Maintains standards of nursing care and implements policies and procedures of the facility and nursing department. Manages the interdisciplinary team process including development of the care plan based on completed Minimum Data Set (MDS) to assure regulatory compliance and address special needs of each resident.
• Maintains current knowledge and skills with respect to Title 22, OBRA, nursing procedures, and computer technology.
• Responsible for the Resident Assessment Instrument (RAI), admission process for new residents, and for initiating the discharge planning process.
• Institutes and helps to maintain resident care plans by utilizing the MDS, Resident Assessment Protocols (RAP), and computerized care planning program.
• Schedules initial, quarterly, and significant change Minimum Data Sets for each resident. Maintains calendar of interdisciplinary care team. Communicates with residents and families regarding care planning meetings and encourages families, responsible parties, and residents to attend and participate in the care planning process.
• Coordinates with Nurse Manager to assess if a change of resident condition has occurred and initiates a new assessment.
• Assesses each resident quarterly and annually. Completes the manual and computerized nursing assessment sections of the MDS. Initiates “Fall Assessment” protocol and verifies completion.
• Assesses triggered items on the MDS and makes decision to maintain or delete triggered items. Using the information gathered evaluates and develops Resident Care Plans.
• Based on nursing diagnostic indicators and input from RN staff, assesses additional resident needs to be included in the Care Plan. Using the information gathered, evaluates and develops Resident Care Plans.
• Manages the interdisciplinary team process and facilitates weekly meetings; coordinates interdisciplinary staff completion of MDS, Care Plan, and progress notes; verifies that each interdisciplinary member completes a care plan based on assessment and problems triggered by MDS.
• Communicates with physicians regarding resident care plans and obtains signature on the plan.
• Monitors nursing notes on a routine basis to verify that Resident Care Plan is correctly reflected in documentation.
• Monitors special needs of residents on psychoactive drugs, fall prevention program, turning, and toileting schedules. Verifies that all disciplines are care planned appropriately, all approaches considered, and documentation complete.
• Educates RN staff in the care planning process by reviewing MDS form. Mentors RN staff during collection of nursing data and reviews completed form.
• Writes Care Area Assessment (CAA) for residents triggered by MDS after review of Care Plan.
• Performs related work as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED TO PERFORM ESSENTIAL JOB FUNCTIONS:
Demonstrated interpersonal, verbal, and written English communication skills. Interpersonal skills to establish and maintain good working relationships among unit personnel, other departments, and medical staff. Sensitivity to and understanding of issues related to aging. Patience and tact in dealing with residents, personnel, and visitors. Knowledge and skill to coordinate a diversity of components into one comprehensive project. Leadership skills to motivate staff. Thorough knowledge of current nursing theory and practice. Knowledge of Title 22 and OBRA Regulations. Proficient with Microsoft Office suite of products (Word, Excel, Outlook) and the ability to quickly learn other software applications. Judgment in order to make assessments regarding nursing practices and medical conditions. Physical skills and ability to perform work that requires continual standing, walking, stooping, bending, and lifting up to 50 pounds.
Graduation from an accredited school of nursing and licensure to practice as an RN in the State of California. Bachelor degree preferred. Minimum of two (2) years nursing experience. Supervisory responsibility and experience in a geriatric setting preferred. Basic Life Support Certification required.
May provide direction to CNAs and/or LVNs. May act as supervisor in absence of Nurse Manager