Requirements:   NYS RN License and Long term care experience

MAJOR TASKS, DUTIES, and RESPONSIBILITIES:

• Directs and supervises the care provided to the residents by the nursing staff on the evening tour.

• Ensures that assigned staff have reported to work. Ensures that all units have sufficient staff.

• Replaces sick calls and agency cancellations for the next shift.

• Reviews 24 Hour Report and follows up any unresolved issues.

• Notifies physician when resident’s condition changes including accident/incidents, abnormal labs and diagnostic test and documents in the resident’s medical record.

• Document changes in resident’s condition or plan of care (new orders) in the Supervisor’s book.

• Communicates to resident’s family any changes in condition, transfers to hospital, accident/incident and documents on the medical record.

• Conducts resident care rounds at least twice during tour of duty to ensure that the nursing staff is providing care as required.

• Conducts environmental rounds at least once during tour to ensure a clean and safe environmental.

• Ensures that nursing staff are complaint with infection control practices.

• Ensures that care provided is documented in the medical record, care plan, and resident care profile and accountability record.

• Ensures that each unit has resident care assignments.

• Ensures that staff is providing restorative nursing care as per plan of care (ROM, FAP, etc.)

Evening Supervisor

• Monitors medication and treatment records for omissions, transcription errors and takes appropriate corrective action.

• Ensures that physician orders are transcribed and carried out.

• Admits, transfers and discharges residents as appropriate.

• Obtains admission orders from physician and orders medications.

• Completes admission assessments (Nursing Admission Assessment, Fall Risk Assessment, Pressure Ulcer Risk Assessment, Elopement Risk Assessment, Pain Assessment, Bowel and Bladder Assessment) and initiates Resident Care Profile and Accountability Record.

• All accident/incidents require an accident/incident report. Supervisor must assess the resident, complete the accident/incident report, interview the staff and resident, obtain written statements from the staff, witnesses and resident. Completed accident/incident report is forwarded to DNS.
• If abuse, mistreatment or neglect are suspected the DNS must be notified immediately.

• Fall Risk Assessment to be completed post fall.

• Initiates corrective measures to prevent reoccurrence (i.e. floor mats, bed bolsters, toileting schedule etc.).

• Refers resident to Physical Therapy for post fall evaluation.

• Conducts meal rounds daily to ensure that the residents are receiving adequate nutrition, hydration and receiving the appropriate assistance with eating.

• Ensures that weights are taken as assigned.

• Ensures that vital signs are taken and documented as assigned.

• Receives and logs in controlled substances.

• Ensure that the nurses are following the policy and procedure for controlled substances (counting at beginning and end of tour and accurately completing the narcotic records).

Evening Supervisor con’td

• Maintain emergency antibiotic box (reorder as needed).

• Ensure that all required medications are obtained from the pharmacy in a timely manner.

• Reviews labs and reports abnormal results to MD

• Maintains appropriate equipment and supplies.

• Conduct staff meetings as appropriate.

• Evaluates staff performance and takes appropriate action (educational counseling and/or disciplinary action)

• Refers staff to in-service education as appropriate.

• Communicate changes in policy and procedure to nursing staff and provide feedback to DNS

• Attends educational programs.

• Attends meetings as required.

• Other duties as required by DNS

• Assures resident safety

The above statement reflects the general duties considered necessary to describe the principal functions of the job as identified, and shall not be considered as a detailed description of all the work requirements that may be inherent in the position (other duties as required).

Requirements:   NYS RN License and Long term care experience

MAJOR TASKS, DUTIES, and RESPONSIBILITIES:

• Directs and supervises the care provided to the residents by the nursing staff on the evening tour.

• Ensures that assigned staff have reported to work. Ensures that all units have sufficient staff.

• Replaces sick calls and agency cancellations for the next shift.

• Reviews 24 Hour Report and follows up any unresolved issues.

• Notifies physician when resident’s condition changes including accident/incidents, abnormal labs and diagnostic test and documents in the resident’s medical record.

• Document changes in resident’s condition or plan of care (new orders) in the Supervisor’s book.

• Communicates to resident’s family any changes in condition, transfers to hospital, accident/incident and documents on the medical record.

• Conducts resident care rounds at least twice during tour of duty to ensure that the nursing staff is providing care as required.

• Ensures that nursing staff are compliant with infection control practices.

• Ensures that care provided is documented in the medical record, care plan, and resident care profile and accountability record.

• Ensures that each unit has resident care assignments.

Night Supervisor

• Monitors medication and treatment records for omissions, transcription errors and takes appropriate corrective action.

• Ensures that physician orders are transcribed and carried out.

• Complete admission process for residents that may come on the night shift

• Transfers and discharges residents as appropriate.

• All accident/incidents require an accident/incident report. Supervisor must assess the resident, complete the accident/incident report, interview the staff and resident, obtain written statements from the staff, witnesses and resident. Completed accident/incident report is forwarded to DNS.
• If abuse, mistreatment or neglect are suspected the DNS must be notified immediately.

• Fall Risk Assessment to be completed post fall.

