PURPOSE OF YOUR JOB:
The primary purpose of your job position is to provide direct Nursing Care to the residents, and to supervise the day to day nursing activities performed by Nursing Assistants. Such supervision must be in accordance with current Federal, State, and Local standards, guidelines and regulations that govern the facility, and as may be required by the Director or Nursing Services of Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times.
CHAIN OF SUPERVISION:
Reports to Unit Manager, then Nursing Administration, then facility Administrator.
DELEGATION OF AUTHORITY:
As the Charge Nurse, you are delegated the administrative authority, responsibility, and accountability necessary to carry out your assigned duties.
Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position.
ESSENTIAL JOB FUNCTIONS:
ADMINISTRATIVE FUNCTIONS / PERSONNEL FUNCTIONS:
1. Direct the day to day functions of the Nursing Assistants in accordance with current rules,
regulations, and guidelines that govern Long Term Care.
2. In cooperation with all Nursing personnel, comply with the written policies and procedures
established by the facility.
3. Read and understand the Policy and Procedures of the facility.
4. Understands and participates in correcting Medical Records, Dietary, and Pharmacy Audits.
5. Develop and maintain a good working rapport with interdepartmental personnel, as well as, other
departments within the facility to ensure that Nursing Services and ancillary services can be adequately maintained to meet the needs of the residents.
6. Report occupational exposure to blood, body fluids, infectious materials, and hazardous
chemicals in accordance with the facility's policies and procedures governing accidents and incidents,
7. Cooperate with other resident services when coordinating nursing services to ensure that the
resident's total regimen of care is maintained.
8. Monitor that all Nursing Assistants are in compliance with their respective job descriptions.
9. Participate in facility surveys (inspections) made by authorized Government Agencies as may be
10. Participate in the development, maintenance, and implementation of the facility's Quality
Improvement Program for the Nursing Services Department.
11. Assists in planning the nursing services portion of the resident's discharge plan as necessary.
12. Monitor and reinforce the department's policies and procedures to personnel, residents, visitors,
and government agencies as required.
13. Admit, transfer, and discharge residents as required.
14. Perform administrative duties such as completing medical forms, reports, evaluations, studies,
charting, etc., as per policy and procedures.
15. Periodically review the department's policies, procedure manuals, job descriptions, etc. Make
recommendations for revisions.
16. Practices professional conduct and fosters cooperative relationships with coworkers.
17. Receive / give the Nursing Report upon reporting in and ending shift duty hours.
18. Attend and participate in outside training programs.
19. Attend and participate in annual OSHA and CDC In-service Training programs for hazard
communications, TB Management, and Blood Borne Pathogens standard.
20. Attend and participate in Advance Directive In-service Training programs for the staff and
21. Attend and participate in continuing educating programs designed to keep abreast of changes in
the profession, as well as, to maintain your license on a current status.
22. Must do syringe and narcotic counts at each shift change.
23. Conduct patient and environmental rounds throughout shift.
24. Informs and obtains Supervisor's approval for any anticipated overtime.
25. Make written and oral reports / recommendations concerning the activities of your shift as
required. Maintain the daily census reports.
26. Provide leadership to Nursing Personnel assigned to your unit / shift.
27. Account for prompt reporting of aides in work areas. Reports to RN Manager / Supervisor
absence or lateness at start of your shift.
28. Assist and implement with work assignments based on patient / resident acuity needs and staff's
ability to meet the needs in consideration of his / her work, training and experience.
29. Meet with your assigned nursing staff, as well as, support personnel, in planning the shifts
services, programs, and activities at the start of your shift.
30. Provide the necessary patient care to assist in meeting total plan of care.
31. Assist in completing and performing delegated aide assignments.
32. Make daily rounds of your shift / unit to ensure that nursing service personnel are performing their
work assignments in accordance with acceptable nursing standards. Report problem areas to the Nursing Supervisor with recommendations for corrective action.
