LVN

S.P.J.S.T SKILLED NURSING AND REHABILITATION

JOB DESCRIPTION

TITLE: LICENSED PRACTICAL NURSE (VOCATIONAL) LPN/LVN

DEPARTMENT: Nursing

REPORT TO: Director of Nursing

WAGE: Hourly

WORK HOURS: Rotation shifts, holidays, and weekends as scheduled.

MINIMUM QUALIFICATIONS:

• Supports the facility.
• Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the privacy, dignity, and well-being of all residents in a safe, secure environment.
• Agrees to comply with Code of Conduct.
• Graduation from a basic education program in practical (vocational) nursing.
• A minimum of 1 year of nursing experience in a long-term or acute care setting preferred.
• Must have a current license to practice profession in state.
• Must have a reliable source of transportation.
• Must have a valid driver’s license and automobile insurance.
• Must be able to read, write, and speak the English language.
• TFER (Texas Food Established Rules) food handler certificate must be obtained within 90 days upon hire.
• Must be able to transfer residents and assist in emergency evacuations.
• Able to interact with residents, family members, staff, visitors, government agencies/personnel, etc., under all conditions/circumstances.
• Able to relate and work with the disabled, ill, elderly, emotionally upset, and at times, hostile people within the facility.
• Able to effectively communicate with the management staff, medical staff, nursing staff, and other unit supervisors.

RESPONSIBILITIES:

