PT Overnight LPN/RN
PURPOSE OF THIS POSITION
Under general supervision of the Director of Nursing, the Charge Nurse directs the provision of
resident care services for a particular shift and/or unit and supervises the nursing staff assigned
to that unit/shift, with responsibility and accountability for assuring that quality nursing care and
service to facility residents/families, with compliance with applicable laws and regulations, and
adherence to company policy/procedure occur on that unit/shift. Performs direct nursing services
to residents, in accordance with individual plans of care and physicians’ orders. Technical
assistance, professional guidance, and quality monitoring are provided by Administrator, Director
of Nursing, other nursing professionals on staff and Medical Director.
PRIMARY JOB RESPONSIBILITES
The primary functions and responsibilities of this position are as follows. Additional duties may
be added as necessary to meet the needs of the facility. You will be evaluated on your ability
to perform these functions competently with minimal supervision and/or reminders.
1) Follow established standards of nursing practices and implement facility policies and
procedures.
2) Assumes responsibility for unit/shift staff compliance with rules, regulations, standards
of practice and facility policy and procedure; assures that residents receive needed
nursing care and services on that shift, according to plans of care and physicians’
instructions.
3) Interpret existing policies and procedures, rules and regulations to nursing assistants,
restorative nursing assistants, residents, families, physicians and agency personnel.
4) Supervise and evaluate all direct resident care and initiate corrective action as
necessary.
5) Document resident care provided and resident’s response or lack of response to care
provided.
6) Obtain report from nurse being relieved and record sufficient information to implement
appropriate follow-up action as necessary.
7) Provide report to nurse coming on duty, including sufficient information for follow-up
action as necessary.
8) Take appropriate action to assure adequate staffing to meet resident’s needs.
9) Conduct resident rounds daily, reporting problems to nursing supervisor and initiating
corrective action.
10) Identify resident problems and emergency situation and intiate emergency care and
“life-saving” measures in the absence of a physician.
11) Provide supervision to Nursing Assistant providing direct resident care.
12) Follow staffing guidelines and make nursing assignments according to qualifications
of staff and characteristics of the resident population.
13) Plan daily work assignments and schedule based on residents’ needs and available
resources, effectively communicate to unit/shift staff, DON, and care staff, and monitors
staff compliance with assignments and schedule.
14) Counsel and monitor staff’s work behavior and performance of assigned duties and
recommend disciplinary action to the DON, when necessary.
15) Participate in the employee evaluation process by providing information on the
performance of unit/shift staff.
16) Administer and document direct resident care, medications, external/parenternal
nutritional and treatments per physicians’ orders and accurately record all care
provided; administer or approve administration of PRN medications and treatments.
17) Provide instruction and corrective re-instruction of staff concerning quality of care and
quality of life issues, and customer service/positive image issues.
18) Perform and document comprehensive assessment of residents, or parts of
comprehensive assessments, as assigned.
19) Develop and implement an accurate comprehensive care plan based on each resident’s
needs and his/her comprehensive assessment.
20) Utilize head-toe assessment in completing assessments.
21) Promptly report changes in residents’ conditions to the physician, Director of Nursing and
responsible party, according to regulations and facility policy, and take follow-up action
as necessary.
22) Follow facility admission procedures and regulations and communicate resident
admission to other departments, physicians and ancillary service providers.
23) Competently perform basic nursing skills.
24) Check meal trays and nourishment to ensure proper diet is served and residents are
assisted as necessary.
25) Supervise the application and removal of all restraints and devices used to position and
enable residents to function as independently as possible.
26) Order, receive and store medications appropriately.
27) Monitor/control administration of medications according to applicable regulations.
28) Notify physician, when necessary, of changes in residents’ conditions, weight,
medication errors, medication not avaiable, abnormal laboratory/X-Ray results and any
other unusual observations.
29) Document resident progress notes as required.
30) Document daily notes on unstable residents, Medicare residents and rcently admitted
residents.
31) Follow facility discharge/transfer procedure and coordinate discharge/transfer with other
departments, physicians and ancillary service providers.
32) Complete documentation related to the resident’s discharge/transfer.
33) Supervise response to resident’s call for assistance.
34) Listen to resident, family, or physician concerns and initiate corrective action and/or
report concerns to the DON.
35) Receive, investigate, and resolve or report to higher authority concerns from residents
and/or families in accordance with positive customer relations principles.
36) Be responsible for the safety of the residents under his/her supervision.
37) Count narcotics, check emergency kits and exchange keys.
38) Identify staff needs for training and report to the DON and assist as directed.
39) Monitor condition of equipment, supplies, and space; report needs to DON and suggest
solutions.
40) Maintain cooperation and coordination between nursing personnel and other facility
departments in order to provide quality care, quality of life and clean, safe comfortable
surrounding for the residents.
41) To assure resident safety
42) Recognize your role as part of the QAPI efforts of your organization
43) Attend trainings to build understanding and capacity to undertake QAPI work
44) Carry out QAPI roles and responsibilities as assigned
45) Follow established policies and procedures in support of QAPI efforts
46) Look for and share with leadership ideas for improvement in the organization
47) Communicate to leadership upon witnessing a positive outcome of a QAPI project or detecting
barriers preventing project success
48) Support QAPI efforts both verbally and non-verbally (i.e., via actions and attitude), including
adjusting performance and practice in accordance with QAPI initatives and findings.
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED
1) Observe and abide by all HIPPA rules and regulations to ensure that personal health
information is protected during its collection, use, disclosure, storage and destruction,
and to ensure only the minimum necessary information is known to function in this
position.
2) Maintain strict confidentially of resident, employee and other facilty business
information.
3) Assume responsibility and function as an in-house expert on compliance with federal,
state, local regulations and professional code of ethics governing nursing service within
the assigned unit.
4) Consistently work cooperatively with residents, nursing staff, physicians, families,
consultant personnel, community agencies and ancillary service providers.
5) Identify safety hazards and initiate corrective action immediately.
6) Follow, supervise and evaluate implementation of the Residents’ Rights Program.
7) Participate in facility education programs.
8) Attend and participate in staff meetings, interdisciplinary team meetings, rehabilitation
meetings, in-service classes, and committee meetings.
9) Obtain continuing education as related to long term care as required to maintain
licensure.
10) Observe all facility safety policies and procedures.
11) Come to work in a clean, neat uniform and consistently present an appropriate
professional apprearance.
12) Come to work as scheduled and consistently demonstrate dependability and
puntuality, complies with Attendance Policy.
13) Assume accountability for data contained in the employees’ handbook.
14) Accept and perform all duties, instructions, or correction in a cooperative manner,
voicing concerns or disagreement in a professional manner through established chain
of authority according to stated procedures.
15) Assume accountability for using, maintaining and storing facility property according to
established procedures.
16) Utilizes the use of mechanical lift per facility policy.
17) Adhere to and enforces facilty policies and procedures including but not limited to:
infection control, safety, resident rights, and chain of authority.
18) Adhere to universal precautions of body fluids per facility policy.
19) Observe infection control procedures.
20) Follow Residents’ Rights policies at all times.
21) Be responsible for the safety of residents under his/her supervision.
22) Observe all facility policies and procedures.
23) Perform other related duties and projects as directed by his/her supervisor.
Company Info
Company Name
Company URL
Contact Name
Email
Phone
Location
610 N. Eastern St.
Sanborn, IA 51248