33. Review complaints and grievances made or filed by your assigned personnel and report to
34. Make appropriate reports to the Supervisors as required or as may be necessary. Follow facility's
35. Meet with the shift's Nursing personnel on a regular scheduled basis to assist in identifying and
correcting problem areas and / or to improve services.
36. Participates and / or initiates 1:1 staff and patient education.
37. Participates in Nursing Assistant Performance Improvement.
38. Maintain effective team spirit and cooperative working rapport with interdepartmental personnel.
39. Create and maintain an atmosphere of mutual respect, professionalism, warmth, personal
interest, and positive emphasis as well as a calm environment throughout the unit and shift.
40. Implement and maintain established nursing objectives and standards.
41. Inform Nursing personnel of new admissions, their expected time of arrival, room assignment,
42. Monitor that rooms and equipment are ready for new admissions.
43. Greet newly admitted residents upon admission. Escort them to their rooms as necessary.
44. Participate in the orientation of new residents / family members to the facility.
45. Make rounds with Physicians as necessary.
NURSING CARE FUNCTIONS:
(Charting and Documentation)
1. Requisition and arrange for diagnostic and therapeutic services as ordered by the Physician and
in accordance to our established procedures.
2. Consult with the resident's Physician in providing the resident's care, treatment, rehabilitation as
3. Complete and file required recordkeeping forms / charts upon the resident's admission, transfer,
and / or discharge.
4. Encourage attending Physicians to review treatment plans, records and sign their orders,
progress notes, etc. in accordance with established policies.
5. Receive telephone orders from Physicians and record on the Physician Order Form.
6. Transcribe Physician's orders to Medication Administration Record (MAR) and Treatment
Administration Report (TAR).
7. Notify other Departments of new / changed physician orders following policy and procedure.
8. Checks monthly order recaps for accuracy as assigned and make correction as appropriate.
9. Notify the Supervisor and resident's attending Physician when the resident is involved in an
accident or incident.
10. Completely fill out Accident / Incident Reports. Submit to RN / Manager / Supervisor.
11. Chart all reports of accidents / incident involving residents. Follow established procedures.
12. Report all discrepancies noted concerning Physician's order, diet change, charting error, etc. to
the Nurse Supervisor.
13. Review the resident's chart for specific treatments, medication orders, diets, etc. as necessary.
14. Assist personnel providing direct care to residents in accordance with the resident's Care Plan
15. Ensure that residents who are unable to call for help and seriously ill residents are checked
16. Answer resident call bells and provide assistance as needed.
17. Monitor provision for comfort measures, positional changes and mouth care by Nursing
Assistants and assist as indicated per resident's plan of care.
18. Ensure that direct nursing care be provided by a licensed Nurse, a Certified Nursing Assistant
and / or a Nurse Aide Trainee qualified to perform the procedure.
19. Notify the resident's Attending Physician and next of kin when there is a change in the resident's
condition and write in the Integrated Notes.
20. Take and record TPR's, blood pressure, etc. in accordance with policies and procedures.
21. Obtain sputum, urine, and other specimens for lab tests as ordered.
22. Performs procedures and administer prescribed medication and treatments and promptly
23. Licensed personnel monitors Dining Room service and ensures staff are present in Dining Areas
A. Aides and nurses are assigned mealtime breaks before or after patients / residents
scheduled meal times Ensure that Aides and LPN can safely perform Heimlich maneuver as needed. Assist patients / residents with toileting, hand washing and assisted to a comfortable position
before the food arrives. D. Ensures prompt distribution of mealtime trays. E. Communicates with Aides needs to order meal substitutes or missing trays. F. Make rounds to ascertain staff performance in encouraging or assisting patients / residents
needs. G. Assist patients as indicated and ensure that meal trays are not taken away before patient /
resident is done eating. H. Maintain and updated list of NPO, thickened fluid needs and iced fresh tap water preference
and ensure compliance by Nursing Assistants. Check assistant's recording of food and fluid intake. Do systematic spot checks and end of
shift review of aide's documentation. J. Assist with feeding residents.