• Works under direct supervision in accordance with the state-specific Nurse Practice Act, facility Policies and Procedures, and nursing judgement.
• Delivers nursing care to patients/residents requiring long-term or rehabilitative care.
• Collects patient/resident data, make observations, and reports pertinent information related to the care of the patient/resident.
• According to state-specific regulations, implements the patient/resident plan of care and evaluates the patient/resident response.
• In accordance with state-specific regulations, direct and supervises care given by other nursing personnel in selected situations.
• Maintains knowledge of necessary documentation requirements.
• Maintains knowledge of equipment set-up, maintenance, and use, i.e., monitors, infusion devices, drain devices, etc.
• Maintains confidentiality and patient/resident rights, regarding all patient/resident/personnel information.
• Provides patients/residents/family/caregiver education as directed.
• Conducts self in a professional manner in compliance with unit and facility policies.
• Initiates emergency support measures (i.e., CPR, protects patients/residents from injury).
• Data Collection:
  • Admission and routine patient/resident observations/transfer notes are completed and accurately reflect the patient’s/resident’s status.
  • Documentation of observations in complete and reflects knowledge of unit documentation policies and procedures.
  • Nursing history is present in the medical record for all patient/residents.
  • Changes in a patient’s/resident’s physical/psychological condition (i.e., changes in lab data, vital signs, mental status), are reported appropriately.
• Planning of Care: Contributions to the formula/review of nursing care plans are made as appropriate, under the direct supervision or delegation of an RN.
  • Pertinent nursing problems are identified.
  • Goals are stated.
  • Appropriate nursing orders are recommended.
• Evaluation of Care
  • Observations related to the effectiveness of nursing interventions, medications, etc. are reported as appropriate and documented in the progress note.
  • Care Plans:
    • Evaluation of care plan is noted monthly or as indicated.
    • Contributes to care plan revision are made as indicated by the patient’s/resident’s status.
• General Patient/Resident Care
  • Patient/Resident is approached in a kind, gentle, and friendly manner. Respect for the patient’s/resident’s dignity and privacy is consistently provided.
  • Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
  • Independence by the patient/resident in activities of daily living is fully encouraged.
  • Treatments are completed as indicated.
  • Safety concerns are identified, and appropriate actions are taken to maintain and assure patient safety including but not limited to:
    • Guard rails and height of bed are adjusted.
    • Patient/Resident call light and equipment is within reach.
    • Restraint, when used, are maintained properly.
    • Rooms are neat and orderly.
  • Patient/Resident identification bands and allergy bands (if applicable) are present.
  • Functional assignments are completed.
  • Emergency Situations are recognized, and appropriate action is instituted.
  • All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguisher, etc.)
• Patient/Resident Education /Discharge Planning
  • Patient /resident/Family teaching is conducted according to the nursing care plan.
  • Explanations are given to the patient/resident prior to intervention.
  • Discharge/death summaries are complete and accurate.
  • Transfer forms are complete and accurate.
  • Active participation in patient/resident care management is evident.
• Adherence to Facility Procedures
  • Facility Policy and Procedures Manual or reference materials are utilized as needed.
  • Procedures are performed according to the method outlined in the procedure manual.
  • Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
  • Safety guidelines established by the facility (i.e., proper needle disposal) are followed.
• Documentation
  • The patient’s/resident’s full name and room number are presented on all chart forms. Allergies are noted on the chart cover.
  • Only approved abbreviations are utilized.
  • Vital signs are properly and timely recorded.
  • I&O summaries are recorded and added correctly.
  • Progress notes are timed, dated, and signed with full signatures and title.
  • Unit Flow sheets are completed properly (i.e., wound care records, treatment record, weight sheets, etc.).
• Medication Administration/Parenteral Therapy Record
  • Adheres to state-specific Nurse Practice Act for administration of medication and parental therapy.
  • Dates that medications are started or discontinued are documented.
  • Medications are charted correctly with name, dose, route, site, time, and initials, of nursing administering.
  • Pulse and blood pressure are obtained and recorded when appropriate.
  • Medications not given are circled, reason noted, and physician notified if applicable.
  • Appropriate notes are written for medications not given and actions taken.
  • Name and title of nurse administering medication are documented.
  • Patient’s/Resident’s medication record is labeled with full names, room number, date, and allergies.
  • The procedure for administration and counting of narcotics is followed.
  • All parenteral fluids, including additives, are charted with time and date started, time infusion completed, site of infusion, and signature of nurse.
  • All parenteral fluids are administered according to the ordered infusion rate.
  • Parenteral intake is accurately recorded on the unit flow sheet or I&O record.
  • Appropriate actions are taken related to identified IV infusion problems (infiltration, phlebitis, poor infusion, etc.).
  • IV sites are monitored, and catheters changed according to unit policy.
  • IV bags and tubing’s are changed according to unit policy.
• Coordination of Care
  • Tests are scheduled and preps are completed as indicated.
  • Co-workers are informed of changes in patients/resident conditions or of any other changes occurring on the unit.
  • Information is relayed to other members of the health care team (i.e., physicians, respiratory therapy, physical therapy, social services, etc.) and family/responsible party.
  • Unit activities are coordinated (i.e., changing patient’s/resident’s rooms for admissions, coordinating transfer/discharge forms, etc.).
• Leadership
  • Equitable care assignments appropriate to patient/resident needs are made prior to the beginning of the shift.
  • Staffing needs are communicated to the nursing supervisor.
  • Assistance, direction, and education are provided to unit personnel and families.
  • Problems are identified, data are gathered, solutions are suggested, and communication regarding the problem is appropriate.
  • Transcription of all orders is checked.
  • All work areas are neat and clean.
• Communication
  • Change of shift report is complete, accurate, and concise.
  • Incident reports are completed accurately and in a timely manner.
  • Staff meetings are attended, if on duty, or minutes read and initialed if not on duty.
• Professionalism
  • Decisions are made that reflect knowledge and good judgement and demonstrate an awareness of patient/resident/family/physician needs.
  • Awareness of their own limitations is evident, and assistance is sought when necessary.
  • The dress code is adhered to.
  • Committee meetings (if assigned) are attended. Reports related to the committee are given during staff meetings.
  • Responsibility is taken for own professional growth. All mandatory and other in-services are attended annually.
  • Organizational ability and time management demonstrated.
  • Confidentiality of patient/resident is always respected (i.e., when answering telephone and/or speaking to co-workers).
  • Professional behavior is demonstrated.
• Human Relations
  • A positive working relationship with patients/residents, visitors, and facility staff is demonstrated.
  • Authority is acknowledged and response to the direction of supervisors is appropriate.
  • Time is spent with patient/resident rather than other personnel.
  • Co-workers are readily assisted as needed.
• Cost Awareness
  • Supplies are used appropriately.
  • Charge stickers (or charge system) are utilized appropriately.
  • Minimal supplies are stored in the patient’s/resident’s room.
  • Discharged medications are given to ADOM.
  • Floor-stock medications are charged and re-stocked.
• Participates in the identification of staff educational needs.
• Serves as a preceptor, as delegated, for new staff.
• Maintains patient/resident care supplies, equipment, and environment.
• Participates in the development of unit objectives.
• Provides input in the formulation and evaluation of standard of care.
• Supports, cooperates with, and implements specific procedures and programs for:
  • Safety, including precaution and safe work practices, established, fire/safety/disaster plans, risk management, and security report and/or correct unsafe working conditions, equipment repair and maintenance needs.
  • Confidentiality and privacy of all data, including patient/resident, employee, and operation data.
  • Compliance with all regulatory requirements.
  • Compliance with and enforcement of current law and policy to provide a work environment free from harassment and all illegal and discriminatory behavior.
• Supports and participates in common teamwork:
  • Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction, including appropriate judgement.
  • Uses tactful, appropriate communications in sensitive and emotional situations.
  • Reports complaints, problems and concerns regarding co-workers, management, or residents in accordance with facility policy.
  • Promotes positive public relations with patients, residents, family members, and guests.
  • Completes requirements for in-service training, acceptable attendance, uniform, and dress code including personal hygiene, and other work duties as assigned.
• May be involved in community/civic health matters/projects.
• Maintains a liaison with residents, their families, support staff, etc. to ensure that the residents’ needs are continually met.
• Other duties as assigned.

WORK ENVIROMENT:

• Office areas as well as throughout the facility.
• Able to move intermittently including standing, lifting, bending, stooping, twisting, pushing, and pulling with or without accommodations.
• May be exposed to infectious waste, diseases, conditions, etc., including exposure to the AIDS and hepatitis B viruses.