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Casa de Paz Health Care Center

Licensed Practical Nurse

Casa de Paz Health Care Center, Sioux City, IA, United States



Job Summary:
The primary purpose of the Licensed Practical Nurse 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 our
facility, and as may be required by the Director of Nursing Services or Unit Manager to ensure that the highest
degree of quality care is maintained at all times.
Supervisory Responsibilities:
• Supervises CNAs
• Reports performance related issues of CNAs


Duties/Responsibilities:


CUSTOMER SERVICE
• Demonstrates positive customer service when performing the role of the Charge Nurse, with residents,
family members, facility staff and medical staff.
• Displays flexibility, team spirit compassion, respect honesty, politeness and accountability when
dealing with residents, family members and facility staff.
• Demonstrates an awareness of and sensitivity for resident's rights in all interfaces with residents and family
members.
• Communicates effectively via open, straightforward communication, including use of listening skills
and by accessing the appropriate chain of command.
• Seeks validation of knowledge base, quality, decision-making and skill level byactively questioning when
necessary.
• Participates in interdisciplinary communication activities; actively listens and actively contributes.


ESSENTIAL DUTIES AND RESPONSIBILITIES


Administrative Functions:
• Direct the day-to-day functions of the nursing assistants in accordance with current rules,regulations,
and guidelines that govern the long-term care facility.
• Ensure that all assigned nursing personnel comply with the written policies and procedures established by the
facility.
• Periodically review the department's policies, procedure manuals, job descriptions, etc. Make
recommendations for revisions.
• Meet with assigned nursing staff, as well as support personnel, in planning the shifts' services, programs,
and activities.
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service
Procedures Manual.
• Make written and oral reports/recommendations concerning the activities of your shift as required.
• Cooperate with other resident services when coordinating nursing services to ensure that the residents
total regimen of care is maintained.
• Participate in the development maintenance ,and implementation of the facility's quality assurance
program for the nursing service department
• Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
• Periodically review the residents written discharge plan. Participate in the updating of the residents
written discharge plan as required.
• Assist in planning the nursing services portion of the resident's discharge plan as necessary.
• Interpret the department's policies and procedures to personnel, residents, visitors, and government
agencies as required.
• Admit, transfer, and discharge residents as required.
• Complete accident/incident reports as necessary.
• Maintain the Daily Census Report and submit to the Business Office as required.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc.,
as necessary.


Charting and Documentation:
• Complete and file required record keeping forms/charts upon the resident's admission, transfer, and/or
discharge.
• Encourage attending physicians to review treatment plans, record and sign their orders, progress notes,
etc., in accordance with established policies.
• Receive telephone orders from physicians and record on the Physicians' Order Form.
• Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans, as
required.
• Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the
resident, as well as the resident's response to the care.
• Fill out and complete accident/incident reports. Submit to Director as required.
• Chart all reports of accidents/incidents involving residents. Follow established procedures.
• Record new/changed diet orders. Forward information to the Dietary Department.
• Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse
Supervisor.
• Fill out and complete transfer forms in accordance with established procedures.
• Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident's
medical record in accordance with established procedures.
• Perform routine charting duties as required and in accordance with established charting and
documentation policies and procedures.
• Sign and date all entries made in the residents' medical record.


Drug Administration Functions:
• Prepare and administer medications as ordered by the physician.
• Verify the identity of the resident before administering the medication/treatment.
• Ensure that prescribed medications for one resident is not administered to another.
• Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet
the nursing needs of the residents. Report needs to the Nurse Supervisor.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with established
policies.
• Ensure that narcotic records are accurate for your shift.
• Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift.
• Review medication records for completeness of Information, accuracy in the transcription of the
physician's order, and adherence to stop order policies.
• Dispose of drugs and narcotics as required, and in accordance with established procedures.


Personnel Functions:
• Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work.
• Report absentee call-ins to the Nurse Supervisor.
• Develop work assignments and/or assist in completing and performing such assignments.
• Provide leadership to nursing personnel assigned to your unit/shift
• Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their
work assignments in accordance with acceptable nursing standards. Report problem areas to the
Nurse Supervisor.
• Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse.
• Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and
correcting problem areas, and/ortoimprove services.
• Ensure that department personnel, residents, and visitors follow thedepartment's established policies
and procedures at all times.
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other
departments within the
facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the
residents.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a
calm environment throughout the unit and shift
• Review complaints and grievances made or filed by your assigned personnel. Make appropriate
reports to the Nurse Supervisor as required or as may be necessary. Follow facility's established
procedures.
• Ensure that departmental disciplinary action is administered fairly and without regard to race, color,
creed, national origin, age, sex, religion, handicap, or marital status.
• Receive/give the nursing report upon reporting in and ending shift.
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in
accordance with the
facility's policies and procedures governing accidents and incidents.


