LPN

Essential Functions Provides direct care and/or assists with care as directed and consistent with their scope of practice and competency.

Initiates the SBAR process and collaborate with the RN for assessment and recommendations.

Makes rounds with physicians and other team members, as needed.

Participates in resident evaluations and care planning activities, reviews and revises residents’ assessments and care plans as needed to the extent permitted by state nurse practice act.

Coordinates residents’ care activities and communicates changes to other team members and resident family/significant other.

Oversees Medication Aide/Tech in medication/treatment administration.

Administers treatments.

Reviews, transcribes, communicates and implements physician orders, obtaining RN signature as required by state regulations.

Communicates with resident’s physician.

Assists with emergencies; administers cardiopulmonary resuscitation.

Documents care performed and observations of resident status in the clinical record promptly by utilizing standard clinical documentation guidelines as required by the company, and local, state and federal rules and regulations.

Participates in medication management to promote optimal safety and effectiveness for residents by administering medications as ordered, including next scheduled dose following admission/readmission.

Notifying Charge Nurse of medications not available; Preparing, administering and documenting medications as prescribed; Observing and reporting resident responses to medication; Identifying and promptly communicating adverse drug reactions; Maintaining narcotic records accurately within scope of practice; Completing medication interchange and insurance prior to authorization as assigned; Ordering or arranging for ordering of pharmaceuticals; Notifying physicians of automatic stop orders; Completing recapitulated physician orders review, as assigned; and/or, Cleaning, organizing and replenishing supplies on medication/treatment carts after each use and prior to shift change.

Completes clinical admission paperwork for new admissions.

Initiates and assists consultants while providing services.

Reviews documentation from consultant visit and follows up on recommendation.

Assist with follow up on results of qualitative and quantitative medical record audits.

Communicates and implements pharmacy review/drug regime review recommendations, as assigned.

Assists with clinical discharge process.

Ensures punctuality and regular attendance for assigned shifts.