LVN - FT - H
PACS IncSan Diego, CA, United States16 hours ago
Job type
- Full-time
Job descriptionComplete 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. Receive telephone orders from physicians and record on the Physicians' Order Form Transcribe physician's orders to resident charts, cardex, medication cards, treatment / care plans, 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 Chart all reports of accidents / incidents involving residents Record new / changed diet orders Report all discrepancies noted concerning physician's orders, diet change, charting error, etc. 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 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 Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies Ensure that narcotic records are accurate for your shift Notify the Nurse Supervisor 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 Participate in employee performance evaluations, determining your shift's staffing requirements, and making recommendations to the Nurse Supervisor 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 Review and evaluate your department's work force and make recommendations to the Nurse Supervisor 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 nursing service personnel are performing their work assignments in accordance with acceptable nursing standards 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-departmental 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 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 fluids, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures governing accidents and incidents Report known or suspected incidents of fraud to the Administrator Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines Inform nursing 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 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 physician in providing the resident's care, treatment, rehabilitation, etc. Review the resident's chart for specific treatments, medication orders, diets, etc. 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
Licensed Practical Nurse / Licensed Vocational Nurse
Pay Range : $38.00 - $49.00 an hour (based on experience)
Benefits : Medical, Dental, Vision, 401k matching
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.
Administrative Functions
- Direct the day-to-day functions of the nursing assistants
- Ensure that all nursing personnel comply with the written policies and procedures established by this facility
- Periodically review the department's policies and procedure manuals, job descriptions
- Meet with your assigned nursing staff, as well as support personnel, in planning the shifts' services, programs, and activities
- Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this 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 program 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
- Assist in planning the nursing services 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
- Report any known or suspected unauthorized attempt to access facility's information system
- Agree not to disclose assigned user ID code and password for accessing resident / facility information and promptly report suspected or known violations of such disclosure to the Administrator
- Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator
Charting and Documentation
Drug Administration Functions
Personnel Functions
Nursing Care Functions
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Lvn • San Diego, CA, United States