Charge Nurse

Purpose of Your Job Position

The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities. Such supervision must be in accordance with current federal, state & local standards, guidelines, and regulations that govern our facility, and as may be directed by the Director of Nursing or Nurse Supervisor/Unit Manager to ensure that the highest degree of quality care is maintained at all times.

Delegation of Authority

As the 3p-11p Nurse Supervisor , you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Duties and Responsibilities            

Administrative Functions

Direct the day-to-day functions of the nursing assistants/ nurse's in accordance with current rules, regulation, and guidelines that govern the long-term care facility.

Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.

Periodically review the department's policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.

Meet with you assigned nursing staff, as well as support personnel, in planning the shift's services, programs, and activities.

Ensure that the Nursing Service Procedures Manual is current at all times and reflects the day-to-day nursing care procedures used by the facility.

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 resident's total regimen of care is maintained.

Ensure that all nursing service personnel are in compliance with their respective job descriptions.

Participate in the development, maintenance, and implementation of the facility's Quality Assurance (QA) and Quality Assurance Performance Improvement (QAPI) programs for the nursing service department.

Participate in facility surveys (inspections) made by authorized government agencies as may be requested.

Periodically review the resident's written discharge plan. Participate in updating the resident's written discharge plan as required.

Assist in planning the nursing service 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.

Write resident charge slips and forward to the Business Office.

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 recordkeeping 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 in the resident’s EMR.

Transcribe physician's orders to resident  EMR, card-ex, medication cards, treatment care plans in electronic format or paper 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/Unit Manager.

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 resident's 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 medication 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 need to the Nurse Supervisor/Unit Manager.

Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.

Ensure that narcotic records are accurate for you shift.

Notify the Nurse Supervisor/Unit Manager of all drug and narcotic discrepancies noted on your shift.

Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies.

Notify the attending physician of automatic stop orders prior to the last dosage being administered.

Dispose of drugs and narcotics as required, and in accordance with established procedures.

Personnel Functions

Participate in employee performance evaluations, determining your shift's staffing requirements, and making recommendations to the Nurse Supervisor/Unit Manager concerning employee dismissals, transfers, etc.

Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work.

Report absentee call-ins to the Nurse Supervisor/Unit Manager.

Review and evaluate your department's work force and make recommendations to the Nurse Supervisor/Unit Manager.

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 all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards.

Report problem areas to the Nurse Supervisor/Unit Manager.

Ensure that all nursing assistants are enrolled in or have graduated from an approved nursing assistant training program.

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/or to improve services.

Ensure that department personnel, residents, and visitors follow the department's established policies and procedures at all times.

Develop and maintain a good working rapport with inter-department 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/Unit Manager 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 duty hours.

Report occupational exposures to blood, body fluid, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures governing accident and incidents.

Nursing Care Functions

Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc.

Ensure that rooms are ready for new admissions.

Greet newly admitted residents upon admission and escort them lo their rooms as necessary.

Conduct and document a thorough assessment of each patient's medical status upon admission and throughout the patient's course of treatment.

Assist is the development and implementation of an individualized treatment plan for each assigned patient.

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 physicians 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 properly administered by certified nursing assistants and to evaluate the resident's 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 when the resident is involved in an accident or incident.

Notify the resident's attending physician and next-of-kin 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 Jab tests as ordered.

Take and record TPRs, blood pressures, etc., as necessary.

Monitor seriously ill residents as necessary.

Check food brought into the facility by the resident's family/visitors to ensure that it is within the resident's dietary allowances.

Report problem areas to the Nurse Supervisor/Unit Manager 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 problems to the Nurse Supervisor/Unit Manager.

Admit, transfer and discharge residents as necessary.

Assist in arranging transportation of discharged residents as necessary. Ensure that discharged residents are escorted to the pick-up area.

Inform family members of the death of the resident.

Call funeral homes when requested by the family.

Ensure that established post-mortem procedures are followed.

Act in compliance with established regulatory and professional standards and guidelines.

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 department.

Implement and maintain an effective orientation program that orients the new employee to your shift, its policies and procedures, and to his/her job position and duties.

Assist in standardizing the methods in which work will be accomplished.

Assist in training department personnel in identifying tasks that involve potential exposure to blood/body fluids.

Assist the Director in planning clinical supervision for nurse aide trainees when needed. 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 standards.

Attend and participate in advance directive in-service training program 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 all personnel are following established safety policies and procedures.

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 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 preparations 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 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.

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 moving or lifting a resident.

Report missing/illegible labels and MSDSs to the safety officer or other designated person.

Equipment and Supply Functions

Recommend to the Nurse Supervisor/Unit Manager 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 shift at all times to adequately meet the need of the resident.

Participate in the 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 MSDSs are on file for hazardous chemicals used in the nursing department.

Care Plan and Assessment Functions

Review care plans daily to ensure that appropriate care is being rendered.

Inform the Nurse Supervisor/Unit Manager 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 resident rights and responsibilities, including the right to refuse treatment.

Review complaints or grievances made by the resident and make a written/oral report to the Nurse Supervisor/Unit Manager indicating what action(s) were taken to resolve the complaint or grievance. Follow facility's established procedures.

Maintain a written record of the resident's complaints and/or grievances that indicates the action 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.

Miscellaneous

Provide data to the Quality Assurance & Assessment Committee as requested. Adheres to facility policies and procedures and participates in facility quality improvement and safety programs.

Working Conditions

Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses' stations, resident rooms, etc.).

Moves intermittently during work hours.

ls subject to frequent interruptions.

ls involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.

Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.

Communicates with the medical staff, nursing personnel, and other department supervisors.

Works beyond normal working hours, weekends and holidays when necessary.

Is subject to call-back during emergency conditions (e.g. severe weather, evacuation, post-disaster, etc.).

Attends and participates in continuing educational programs.

Is subject to injury from falls, bums from equipment, odors, assaults from hostile residents, etc. throughout the work day, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the

AIDS and Hepatitis B viruses.

May be subject to the handling of and exposure to hazardous chemicals. Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents' needs.

Education Requirements

Graduate of an accredited school of nursing.

Experience

None. On-the-job training provided. Two (2) years supervisory experience in a health care facility preferred.

Specific Requirements

Must possess and maintain an “Eligible” ACHA Background Screening status.

Valid license as a Registered and/or Licensed Practical Nurse in the State of Florida. Excellent communication and interpersonal skills.

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.

Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical  and Sensory Requirements

(With or Without the Aid of Mechanical Devices)

Must be able to move intermittently throughout the work day.

Must be able to speak ahd write the English language in an understandable manner.

Must be able to cope with the mental and emotional stress of the position.

Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of the position can be fully met.

Must function independently, 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 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 35 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of  450 feet.

Hours and days may be varied at times as necessary to maintain good nursing care. May be necessary to assist in the evacuation of residents during emergency situations.