Nursing Care Functions:
• Inform nursing personnel of new missions, their expected time of arrival, room assignment etc.
• Ensure that rooms are ready for new admissions.
• Greet newly admitted residents upon admission. Escort them to their rooms as necessary.
• Participate in the orientation of new residents/family members to the facility.
• Make rounds with physicians as necessary.
• Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in
accordance with our established procedures.
• Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as
necessary.
• Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary.
• Implement and maintain established nursing objectives and standards.
• Make periodic checks to ensure that prescribed treatments are being property administered by certified
nursing assistants and to evaluate the residents' physical and emotional status.
• 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.
• Cooperate with and coordinate social and activity programs with nursing service schedules.
• Notify the resident's attending physician and next-of-kin/responsible party when the resident is involved
in an accident or incident.
• Notify the resident's attending physician and next-of-kin/responsible party when there is a change in the
resident's condition.
• Carry out restorative and rehabilitative programs, to include self-help and care.
• Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe
manner.
• Administer professional services such as; catheterization, tube feedings, suction, applying and
changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages
and range of motion exercises, care for the dead/dying, etc., as required.
• Use restraints when necessary and in accordance with established policies and procedures.
• Obtain sputum, urine and other specimens for lab tests as ordered.
• Take and record TPRs, blood pressures, etc., as necessary.
• Monitor seriously ill residents as necessary.
• Check foods brought into the facility by the residents' family/visitors to ensure that it is within
the resident's dietary allowances. Report problem areas to the Nurse Supervisor and
Dietary Supervisor.
• Ensure that personnel providing direct care to residents are providing such care in accordance with the
resident's care plan and wishes.
• Ensure that residents who are unable to call for help are checked frequently.
• Meet with residents, and/or family members, as necessary. Report problem areas to the Nurse Supervisor.
• Admit, transfer and discharge residents as necessary.
• Assist inarranging transportation for discharged residents as necessary.
• Ensure that discharged residents are escorted to the pick-up area.
• Inform family members of the death of the resident once physician has been notified.
• Call funeral homes when requested by the family. Ensure that established post-mortem procedures are
followed


Staff Development
• Participate in developing, planning, conducting, and scheduling in-service training classes that provide
instructions on "how to do the job, and ensure a well-educated nursing service department.
• Assist intraining department personnel in identifying tasks that involve potential exposure to blood/body
fluids.
• Assist the Director in planning clinical supervision for nurse aide trainees.
• Attend and participate in outside training programs.
• Attend and participate in annual OSHA and CDC in-service training programs for hazard communication,
TB management and blood borne pathogens standard.
• Attend and participate in advance directive in-service training programs for the staff and community.
• Attend and participate in continuing education programs designed to keep you abreast of changes in
your profession, as well as to maintain your license on a current status.
Safety and Sanitation:
• Monitor your assigned personnel to ensure that they are following established safety regulations in the
use of equipment and supplies.
• Ensure that established departmental policies and procedures, including dress codes, are followed by your
assigned
nursing personnel.
• Assist the Director and/or Infection Control Coordinator in identifying, evaluating, and classifying
routine and job-related functions to ensure that tasks in which there are potential exposure to
blood/body fluids are properly identified and recorded.
• Ensure that all personnel performing tasks that involve potential exposure to blood/body fluids
participate in appropriate in· service training programs prior to performing such tasks.
• Ensure that an adequate supply of personal protective equipment is on hand and are readily
available to personnel who perform procedures that involve exposure to blood or body fluids.
• Ensure that your assigned work areas (i.e., nurses' stations, medicine preparation rooms, etc.) are
maintained in a clean and sanitary manner.
• Ensure that your unit's resident care rooms, treatment areas, etc., are maintained in a clean, safe, and
sanitary manner.
• Ensure that your assigned personnel follow established hand washing techniques in the
administering of nursing care procedures.
• Ensure that your assigned personnel participate in and conduct all fire safety and disaster preparedness
drills in a safe and professional manner.
• Participate in the development, implementation, and maintenance of the infection
control program for monitoring communicable and/or infectious diseases among the
residents and personnel.
• Ensure that your assigned personnel follow established infection control procedures when isolation
precautions become necessary.
• Ensure that nursing personnel follow established procedures in the use and disposal of personal protective
equipment
• Participate in the development, implementation and maintenance of the procedures for reporting
hazardous conditions or equipment
• Ensure that all personnel wear and/or use safety equipment and Supplies (e.g., back brace,
mechanical lifts, etc.) when lifting or moving residents.
• Report missing/illegible labels and MSDSs to the safety officer or other designated person.
• Ensures emergency exits and hallways are not cluttered and that hallways are clear with items in hall to
one side.


