Work Hours: 40
To assure that MDS forms are accurate and timely. Such activity must be in accordance with current Federal, State, and local standards, guidelines, and regulations that governing our facility, and as may be directed by the Director of Nursing, to endure that the highest degree of total quality care is maintained at all times. There may be times you will be acting as a Charge Nurse in carrying out this function.
Experience: Must have a minimum, one (1) year experience in a hospital, skilled nursing facility, or other comparable institution, computer skills and an understanding of the MDS process. Training in rehabilitive and restorative nursing practices.
Licenses/Certification: RN License in State of Colorado. Prefer approved MDS course completion/certification.
- Assist in the day-to-day functions of the nursing activities in accordance with current rules, regulations and guidelines that govern the long -term care facility.
- Ensure that the Nursing Services procedures Manual is followed by Nursing Service Department personnel and that it reflects the day-to-day nursing care procedures used by this facility.
- Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary
- Assist the Director of Nurses in planning the nursing service portion of the residents care/discharge plan as necessary.
- Participate in surveys made by authorized governmental agencies.
- Interpret the department's policies and procedures to personnel, residents and visitors.
- Assist in the admission, transfer, or discharge residents as required.
- Monitor and report on all accidents/Incidents. Run on call as assigned by DON, schedule and facilitate all care plan reviews.
- Establish and Periodically review the residents written care plans. Participate in the updating of the residents care plan as necessary.
- Make written or oral reports/recommendations to the Director of Nursing as necessary/required concerning the operation of the Nursing Services Department.
- Complete accident and incident reports as necessary.
- Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc. in accordance with established procedures.
- Chart nurses notes in an informative and descriptive manner that reflects the care provided to the resident as well as the residents response to the care.
- Records new/changed diet orders to resident charts, MAR medication cards, treament.care plans as required.
- Assure that proper documentation concerning unauthorized discharges is entered in the resident’s medical record in accordance with established procedures.
- Report all discrepancies noted concerning physicians orders, diet change, charting error, etc. to the Director of Nursing.
- Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures.
- Sign and date all entries made in the residents medical record.
- Fill out and complete transfer in accordance with our established procedures.
- Complete all required MDS's and submit timely to state Agency.
- Participates in drills and emergency response training
- May be called in for SCC disaster response.
- Other duties as assigned.