Job Summary

• Provide holistic, patient-centered care using the nursing process: assessment, diagnosis, planning, implementation, and evaluation.
• Act as a resident advocate, ensuring informed decision-making and coordination of care to achieve optimal functioning.
• Maintain compliance with legal and professional standards while serving as a role model for the healthcare team.

Essential Duties and Responsibilities

Assessment

• Conduct comprehensive, age-specific admission histories, physical assessments, and nursing care plans.
• Analyze clinical data (e.g., lab results, diagnostics) to develop individualized care plans.
• Identify and document risks related to nutrition, functional status, and signs of neglect or abuse.

Planning

• Collaborate with residents, families, and healthcare teams to set priorities and review care plans.
• Delegate tasks based on resident needs and staff capabilities.
• Communicate with physicians to align medical and nursing care plans.

Implementation

• Perform technical nursing skills and manage urgent/emergent care situations.
• Administer medications and IVs per scope of practice and hospital policy.

Evaluation

• Document nursing interventions, resident responses, and outcomes.
• Revise care plans based on changing resident needs and evaluation data.

Patient Education and Continuum of Care

• Assess and document resident/family learning needs and provide education accordingly.
• Coordinate discharge planning, including instructions on medications, wound care, and follow-up appointments.
• Ensure documentation supports compliance with CMS regulations and Medicare criteria.

Team Leadership

• Supervise, coach, and evaluate assigned CNA staff.
• Delegate tasks effectively to ensure efficient care delivery.

Required Qualifications

• Associate Degree in Nursing (ASN) from an accredited school.
• Current Registered Nurse (RN) license in the state of practice.
• Basic Life Support (BLS) certification from the American Heart Association.
• Ability to read and write to meet documentation requirements.
• Physical ability to lift objects over 100 lbs. and perform frequent lifting/carrying up to 50 lbs.

Preferred Qualifications

• None specified.