Per Diem LVN: Lead Nurse for Resident Care

Houston Transitional Care in; Houston (TX); On-site; USD 80,000 - 110,000; Full time

Job summary

Houston Transitional Care in is seeking a nurse leader to provide direct nursing care and supervise day-to-day nursing activities in a long-term care facility. This role ensures compliance with federal, state, and local standards while coordinating with the Director of Nursing Services to maintain high-quality resident care.

Responsibilities include directing nursing assistants, maintaining policies, reviewing procedures, preparing reports, and participating in discharge planning, QA activities,

Responsibilities

• Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
• Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility.
• Periodically review the department's policies, procedure manuals, job descriptions, etc. Make recommendations for revisions.
• 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. Participate in the updating of the resident's written discharge plan as required.
• Assist in planning the nursing services portion of the resident's written 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.
• 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.
• Report any known or suspected unauthorized attempt to access facility's information system.
• Complete 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., in accordance with established policies.
• 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. Submit to Director as required.
• Chart all reports of accidents/incidents involving residents. Follow established procedures.
• Record new/changed diet orders. Forward information to the Food Services Department.
• Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor.
• 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. Report needs to the Nurse Supervisor.
• 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. Report problem areas to the Nurse Supervisor.
• 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

Job description

Houston Transitional Care in is seeking a nurse leader to provide direct nursing care and supervise day-to-day nursing activities in a long-term care facility. This role ensures compliance with federal, state, and local standards while coordinating with the Director of Nursing Services to maintain high-quality resident care.

Responsibilities include directing nursing assistants, maintaining policies, reviewing procedures, preparing reports, and participating in discharge planning, QA activities,