Brighton Place - San Diego - POSITION DESCRIPTION:A licensed professional nurse directly under the supervision of the Assistant Director of Nursing Services.The Charge Nurse is responsible for staff assignment and provides overall supervision of resident care activities.QUALIFICATIONS Graduate of an accredited school of nursing or an approved LVN program. Current California LVN license. Strong organizational skills. Possess, as a minimum, training in a skilled nursing care facility, hospital, or other related medical facility. Possess leadership ability and the willingness to work with and supervise professional and nonprofessional personnel. Knowledgeable of nursing and medical practices and procedures. Ability to Read, write and speak the English language. Possess mental and physical health.GENERAL DUTIES AND RESPONSIBILITIES:CLINICAL Complete all required record keeping forms/charts upon the residents admission, discharge, transfer, etc. File in the residents chart and/or forward to the appropriate department. Receive verbal orders from attending/alternate physician and transcribe the physicians order sheet. Initiate resident Plans of Care on admission. Chart TPRs, blood pressures and blood glucose as required. Order prescribed medications, supplies and equipment as established by the facilitys policies and procedures. Review physicians orders and transfer/preadmission information for completeness. Prepare/administer medications as ordered by the physician. Answer telephone inquiries as outlined in the facilitys established policies and procedures. Chart licensed nurses notes in an informative and d3scriptive manner that reflects the care provided as well as the residents response to the care. Forward new diet orders, and/or diet changes to the dietary department. Transcribe physicians orders to residents charts, Medication Administration Records, Treatment Administration Records and RNA sheets to assure that they remain current. Verify the identification of the resident before administering medication or treatment. Requisition and arrange for diagnostic and therapeutic services as ordered by the physician. Assure that narcotic records are current at all times Admit, transfer and discharge resident. Assist in arranging transportation and packing as necessary. Check resident charts for specific treatment, medication orders and schedules daily. Administer professional services such as: catheterization, tube feeding, suction, applying and changing dressings/bandages, packs, colostomy and drainage bags, taking blood, sputum, and urine specimens, care of the dead/dying, etc., as established by the facilitys policies and procedures. Make rounds with the physician and assist with examination and treatment. Review medication sheet for completeness of information, accuracy in the transcription of physician orders and adherence to stop order policies. Assist in carrying out restorative and rehabilitative programs to include self-help/care. Perform routine charting as required. Report all discrepancies of physician order, diet or charting to the RN Supervisor or Assistant Director of Nurses. Check food in residents rooms that is brought in by the residents family or visitors in accordance with the facilitys established policies and procedures. Initiate restraint assessment on all new admissions. Monitor and document behavior of residents on psychoactive medications Record Intake and Output, and complete monthly evaluation as per the facilitys policy and procedure. Following completion of an approved competency check with an RN an LVN may reinsert a G-Tube on an established track only.SUPERVISION Meet with unit personnel, on a regular basis, to assist in identifying and correcting problem areas, and/or the improvement of services. Review and evaluate assigned personnel and make written evaluations to the RN Supervisor or Assistant Director of Nurses. Coordinate Nursing service with other departments and nursing units. Notify the attending physician, RN Supervisor and Director of Nurses when a resident is discharged without approval. Assure that appropriate documentation is made in accordance with the facilitys established policies and procedures. Assure that a stock of medications, medical supplies, equipment, etc., is maintained at all times. Requisition equipment and supply needs as required. Initiate investigation of accidents and unusual occurrences and make the necessary written report to the Director of Nurses as established in the facilitys policies and procedures. Notify the residents attending/alternate physician, as well as the residents legal guardian/representative, when the resident has a significant change of condition or becomes critically ill or injured, as outlined within facilitys established policies. Work with the facilitys consultants as necessary and implement recommended changes as directed by the RN Supervisor of the Director of Nurses. Investigate complaints and grievances and make necessary oral/written reports to the RN Supervisor or Director of Nurses. In cases of death, notify the funeral home and ensure that the body is properly prepared/cleaned for pick-up. Evaluate emergencies and determine emergency measures to be used, including the use of chemical or mechanical restraints. Notify the RN Supervisor and physician and record and follow orders. Assure that the unit area is maintained in a clean and safe manner for resident comfort and convenience, by ensuring that necessary equipment and supplies are maintained to perform such duties/services. Assist in standardizing the methods in which work will be accomplished. Make residents rounds to review physical, medical an emotional status and to implement required nursing interventions. Notify physician and residents responsible party of any resident accidents/incidents. Fill out and complete Accident/Incident Report forms on all such occurrences and chart such information in the residents medical records as outlined in the facilitys established policies and procedures Assure that nursing personnel follow established nursing procedures. Remind attending physician(s) to review treatment plans, record and sign physicians orders, progress notes, etc., during physician visits. Give/receive nursing reports upon reporting in and ending shift duty hours. Check all residents daily to assure that prescribed treatment is being properly administered by nursing personnel/assistants and to evaluate their physical and emotional status. Record findings in the residents chart. Assist in orientation of newly assigned personnel as well as supervise and instruct other nursing personnel. Orient new residents/family members as necessary. Assure that nursing personnel are providing adequate nursing car in accordance with established nursing service procedures. Assure that all personnel follow established infection control and aseptic techniques when isolation procedures become necessary. Report all hazardous conditions and equipment to the RN Supervisor and maintenance department immediately. Keep the RN Supervisor informed about the status of residents, staff and related matters. Assume the authority, responsibility and accountability of directing your unit/shift. Follow required coaching and progressive disciplinary procedures. Others as may become necessary and appropriate or as may be directed by the Director of Nurses or Administrator.CONSUMER SERVICE Presents professional image to consumers through dress, behavior and speech. Adheres to Company standards for resolving consumer concerns. Ensures that all consumer/resident rights are protected.