• Initiates corrective measures to prevent reoccurrence (i.e floor mats, bed bolsters, toileting schedule etc.).

• Refers resident to Physical Therapy for post fall evaluation.

• Ensures that vital signs are taken and documented as assigned.

• Receives and logs in controlled substances.

• Counts emergency controlled substances at start and end of tour.

• Ensure that the nurses are following the policy and procedure for controlled substances (counting at beginning and end of tour and accurately completing the narcotic records).

• Maintain emergency antibiotic box (reorder as needed).

• Ensure that all required medications are obtained from the pharmacy in a timely manner.

• Maintains appropriate equipment and supplies.

• Conduct staff meetings as appropriate.

• Evaluates staff performance and takes appropriate action (educational counseling and/or disciplinary action)

Night Supervisor

• Refers staff to in-service education as appropriate.

• Communicate changes in policy and procedure to nursing staff and provide feedback to DNS

• Initiate emergency response if required. Inform administrator, DNS, CEO, CFO

• Inform IT Director if any interruption in internet service

• Attends educational programs.

• Attends meetings as required.

• Assures resident safety

• Other duties as required by DNS

The above statement reflects the general duties considered necessary to describe the principal functions of the job as identified, and shall not be considered as a detailed description of all the work requirements that may be inherent in the position (other duties as required).

Statement of Purpose:

The Clinical Nurse Manager plans, coordinates and directs resident care activities on assigned unit (s) in order to provide quality care.

Ensures that care is delivered to each resident in accordance with the plan of care and is documented in the clinical record.

Duties & Responsibilities:

Directs, supervises and evaluates nursing care provided to residents.

Assesses the resident’s condition and nursing needs and takes appropriate action  

1.      Review 24 Hour Report

            2          Review Physician Communication Book

3. Make resident rounds
4. Review consults

            5          Review labs/diagnostic test

6. Makes resident care rounds at least daily

Reports change of condition to the physician and resident’s family.

Acts as liaison between the physician, resident, family and care team.

Assists physician as required

Makes wound/ulcer rounds weekly

Coordinates discharge planning with care team.

Admits, transfers and/or discharges residents as warranted

Ensures that Nursing Admission Assessments are completed as required.

 Ensures that plan of care is implemented and maintained current.

Reviews and revises plan of care at least quarterly and as needed.

Attends care planning meetings for residents on assigned unit (s)

Plans and assists in resident/family teaching

Evaluates staff performance and takes appropriate action (education, counseling, disciplinary action)

JOB DESCRIPTION:   Clinical Nurse Manager (Page 2) 

Monitors staff treatment of residents and adherence to facility policies and procedures in regards to preventing abuse, neglect, mistreatment and misappropriation of residents property.

Ensures that residents are treated with dignity and respect.

Ensures that residents are provided privacy during care and treatment activities.

Prepares nursing staff assignments

Prepares/reviews and revises Resident Care Profile/Accountability Record

Communicates changes in policy and procedure and other appropriate communication to staff and provides feedback to nursing administration.

Conducts unit meetings and provides feedback to nursing administration.

Seeks assistance from appropriate resource person as necessary in solving clinical and management problems.

Promotes an environment in which the care team can work cooperatively toward objectives.

Ensures a safe, clean, neat environment for residents, staff and visitors at all times.

Delegates responsibilities within scope of personnel abilities.

Maintains proper equipment and supplies

Ensures that emergency equipment and supplies are available and in proper working order.

Ensures that all pertinent data is documented in the resident’s electronic medical record

Completes resident Accident/Accident Report & initiates investigation by interviewing resident, staff, and witnesses and obtains written statements.

Completes Accident/Incident Report for staff and visitors as required

Ensures that all assigned staff has reported on duty and reassigns staff as required.

Ensures that all nursing personnel are in compliance with dress code.

Attends meetings as assigned ( CCP, Morning Meeting, Afternoon Report with DNS, Falls Committee etc.,)

Assures Resident safety

Other duties as required

TITLE:                                                          CNA

RESPONSIBLE TO:                                    NURSE

QUALIFICATIONS:

1. Current New York State C.N.A. Certification.

2. High School Diploma preferred.

3. Nursing Home experience preferred.

4. Acceptable work preferences with a genuine interest in caring for the elderly.

5. Capable of reading, writing, and comprehending the English Language.

6. Physically and mentally able to perform job responsibilities.

7. Ability to follow instructions and understand Policies and Procedures.

PERSONAL APPEARANCE:

–           Uniform must fit properly- may be all white or combination of colored uniform top with white skirt or slacks.  No spandex, jeans, capri’s or micromini skirt.   Top must be uniform top- no logos, must have sleeves.

• White uniform regulation rubber sole shoes (closed toe) and white stockings. Sneakers must be “uniform” style sneakers- white.

• Exhibit good personal hygiene and cleanliness.

• Jewelry is restricted to simple rings and wrist watch. Dangling jewelry (hoop earrings/long chains are a hazard).

• ID badge is to be worn at all times while on duty.

• Hair should be tied up and off the shoulders.                                                                                                                                   

Employee may be assigned to any unit depending upon the needs of the Nursing Home or may be called upon to escort a resident out of the facility.

