Charge Nurse RN

KALESTA HEALTHCARE GROUP; Merced (CA); On-site; USD 75,000 - 95,000; Full time

Job summary

KALESTA HEALTHCARE GROUP is seeking a Charge Nurse responsible for overseeing nursing services for residents, administering medications, and coordinating care with the interdisciplinary team.

The ideal applicant should be a Registered Nurse with the ability to lead staff effectively, ensure compliance with regulations, and maintain high standards of resident care. Candidates must have exceptional communication skills and experience in performance evaluations.

Qualifications

• Registered Nurse with experience in managing nursing staff.
• Strong understanding of resident care plans and ability to assess resident needs.
• Excellent leadership and interpersonal skills.

Responsibilities

• Oversee nursing services for all residents during shifts.
• Administer medications and treatments according to physician orders.
• Train and develop nursing staff and perform performance evaluations.
• Ensure compliance with regulatory standards and facility policies.

Skills

Clinical competence

Staff supervision

Medication administration

Performance evaluation

Effective communication

Education

Registered Nurse License

Job description

About the Role

As a member of the interdisciplinary team, the Charge Nurse assumes responsibility and accountability for nursing services delivered to all residents of a designated unit for the duration of the shift. The Charge Nurse provides direct care, administers treatments and medications, organizes and distributes daily assignments to direct care staff consistent with staff competency and each individual resident’s comprehensive resident observation and plan of care. This position also supervises direct care staff, including participating in the hire and termination process, doing annual performance reviews and raises and performing disciplinary actions. This position makes decisions about resident care needs during shift within scope of clinical competence, consistent with facility policies and procedures.

Responsibilities

• Make daily rounds on assigned unit at least at beginning and at end of shift to observe, assess or interview residents, to verify information for or from ongoing shift, to monitor regulatory compliance and to determine staff assignments or completion of assignments
• Develop and distribute resident care assignments to direct care staff. Assignments match resident needs with skills of direct care staff, and maintain consistency to the extent practicable. Adjust assignments according to availability of qualified staff. Change assignments if necessary during shift to meet resident needs
• Provide orientation to unit and unit routines to new staff members or staff from temporary agencies
• Perform performance evaluation reviews for staff, including determination of wage increases if applicable
• Correct staff performance and administer discipline, if required
• Train and develop staff by conducting skills observations of nurse aides identifying learning needs and taking advantage of opportunities to teach on the unit
• Keys information into computer systems, including EMR
• Describe care plan goals and approaches to direct care staff so that care plan is consistently implemented on all shifts by all caregivers. Seek input from nurse aides about resident condition, functional abilities, preferences and alternative approaches to care. Monitor delivery of care and services throughout shift to ensure needs are met, tasks are completed and that work of direct care staff is of acceptable quality and quantity
• Administer medications, treatments and provide direct care to residents on unit according to physician orders and in compliance with facility policies and procedures
• Perform physical observation of new admissions and current residents as indicated by change in condition or as required by regulation. Complete assigned sections of resident observation instruments used in facility
• Based on observation of the resident’s condition, develop or revise the plan of care with interventions and time measurable objectives to assist each resident to attain or maintain highest practicable physical, mental and psycho social well being. Develop or revise the plan of care with participation of the interdisciplinary team members and resident to the extent feasible. Consult with and refer relevant resident care issues to attention of interdisciplinary care team members
• Coordinate care and delivery of services with all disciplines, outside agencies and community providers as required
• Respect rights of residents regarding freedom of choice, consent for care and services, refusals of treatment and implementation of advance directives if any. Promptly consult with nursing supervisor and Social Worker if unsure of proper course of action that respects resident's rights, comply with facility policies and procedures that is consistent with county, state and federal laws and regulations, as applicable, including abuse reporting
• Complete required documentation of care and services delivered during shift including subjective findings, objective symptoms, interventions and resident responses to interventions. Complete required documentation of special circumstances including accident/incident reports in compliance with facility policy and procedures and regulations
• Present to the on-coming shift or receives from the off-going shift charge nurse a report making special note of significant changes in condition, admissions, transfers, discharges, initiation or use of physical or chemical restraints, incidents, unexplained injuries, medication errors, loss of resident property or expression of resident and/or family complaint or concern
• Inform the resident in advance about care and treatment and any changes to the plan of care
• Immediately inform the resident, consult with the resident’s physician and notify the designated family member and/or the resident’s legal representative when there is an accident involving an injury which has potential for requiring physician intervention; a significant change in the resident’s physical, mental or psycho social status; a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility. Promptly notify the resident, designated family member and/or resident’s legal representative when there is a change in room or roommate
• Report relevant information to the Supervisor including, interdisciplinary team functioning and communication, regulatory compliance issues, quality improvement issues, resident risk factors, sudden changes in resident behavior, expressed dissatisfaction by resident or family, refusals of treatment, unexplained injuries, staff conduct
• Monitor staff for compliance with OSHA mandates on workplace safety including hazard communication and blood staff member for post-exposure follow-up
• Report all injuries to self or others to supervisor immediately
• Take job actions with staff members under appropriate circumstances. Apply facility policies about progressive discipline correctly. Remove staff member from unit if necessary to avoid endangerment to health and safety of residents or other staff members. Report all job actions taken to supervisor promptly
• Attend in-service education programs as assigned. Apply information to job tasks
• Assist supervisor with preparation for long term care survey. Attend survey training, interacts with state surveyors as instructed by supervisor