24. Meet with residents and / or family members as necessary. Report problem areas to the
25. Check foods brought into the facility by the resident's family / visitors to ensure that it is within the
resident's dietary allowances. Report problem areas to the Nurse Supervisor and Dietary Supervisor.
26. Cooperate with and assist in coordinating social and activity programs with nursing service
27. Check that the Nursing Restorative Program has been completed and documented by the CNA's.
28. Communicates Restorative Program and Rehabilitative Program to aides involving patients/
residents on written ambulation, dysphagia, bowel / bladder and passive or active ROM programs.
29. Follow policy and procedure for Focus and Alert Charting System.
30. Document monthly psycho-behavioral response to treatment plan as assigned.
31. Perform routine charting duties as required in accordance with established charting and
documentation policies and procedures.
32. Ensure that appropriate documentation concerning unauthorized discharges is entered in the
patient's medical record in accordance with established procedures.
33. Fill out and complete transfer forms in accordance with established procedures.
34. Assist in arranging transportation for discharged residents as necessary.
35. Ensure that discharged residents are escorted out of the facility.
36. Sign, date, and time all entries made in the resident's medical record.
CARE PLAN AND ASSESSMENT FUNCTIONS:
1. Review Care Plans daily to ensure that appropriate care is being rendered.
2. Inform the Supervisor of any changes that need to be made on the Care Plan.
3. Ensure that your Nurses' notes reflect that the Care Plan is being followed when administering
Nursing care or treatment.
4. Ensure that the CNAs refer to the resident Care Plan prior to administering daily care to the
5. Assist the RN Assessment Coordinator in completing the MDS, including the evaluation of CAAs
and Triggers and implementation of care.
SAFETY AND SANITATION:
1. Monitor your assigned personnel to ensure that they are following established safety regulations
in the use of equipment and supplies.
2. Ensure that the established departmental policies and procedures including dress codes are
followed by assigned Nursing personnel.
3. Participate in the development, implementation and maintenance of the Infection Control Program
for monitoring communicable and / or infection diseases among the residents and personnel.
4. Ensure that assigned personnel follow established infection Control procedures when isolation
Precautions become necessary.
5. Ensure that Nursing personnel follow established procedures in the use and disposal of personal
6. Participate in the development, implementation and maintenance of the procedures for reporting
hazardous conditions or equipment.
7. Ensure that all personnel use safety equipment and supplies (e.g. mechanical lifts, etc.) when
lifting or moving residents.
8. Report missing / illegible labels and MSDSs to Safety Officer or other designated person.
Ensure that all personnel performing tasks that involved potential exposure to blood / body fluids participate in appropriate in-service training programs prior to performing such tasks.
10. Ensure that an adequate supply of personal protective equipment is on hand and readily available
to personnel who perform procedures that involve exposure to blood and body fluids.
11. Ensure that work areas (i.e. nurse's station, medicine preparation room, etc.) are maintained in a
clean, safe, and sanitary manner.
12. Ensure that Resident care rooms, treatment areas, etc. are maintained in a clean, safe and
13. Ensure that assigned personnel follow established hand-washing techniques in the administering
of Nursing Care procedures.
14. Ensure that assigned personnel participate in and conduct all Fire Safety and Disaster
Preparedness Drills in a safe and professional manner.
EQUIPMENT AND SUPPLIES:
1. Recommend to the Supervisor the equipment and supply needs of the unit / shift.
2. Ensure that an adequate stock level of medications, medical supplies, equipment, etc. is
maintained on the unit / shift at all times to meet the needs of the residents.
3. Participate in the development and implementing of the procedures for the safe operation of all
Nursing equipment. Report needs to supervisor.
4. Ensure that only trained and authorized personnel operate unit / shift's equipment.
5. Monitor Nursing procedures to ensure that Nursing service supplies are used in an efficient
manner to avoid waste.
