Summary: Shift RN

The Staff Registered Nurse (RN) functions independently in performing nursing care through assessment, planning, intervention and evaluation of safe therapeutic care for patients' overt and covert needs and/or complications of treatment during his or her assigned shift. Also leads and directs ancillary members of the health care team.

Responsibilities:

*Completes appropriate written history/assessment on residents' clinical record within 4 hours of admission, including details from interviews with family, responsible parties and other nurses and physicians.

*Legibly documents symptoms that indicate risk on the clinical record; incorporates nursing diagnostic data into written assessments.

*Documents information from family, other nurses and physicians in the written assessment.

*Prepares documents reflecting knowledge of expectations included in the Minimum Data Set (MDS); contributes in an appropriate and timely manner to the MDS.

*Documents identified problems; develops and contributes to the care plan using nursing diagnosis; adds resident teaching needs and discharge planning to clinical records.

*Uses resources and involves resident and/or family when formulating a written plan of care.

*Incorporates the medical plan into the interdisciplinary plan for care.

*Updates the Kardex and care plans using nursing diagnosis and outcome criteria.

*Follows time frames when carrying out medical/nursing plan of care.

*Communicates changes and responses to care in shift report.

*Documents and sets priorities for care of residents based on need and resident preference.

*Safely performs and documents nursing interventions required by the resident assignment and consistent with scientific principles and facility policy.

*Carries out and documents medical and nursing care plans for residents; coordinates resident care activities with other members of the healthcare team.

*Responds to information or data indicating acute risk to resident; initiates and documents action to reduce or correct the risk.

*Explains tests, procedures and disease progression to resident and/or family. Instructing and informs resident or family of skills essential to understand and cope with illness and to promote optimal health or, if indicated, the discharge process; assesses and records family level of understanding on the clinical record.

*Ensures that resident is reassessed as status requires. Documents resident response to care in clinical record.

*Regularly evaluates effectiveness of nursing intervention per the intended goals; revises care plans accordingly.

*Participates in resident care conferences.

*Provides formal and informal teaching activities to promote staff education and knowledge.

*Communicates identified learning needs of others to resources able to meet learners' needs.

*Assists in orientation of new staff; shares knowledge, experiences and acts as a preceptor or mentor. Assists others in choosing nursing intervention, developing skills and applying knowledge.

*Assists in employee performance evaluation as needed.

*Is knowledgeable of, follows and directs others to follow facility policies and department procedures and nursing unit protocols.

*Administers medications safely and accurately, following existing department procedures.

*Follows infection control policies, procedures and standard precautions.

*Recognizes and communicates to proper authority any ethical and legal issues relative to patient care.

*Completes notification forms according to protocol and notifies appropriate personnel.

*Models prevention and safety principles for residents and staff. Uses mechanical equipment correctly and appropriately per the procedure manual. Detects faulty equipment and notifies appropriate person for repairs.

*Supervises delegated care based on patient acuity and abilities or limitations of health care personnel.

*Notes changing resident status that affects nursing unit staffing needs and adjusts assignments accordingly.

*Responds cooperatively to immediate staffing and/or resident care needs; assists other staff when necessary and available.

*Utilizes the steps of problems solving to resolve identified resident related problems. Acts as a staff resource to in problem identification and resolution.

*Reports unit related problems using the supervisory communications structure.

*Listens to and respects the ideas, opinions and feelings of others.

*Completes clinical assignment in a timely fashion including maintenance of equipment and supplies necessary for the provision of resident care through the next shift.

*Completes non-clinical assignments, tasks and projects within a pre-established agreed upon time frame.

*Prioritizes own workload relative to resident care needs.

*Participates in staff meetings; obtains information presented in staff meetings when unable to attend.

*Participates in nursing unit goal-setting.

*Attends all mandatory in-service programs and performs committee work as requested.

*Performs other duties within capabilities as assigned by Supervisor.

*Participates in setting measurable, individual professional goals; acquires knowledge and experience to meet goals; achieves change and growth based on evaluation and feedback

*Treats all guests, resident contacts, employees and staff with respect and courtesy. Receives, places and transfers calls using appropriate telephone etiquette.

*Handles information requests with courtesy, accuracy and respect for confidentiality.

*Respects attendance, time-off and sick call policies. Arrives to work on time and prepared to start assignment.

*Understands department and facility policies and procedures, as well as safety and security policies and performs to those standards.

*Completes mandatory safety and security education.

*Maintains Universal Precautions (Standard Precautions).

*Attends annual fire/safety and hazardous materials review.

Knowledge, Skills, and Abilities:

*Understanding of and compliance with HIPAA standards of practice and the California Nurse Practice Act.

*Utilize an Electronic Health Records system like Point Click Care (PCC)

*Able to work patients from ages 55 to 120.

*Able to work well with others and to perform a variety of assigned duties.

Education and Other Qualifications:

*Current license to practice as a Registered Nurse in the state of California.

*One year of experience in either acute care or long-term care preferred.

*Current CPR certification.

*Must complete and pass a physical examination with tuberculosis (TB) screen prior to employment.