Job Description

Job Description

Certification Details

• BLS
• Montana State RN Licensure

Job Details

• The RN utilizes an interpersonal process that uniquely focuses on the total individual and his/her role in their family, culture and society.
• The RN utilizes the nursing process, which includes assessment, diagnosis, planning, implementation and evaluation.
• The RN fulfills a resident advocacy role by ensuring the resident and/or their representative has adequate information to make health decisions; by coordinating total care; and by working with the resident to achieve or maintain their highest practicable level of function.
• The RN is guided by substantial specialized knowledge of nursing based on physiological and psychological sciences.
• The RN ensures that the quality of resident care meets legal and professional standards and acts as a role model to other members of the health care team.
• Completes holistic, age-specific admission history, physical assessment and nursing plan of care on all assigned residents in an ongoing manner to monitor for deviations.
• Analyzes and incorporates clinical data (lab, x-ray, diagnostics) to formulate individualized plan of care.
• Identifies and documents residents at risk for nutritional and functional status.
• Identifies and reports signs/symptoms of neglect/abuse related to child, domestic or elder abuse.
• Sets priorities for and reviews daily plan of care in collaboration with resident/family/significant other and other healthcare disciplines.
• Delegation to team members is based on resident needs, continuity of care, staff and knowledge.
• Communicates with physician to ensure coordination of medical and nursing plan of care.
• Demonstrates competence in performing technical skills.
• Proactively recognizes and manages urgent/emergent resident care situations.
• Demonstrates knowledge and technical competence in preparation and administration of medications and IVs per scope of practice and hospital policy.
• Documents nursing interventions, residents' response to care, and resident outcomes.
• Evaluates data to revise plan of care to meet changing needs of resident.
• Evaluates response to interventions against expected norms for age and development.
• Identifies and documents resident/family learning needs and provides education based on assessment in collaboration with resident, family and interdisciplinary team members.
• Identifies and documents discharge planning needs.
• Coordinates or delegates discharge activities including transfer/discharge documents, instructions related to medications, activity, wound care and follow-up appointments.
• Documents resident/family response to education.
• Maintains working knowledge of CMS regulations to support documentation compliance.
• Maintains working knowledge of Medicare skilled and MDS criteria to support need for care and reflect resident status.
• Incorporates resident needs and preferences into organized, efficient delivery of care by a team assigned for daily cares and delegates tasks appropriately.
• Supervises, coaches, counsels, and evaluates performance of assigned C.N.A. staff.

Job Requirements

• Able to read and write at a level to fulfill documentation requirements.
• Physical demands include standing, walking, sitting, pushing (100+ lbs), pulling (100+ lbs), lifting, carrying, stooping, kneeling, crouching, reaching, filing, typing, xeroxing, talking, hearing, and color vision.
• Lifting objects over 100 lbs with frequent lifting/carrying up to 50 lbs.

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