RN/Charge Nurse

Responsible for ensuring continuity of care by providing direct care as well as supervising the care given by CNAs, LVNs, RNs and support staff members. Communicates with physicians and health team about changes in patient’s clinical condition including, results of diagnostic studies and symptomology and is able to respond quickly and accurately to changes in condition or response to treatment. Participates in Quality Improvement activities. Assesses, plans, implements and evaluates the nursing care of residents within the skilled nursing setting. Maintains role as resident advocate with a focus on the facility’s mission.

• Assesses residents on admission and when conditions change. Documents include resident care plans, restraint assessment tools, fall assessments, behavior logs, wander assessments, pain assessments, skin assessments, safety assessments, nursing progress notes, physician orders, and interdisciplinary notes.
• Ability to adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the residents and family regarding pain management. Update primary care physician if current plan is ineffective.
• Assesses the unit’s needs and formulates a daily plan with staff and support staff to maintain smooth daily operations.
• Assures care plans are updated with changes in resident’s health, mobility, safety, psychosocial, behaviors and medications.
• Reviews and assesses intake/output, nutritional intake, weights, wounds, and other resident quality monitors. Notifies physician, director of nursing, dietitian, and/or pharmacist as needed.
• Ability to fill in as medication nurse when needed.
• Review/Update resident care plans monthly and as needed.
• Assure support staff complete daily requirements, such as, documentation of vital signs, weights, showers, alert charting, weekly summaries, meal percentages, behavior logs, and wander/fall assessments.
• Notifies physician of changes in resident’s condition and follows through until appropriate action is taken. This includes weight loss, nutritional concerns, and falls.
• Notes and conducts physician’s orders in a timely manner.
• Obtain a morning report from nursing staff. Assured follow-through is completed regarding resident concerns.
• Assure diagnostic and laboratory physician orders are followed through.
• Attend stand-up, psychotropic drug review, MERP, nutrition at risk and fall program meetings to provide unit input.
• Treats residents and their families with respect and dignity. Identifies and addresses the psychosocial, cultural, ethnic, and religious/spiritual needs of residents and their families.
• Supervises other members of the healthcare team, as needed, to accomplish the plan of care which has been developed.
• Demonstrates competence in technical and manual skills, according to the scope of practice for RNs.
• Functions as a resident advocate by protecting the resident’s rights.
• Administers medications, following the six medication rights and reduces the potential for medication errors.
• Perform daily walking rounds of unit with director of nursing when available.
• Serve as a clinical resource to unit staff on issues pertaining to resident’s plan of care.
• Communicate with mental health coordinator, staff, physicians, director of nurses, unit staff, activities coordinator and social service designee as appropriate about changes in resident/patient’s clinical/psychosocial condition including results of diagnostic studies and symptomatology.

• Current California RN license with minimum two (2) years prior experience in a long-term care facility with working knowledge of Title 22, OBRA and other regulations with operating knowledge of Electronic Medical Records preferred.
• Must pass nursing medical test and have current BLS certification.
• Must be able to effectively communicate in English; both verbal and written.
• Must have good interpersonal skills and interface professionally, tactfully and respectfully with residents, patients, staff, general public and governmental agency reps.
• Basic computer skills required.