Basic Care Nurse (LPN or RN) - Days

## Overview **RESPONSIBILITIES:** · Hardwiring Excellence. Responsible to know and adhere to evidence based leadership to achieve excellence. · Professional attitude, leadership role and team member abilities. Maintains a positive professional role throughout the facility and community. · Familiarizes self with and adheres to all facility and department safety policies and procedures. · Promotes a culture of safety to improve employee safety. · Safeguarding the privacy and security of protected health information (PHI) in any form including electronic, written or oral. · Admission assessment, completion of admission checklist, admission forms and nursing narrative. · Observes and initiates provider orders and Haaland Home standing orders, assuring documentation and protocols are observed and communicated so all aspects are carried out accurately. · Assessment of resident – monitoring for any health changes and makes referrals as needed. · Assists with initial resident care planning. Assessing health, behavior, and ADL ability, while maintaining care plan goal of highest level of independence. · Re-evaluate and updates care plans according to resident needs and adjusting for any changes. · Responsible to see that care plan is implemented and carried out in daily cares. Assists resident to maintain independence. · Assesses resident health, ADL abilities and behavior concerns of residents on admission, discharge from hospital and quarterly. · Carries out Haaland Home clinic duties and serves as clinic nurse on clinic days. · Maintains good relationship with resident and families. Contact families and updates them regarding resident care changes. · Coordinates or assists with seating arrangement in dining room. · Assists as necessary in dining room to maintain excellent of service. · Communicates resident needs with coworkers during report and throughout the shift. · Operates intercom system. · Office and departmental duties as needed and as assigned. · Administers medications and treatments as ordered by provider. · Keeps accurate record of medications administered. · Maintains cleanliness and order to medication cart. · Maintains cleanliness and order to treatment cart. Discard outdated or unused prescriptions. Order prescriptions as needed. · Maintain treatment book for current orders. Have resolved treatments discontinued. · Direct CMA’s to administer needed PRN medications and co-sign these medications that are administered. · Is observant to resident condition and/or symptoms in relation to medications the resident is receiving. · Provides oral and/or written communications to director of nursing or provider regarding any change in resident status. · Provides oral and/or written communications of any variances in medication pass as ordered. · Assess resident self-administration of medications, creams or ointments and documents appropriately. · Verbalizes knowledge of adverse reaction, drug/drug interaction and drug/food interaction. · Follows governmental regulations for administering and storing mediations, including narcotics. · Makes decisions concerning the administration of medications for comfort or bowel protocol and documents results. · Respects residents’ rights, including the right to refuse medication and the right to be informed of the consequences of that refusal. · Maintain resident medications and stock medication, and reorders as needed. · Responsible for receiving and counting medications, including narcotics. · Removal of mediations that have been discontinued, following facility policy. · Reviews and observes the resident MAR for accuracy.: · Provides guidance for staff. · Communicates with nursing personnel in and organized manner while prioritizing and coordinating residents’ needs. · Delegates responsibilities to CNAs and CMAs appropriately. · Collaborates in the development of policies and procedures. · Observes and transcribes physician orders accurately. · Communicates with other departments as nece…