/updates patient plan of care.
Performs treatments as prescribed.
Passes medications as prescribed.
Follows infection control policies in performing nursing care: Hand washing; Universal precautions; and Linen handling procedures.
Follows all safety policies in performing nursing care.
Initiates and conducts emergency measures required to stabilize patient condition.
Follows Company nursing policies and procedures at all times when delivering resident care.
Measured by: Time and Attendance Records and direct observation by Director of Nursing.
Admission Checklist, rounds by Patient Care Coordinator, and review of Clinical Record Summary discharge notes.
Results of Quality Assurance Standard review by DON and completion of MDS audits and Plan of Care audits.
Quality Assurance standards outcome properly documented to Treatment Sheet and direct observation by Patient Care Coordinator.
Quality Assurance standards documented to Medication Record and direct observation by Patient Care Coordinator.
Quality Assurance Standards, direct observation by Patient Care Coordinator, and review of Infection Control Report by Patient Care Coordinator.
Review of Safety Committee Reports.
Required documentation (i.e., daily nurse's notes).
Direct observation by the Patient Care Coordinator.
B.
ADMINISTRATIVE: Activity: Communicates patient needs and change of condition to appropriate persons, i.e.
: Other shifts and patient care; Coordinator; Dietary; Activities and social services; Physicians; Responsible parties (i.e., families, conservator); Outside therapies; and Maintenance Department.
2.
Maintain all documentation (current and complete) including, but not limited to: Patient Care Plans; Nursing Progress Notes; Medication Administration Record; Treatment Records; Physician Order Sheets; Quality Assurance audits; Acuity Reports; Incident Reports; and Restorative Progress Summary.
3.
Utilizes nursing supplies as needed.
4.
Orders medications as needed and as ordered by physicians: Logs ordered and received; Removes discounted medications; and Reorder emergency medication kit.
5.
Participates in all meetings as required.
6.
Participates in all in-service as required.
Measured by: Direct observation and review by Patient Care Coordinator.
Review of appropriate documentation by Patient Care Coordinator and Medical Records audit.
Review of supply inventory and observation of patient bedside units by Patient Care Coordinator.
Review of medication storage and preparation areas, review of appropriate documentation by Patient Care Coordinator, and review of pharmacy audit.
Review of minutes, review of attendance records, and direct observation by Patient Care Coordinator.
Review of in-service records by Director of Staff Development and Patient Care Coordinator.
C.
SUPERVISORY: Activity: Assigns staff to meet patient care needs by verbal and/or written Condition Report.
Assists in providing adequate staffing by seeking replacements for current and oncoming shifts.
Uses Absentee Report forms appropriately.
Observes staff performance during patient rounds.
Coaches staff during rounds for both quality and quantity of work performance and work habits.
Demonstrates effective work habits to staff during rounds and as needed.
Praises and recognizes staff for effective performance.
Participates with Patient Care Coordinator in Progressive coaching and follow-up.
Monitors patient appearance and comfort.
Audits documentation by nursing staff.
Measured by: Review of completed Daily Assignment Sheet and direct observation by Patient Care Coordinator.
Review of documentation in Shift Log Book and verbal report.
Completed Absentee Report on file.
Resident outcome Quality Assurance tool and direct observation by Patient Care Coordinator.
Direct observation by Patient Care Coordinator.
Direct observation by Patient Care Coordinator.
Positive feedback from staff and direct observation by Patient Care Coordinator.
Review of documented Progressive Coaching Form.
Direct observation by Patient Care Coordinator and absence of complaints.
Medical Records audit.
D.
CONSUMER SERVICE: Reports for duty in approved uniform and maintains high standards of personal hygiene.
Refrains from rude and discourteous behavior toward consumers and co-workers.
Avoids the use of profanity.
Limits eating and/or smoking to designated areas.
Reports to duty promptly as scheduled (and) takes breaks only during assigned times and in designated places.
Speaks, writes, and understands English for business necessity.
Follows consumer service standards for: Making daily contact with patients; Greeting visitors; Making initial contact with newly admitted residents; Giving information to patients and visitors; Getting information from patients and visitors; Referring patients and visitors; and Handling complaints.
7.
Utilizes the telephone in accordance with consumer service standards when: Answering phones; Placing a caller on hold; Transferring a call; and Taking a message.
8.
Utilizes the paging system effectively.
9.
Monitors general patient care to identify and correct any infringement of patient rights.
Measured by: Visual inspections by Patient Care Coordinator.
Absence of complaints.
Direct observation by Patient Care Coordinator.
Direct observation by Patient Care Coordinator.
Direct observation by Patient Care Coordinator.
A combination of absence of complaints (and) periodic audit of skills by Patient Care Coordinator or other management staff.
A combination of absence of complaints (and) periodic audit of skills by Patient Care Coordinator or other management staff.
A combination of absence of complaints and periodic audit of skills by Patient Care Coordinator and other management staff.
A combination of absence of complaints and periodic audit of skills by Patient Care Coordinator and other management staff.
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