–           It is recommended that the employees clock in 15 minutes before the start of the shift.

–           Employees must be in full uniform before clocking in.

1. Report to the nurse on the unit and listen to the report. Check the daily assignment     record to see which group of residents you are assigned to and what special duties you    must complete before going off duty.  Break assignments and meal time assignment      will appear also on this record.

2. Review the accountability records of each resident you are assigned to in order to know their needs and their Care Plan.  Pay special attention when two staff members or hoyer lift is needed to lift or move a resident, and check if restraints and/or side rails are ordered. 

3. Make rounds amongst your resident assignment to see that residents are safe, comfortable and have access to call bells. See that any assistive devices, heel pads, hand cones, etc. are in place.  If a resident has a restraint order, be sure the restraint is secured properly.  If a resident has side rails ordered, pay attention to whether it is for both rails up or one up and one down.
4. Bring residents to dining area for meals and see that their feet are elevated off the floor if they are in wheelchairs or geri-chairs. Check for residents who are fasting for their blood work.
5. Assist residents with meals in the dinning room. Two residents in close proximity to each other should be fed at the same time.  Dietary cards remain near the tray during the meal.                                  

Residents remaining in bed are fed next.  Do not uncover food items until you reach the

resident’s room.  DO not leave a resident alone who may choke on food while feeding self.

*          Residents should not be sleeping the dayroom- they must be returned to their rooms for a nap.

6. Take and record vital signs as assigned and report results to the Nurse.
7. Begin resident care- prepare residents for scheduled baths or showers, mouth care, hair and nail care, and shaving- these are all part of daily grooming. Never clip a resident’s toenails.  The fingernails of a Diabetic resident should never be clipped.  Resident’s assistive/supportive devices must be clean, e.g. eyeglasses, walkers, wheelchairs and splints.

*          Residents are weighed on their bath day and must be completely undressed and weighed on the whirlpool scales.        

8. Encourage fluids (especially in hot weather) as allowed and record on Intake and Output Record if applicable. Check residents for voiding and bowel movements and record according to procedure.  Always report to the Unit Nurse when and if a resident has not voided or had a bowel movement.  Collect specimens and empty drainage bags when assigned.  Never leave a resident unattended in the bathroom on the toilet.  When a resident demands privacy, however, you should stand directly outside the door or curtain so that you are aware of the resident’s activities.

9. Position resident according to schedule and document appropriate record. State reason on positioning record if designated position is not possible at that time.  Perform range of motion exercises as instructed.  Restraints must be released every two (2) hours throughout your shift .
10. Transport residents to treatment areas, physical therapy and/or recreation as scheduled. Provide ambulation activities as assigned for the resident.
11. Provide nourishments at scheduled times and record intake and output accordingly.  If a resident refuses nourishment report this to the unit nurse.
12. Empty urinary drainage bags, measure and record. Be sure your residents are left clean and dry.  Never leave a resident in the toilet at the change of shift- wait for your replacement to take over before leaving the unit.
13. Soiled linen hampers must be emptied at the end of the shift and special assignment areas clean and in order.
14. Complete all of the documentation required. Report any irregularities or unusual findings to the nurse. Accident Investigation records must be completed by the CNA assigned to

 the unit regardless of his/her presence on the unit or areas at the time of accident.

15. Conduct final round to ensure your residents are comfortable and safe. Sign your name on the daily assignment record before leaving the unit.
16. Clock out time card before leaving the facility.

N.B.    Assistance is to be given to “all” residents when needed regardless of assignment.  This is especially true during co-worker’s break time or meal times.

OTHER RESPONSIBILITIES OF C.N.A.’S:

–           Only residents who meet certain criteria may have an extra sheet as a pull or turn sheet.  This is written on the accountability/assignment record.

–           Make sure all residents are wearing arm bands.

–           Report the need for more clothing, shoes, etc., for your resident to the nurse.

–           Make sure there no medications (unless ordered by the MD) smoking material or food at the bedside of the resident.  Food items must be kept in box provided.

–           Perform post mortem care to the deceased with respect.

–           Bed and wheelchairs are not to be padded with extra linen, diapers, etc.

–           See that all refrigerated items are dated otherwise discard.

–           Temperature of refrigerator is to be maintained between 36 and 46 degrees.

–           Report any safety hazards to maintenance or to the nurse.

–           Make sure all call bells are working.

–           Store assistive devices in appropriate places to avoid injury.  Do not block exits or stairwells.

–           Before bedtime, remove resident’s hearing aid and store safely.  Check for proper functioning before replacing it in resident’s ear.  Assist in removing resident’s dentures if applicable and use denture cup.

–           Hand splints, braces, shoes, should be cleaned during the night shift following removal by the evening shift.

–           Assist in the orientation of new employees or Agency personnel on the unit when instructed to do so.

–           Respond to emergencies and/or fire drills as needed to do so.

–           Follow through and carry out any other orders that your nurse or Supervisor deems necessary.

N.B.    During periods of inclement weather or emergencies, staff is to remain on duty until adequate staff arrives

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