DRUG ADMINISTRATION FUNCTIONS:
1. Prepare and administer medication as ordered by the Physician and initial as soon as done.
2. Verify the identity of the resident before administering the medication / treatment.
3. Order prescribed medications, supplies, and equipment as necessary and in accordance with
4. Ensure that narcotic records are accurate for the shift.
5. Notify the Supervisor of all drug and narcotic discrepancies noted on the shift.
6. Review medication (MARs and TARs) for completeness of information, accuracy, in the
transcription of the Physician's order and adherence to stop order policies.
7. Notify the attending Physician of automatic stop orders prior to the last dose being administered.
8. Dispose if drugs and forward narcotics to the DON and in accordance with established
RESIDENT I PATIENT RIGHTS:
1. Maintain the confidentiality of all resident / patient care information.
2. Monitor Nursing care to ensure that all residents / patients are treated fairly with kindness, dignity
3. Ensure that all Nursing care is provided in privacy and that Nursing service personnel knock
before entering a room.
Ensure that all Nursing service personnel are knowledgeable of the resident's / patient's responsibilities and rights including the right to refuse treatment.
5. Review complaints and grievances made by the resident / patient and make a written / oral report
to the Supervisor indicating what action(s) were taken to resolve the complaint or grievance. Follow the facility's established procedures.
6. Report and investigate all allegations of resident / patient abuse and / or misappropriation of
resident / patient property.
7. Ensure that the resident advance directive requests are honored as directed by the attending
1. Works in all areas of the facility. 2. Moves intermittently during working hours. 3. Is subject to frequent interruptions.
4. is involved with residents, personnel, visitors, authorized agencies/personnel, etc., under all
conditions and circumstances.
5. Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.
6. Communicates with the medical staff nursing personnel and other department personnel.
7. Works beyond normal working hours and on weekends and holidays when necessary, as well as
in other positions as needed.
8. is subject to call back during emergency conditions (e.g., severe weather, evacuation, post
disaster, staffing crisis, etc.).
9. May be required to work on shifts other than the one for which hired.
10. Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well
as reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
11. is subject to exposure to infectious waste, diseases, conditions, etc., including HIV, TB, and
Hepatitis B Viruses.
12. May be subject to the handling of and exposure to hazardous chemicals.
1. Must possess a diploma from an approved practical nursing program.
1. Must be able to read, write, speak and understand the English language.
2. Must possess the ability to make independent decisions when circumstances warrant such
3. Must possess the ability to deal tactfully with personnel, residents, family members, visitors,
government agencies / personnel, and the general public.
4. Be a minimum of 18 years of age and meet state requirements for employment in health care.
5. Must possess a current, unencumbered, active license to practice as an LPN in this State.
6. Must be knowledgeable of nursing and medical practices and procedures, as well as, laws,
regulations, and guidelines that pertain to long term care.
7. Must possess leadership and supervisory ability and the willingness to work harmoniously with
and supervise other personnel.
8. Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals,
objectives, policies and procedures, etc., that are necessary for providing quality care.
9. Must be willing to seek out new methods and principles and be willing to incorporate them into
existing nursing practices.
10. Must be able to relate information concerning a resident's condition.
PHYSICAL AND SENSORY REQUIREMENTS: (With or without the Aid of Adaptive Devices)
1. Must be able to move intermittently throughout the work day.
2. Must be able to speak the English language in an understandable manner.
3. Must be able to cope with the mental and emotional stress of the situation.
4. Must possess sight/hearing senses, or use prosthetics that will enable these senses to function
adequately so that the requirements of the position can be fully met.
5. Must function independently, have flexibility, personal integrity, and the ability to work effectively
with residents, personnel, and support agencies.
6. Must meet the general health requirements set forth by the policies of this facility which include a
medical and physical examination.
7. Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and at times,
hostile people within the facility.
8. Must be able to push, pull, move and / or lift a minimum of fifty (50) pounds, to three (3) feet and
be able to pull, move, push and / or carry such weight a minimum distance of 25 feet intermittently throughout the day.
9. May be necessary to assist in the evacuation of residents during emergency