Job Description
Benefis Health System
Great Falls, Montana, Job Summary: Assesses, plans, implements and evaluates the nursing care of residents within the skilled nursing setting. Responsible for ensuring continuity of care of the residents between shifts by providing direct care as well as supervising the care given by CNAs, LPNs and supportive staff members. Participates in resident and family teaching. Maintains role as resident advocate with a focus on the facility’s mission. FLSA: NON-EXEMPT DUTIES AND RESPONSIBILITIES: Assesses residents on admission and on a weekly basis, as well as when conditions change. Documents appropriately including Minimum Data Sets (if trained to to MDS). Assists with admissions and discharges. Ability to adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the resident, family and CNA regarding pain management.
Does pain assessments for the MDS. Duties as assigned by the nurse manager, DON or administrator. Documents changes in resident’s condition and nursing care on progress notes and plan of care, helps determine significant change in status per MDS protocol. Ability to perform waived testing (point-of-care testing) per Clinical Laboratory’s and the resident care unit’s policies and procedures as necessary. Ability to interpret results of waived tests; take appropriate action on waived tests results. Performs functions that will optimize resident safety and reduce the likelihood of medical/health care errors. Submits documentation in timely, clear, concise and pertinent manner. Notifies physician of changes in resident’s condition and follows through until appropriate action is taken. Understands situations which require notification to DPHHS , with appropriate investigation and follow through, with the assistance of the manager and DON. Notes and carries out physician’s orders in a timely manner.
Monitors orders for completion. Participates in walking rounds and documenting appropriately any issues that are found. Follows through, as needed, on information given by shift report, resident or family regarding resident concerns. Monitors the plan of care and suggests changes as appropriate. Helps direct the care provided to improve the quality of care rendered. Assists with the department’s continuing education and in-service programs. Demonstrates competence in technical, manual and critical thinking skills, according to the scope of practice for RNs. Functions as a resident advocate by protecting the resident’s rights. Administers medications, following the five (5) medication rights and reduces the potential for medication errors. Demonstrates creativity in solving problems and looking at situations in new and innovative ways.
Interacts with residents, families, co-workers, managers and other departmental personnel in a kind, knowledgeable and friendly manner. Consistently involves resident and family in planning for care, treatment, teaching needs and discharge plans. Participates in the performance improvement functions by collecting and verifying data, as needed. Participates in the completion of the MDS. Functions as a resource for the CNAs, RCA, LPNs and RNs. Participates in orientation of new personnel. Follows proper infection control procedures and supervises supportive staff in infection control procedures. Does infection control audits and report them. Demonstrates ability to remain calm in emergency and/or stressful situations and gives everyone a feeling of confidence that the situation is under control. Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.
Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict. Consistently follows the policies and procedures of the facility. Exhibits genuine interest in and appreciation of adults in later years of life and disabled. Is a motivated, independent individual who can organize workload so that all functions are completed appropriately. Professional Requirements: Adheres to dress code. Completes annual educational requirements. Maintains regulatory requirements. Wears identification while on duty. Maintains confidentiality at all times. Attends department staff meetings as required within the department.
Reports to work on time and as scheduled; completes work in designated time. Represents the organization in a positive and professional manner. Actively participates in performance improvement and continuous quality improvement (CQI) activities. Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department. Complies with Benefis Health System Organization Policies and Procedures. Complies with Health and Safety Standards and Guidelines. Education/Experience Requirements: Graduate of an accredited school of nursing. Current licensure as a Registered Nurse in the State of Montana. Current BCLS certification, healthcare provider. Maintains per Benefis policy.
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