The charge nurse is responsible for the supervision of the total nursing activity of a specified area during the tour of duty. Delegates responsibility to nursing personnel for the direct care of specific residents on the basis of psychological, social, spiritual, and physical needs to obtain maximum utilization of staff time and abilities. Insure that each resident receives treatment, medications, diet, and other therapies as prescribed. Plan and supervise rehabilitative and restorative programs, in conjunction with the DON, specific for each resident so they may reach their maximum level of function. Define and implement preventative measures to guard against accidents, injury, deformities, decubitis, and infections. Maintain harmonious relationships with ancillary personnel and the residents. Attend educational classes to better analyze residents and staff, and report to director of nursing and the primary physician. Record all observations, medications, and treatments accurately, concisely, and completely in the medical record. Actively participate on committees to gain knowledge and share information which may facilitate improved resident care.
DUTIES AND RESPONSIBILITIES:
- Receive and give report at the beginning and end of each shift. Relate pertinent information, changes in resident’s conditions, new orders, and evaluate resident’s care needs for planning assignments.
- Assign medication to nurse, assign groups to nursing assistants, and monitor and coordinate assignments to make certain they are completed.
- Count narcotics at the beginning and end of each shift with the in coming nurse and sign the narcotic count book. Administer and chart medications as ordered, perform accu checks and record the results in the MAR, and know the reason for administration of medication, route of administration, desirable and adverse effects, and observe resident’s reaction.
- Supervise tray service in the dining room and in resident rooms. Observe eating habits and assist with serving and feeding residents.
- MEDICAL RECORDS
- Properly obtain and document physician orders after complete transcription of orders. Transcribe new orders into the MAR, TAR, dietary slips, and complete proper documentation of lab orders. Accurate, complete, and concise problem oriented charting based on resident care plan, and according to charting schedule in conjunction with policy and procedure. Complete weekly nursing summaries, and supervise nursing assistants in charting on ADL flow sheets. Complete nursing assessment on new residents.
- NURSING CARE
- Designate assignments to CNAs and supervise and evaluate performance on a daily basis. Assist with orientation of new employees, and teach and observe procedures of employee.
- Transcribe accurately and completely all orders onto the MAR, TAR, dietary forms, and lab book. Document any changes in resident condition or medications/treatments in nursing notes and notify the resident’s physician and family. Arrange transfer and transportation of resident if necessary and fill out appropriate forms.
- Notify family of condition changes, accidents, or incidents. Interpret plan of care and treatments to family as needed, and encourage participation in the plan of care. Be attentive to family complaints and concerns. Always be polite and helpful.
- Attend in service classes, staff meetings, and continuing education courses when offered.
SET A POSITIVE EXAMPLE FOR THE REST OF THE STAFF. BE NEAT, CLEAN, COURTEOUS, AND PROFESSIONAL AT ALL TIMES.
- Graduate of an approved school of nursing.
- Current license of good standing in Indiana.
- Evidence of good health, grooming, maturity, and emotional stability.
- Possess leadership and organizational abilities.
- Have genuine interest and concern for the long term residents with emphasis on restorative and rehabilitation nursing.
- Desire and interest to continue to study, learn, and grow as a professional person.
- Ability to communicate well and establish good interpersonal relationships.
- Direct supervision of certified nursing assistants.
- Direct supervision of medication personnel, if applicable
Certified Nursing Assistant (CNA)
Will assist nursing by giving direct resident care and help to meet the social, psychological, spiritual, and physical needs of the resident and assist the resident to utilize restorative and rehabilitative nursing principle to restore and maintain the resident’s maximum level of function.
Complete assignments in a correct, efficient manner. Recognize changes in the resident and report them to the charge nurse.
Learn procedures necessary to the care of each resident.
Keep technical information and general knowledge up to date through attendance of in services. Foster self-respect and self-esteem in each resident, as well as themselves, by consistent and sincere acceptance, kindness, and understanding of those entrusted to his/her care.
DUTIES AND RESPONSIBILITIES:
- Receive report and assignment at the beginning of each shift from the charge nurse. Report to the charge nurse during the course of the shift any changes in resident condition: physical, mental, and/or behavioral. Complete the work assignment efficiently and correctly. Report to the charge nurse at the end of the shift the general overall condition of the resident, and level of function. Work hall/group assigned.
- Attend to all activities of daily living needs that the resident is unable to complete for themselves, such as bathing, dressing, grooming, eating, and ambulation. Assist or supervise ADL function for activities the resident is able to perform for their self. This includes care of hair, teeth, nails, etc. Attend to these needs throughout the shift. Assist resident to and from therapies and activities as needed. Encourage and enforce restorative programs.
- Perform special procedures as assigned by the charge nurse specific o a resident such as tpr, intake and output, catheter care, urine/stool specimens, weights, use of cane/walker, side rails on bed, and demonstrate knowledge and ability to apply restraints properly.
Express knowledge of all transfer techniques, proper body positioning of resident, as well as proper body mechanics for yourself and the resident.
- Know how to use, care for, clean, and disinfect equipment. Know how to take proper care of residents environment (room), personal belongings (closets, drawers kept organized), and how to assist with general cleaning of utility and services areas as assigned.
- Record all AOL, special procedures, and effect or results on restorative programs and resident daily record, restraint record, or bladder and bowel record. Update weekly summary of restorative progress. Add any belongings to inventory that the family brings in after initial admission.
- Express knowledge of all safety measures and precautionary techniques to prevent and inhibit accidents, injury, and infection.
- Express knowledge of the Fire and Disaster Evacuation Procedures, location of fire extinguishers, and how to use them correctly.
- Attend in services as scheduled. All CNAs must have 12 hours per year of continuing education. Knowledge of personnel policies and resident care policies and procedures is required. Assist with orientation of new personnel. Attend all scheduled staff meetings.
- Assist charge nurse as directed.
- Refer all questions by family members or visitors regarding resident condition, care, or needs to charge nurse.
- Must have satisfied the requirements of the state of Indiana and successfully completed a 105 hour basic nursing assistant class. Must be certified by the Indiana State Board of Health.
- High school education or equivalent preferred but not absolutely necessary.
Good physical condition, emotional maturity, and exhibit ability to lift and transfer residents.
- Kind, courteous, and sincere interest in caring for the residents in long term care.
- Willing to learn and grow personally and professionally.
- Working congenially with others; able to communicate effectively with others and take direction.
- Family obligation must not be a hindrance to the stability of service.
- Holds certificate for CNA or one year experience prior to July 1986.