Equipment and Supplies:
• Recommend to the Nurse Supervisor the equipment and supply needs of your unit/shift
• Ensure that an adequate stock level of medications, medical supplies, equipment etc., is maintained on
your unit/shift at all times to meet the needs of the residents.
• Participate inthe development and implementation of the procedures for the safe operation of all nursing
service equipment.
• Ensure that only trained and authorized personnel operate your unit/shift's equipment
• Ensure that all personnel operate nursing service equipment in a safe manner.
• Monitor nursing procedures to ensure that nursing service supplies are used in an efficient manner to avoid
waste.
• Ensure that appropriate MSOSs are on file for hazardous chemicals used in the nursing service department.
Care Plan and Assessment Functions:
• Review care plans daily to ensure that appropriate care is being rendered.
• lnforms the Nurse Supervisor of any changes that need to be made on the care plan.
• Ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care
or treatment
• Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on
nursing needs.
• Ensure that your assigned certified nursing assistants (CNAs) are aware of the resident care plans.
Ensure that the CNAs refer to the resident's care plan prior to administering daily care to the resident.
• Assist the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising the
MDS, including the implementation of RAPs and Triggers.


Resident Rights:
• Maintain the confidentiality of all resident care information.
• Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect.
• Ensure that all nursing care is provided in privacy and that nursing service personnel knock
before entering the resident's room.
• Ensure that all nursing service personnel are knowledgeable of the residents' responsibilities and rights
including the right to refuse treatment
• Review complaints and grievances made by the resident and make a written/oral report to the Nurse
Supervisor indicating what action(s) were taken to resolve the complaint or grievance. Follow the
facility's established procedures.
• Maintain a written record of the resident's complaints and/or grievances that indicates the
action taken to resolve the complaint and the current status of the complaint
• Report and investigate all allegations of resident abuse and/or misappropriation of resident property.
• Ensure that nursing staff personnel honor the resident's refusal of treatment request Ensure that
such requests are in accordance with the facility's policies governing advance directives.


EXPENSE CONTROL
• Use only the equipment and supplies necessary to do the job. Do not be wasteful.
• Inform the Nurse Supervisor of equipment and supply needs.


Education and Experience:
• Must possess, as a minimum, a graduate of an approved LPN program.
• Must possess a current, unencumbered, active license to practice as an LPN in this state.
• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family
members, visitors, government agencies/personnel, and the general public.
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations,
and guidelines that pertain to long-term care.
• Must possess leadership and supervisory ability and the willingness to work harmoniously with
and supervise other personnel.
• 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.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult
residents.
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing
nursing practices.
• Must be able to relate information concerning a resident's condition.
• Mustnotposeadirectthreattothehealthorsafetyofotherindividualsintheworkplace.


Physical Requirements:
• Must be able to move intermittently throughout the work day.
• Must be able to speak and write the English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately
to ensure that the requirements of this position can be fully met.
• Must function independently and have flexibility, personal integrity, and the ability to
work effectively with residents, personnel, and support agencies.
• Must meet the general health requirements set forth by the policies of this facility which
include a medical and physical examination.
• Must be able to relate to and work with the Ill, disabled, elderly, emotionally upset, and, at times,
hostile people within the facility.
• Must be able to push, pull, move, and/or lift a minimum of 40 pounds to a minimum height of waist
height and be able to push, pull, move, and/or carry such weight a minimum distance of 20 feet.
• May be necessary to assist in the evacuation of residents during emergency situations.