Job Description

The primary purpose of this position is to with the completion of the resident assessment in accordance with the requirements of this state and the policies and goals of this facility.

Care Plan and Assessment Functions

• Assist in the development and completion of the Minimum Data Set (MDS) assessment in accordance with current rules, state and federal regulations, and guidelines that govern the resident assessment, including the implementation and completion of CAAs, CAT and Care Plan.
• Assist the resident and Discharge Planning Coordinator in completing the care plan portion of the resident's discharge plan.
• Participate in facility surveys (inspections) made by authorized government agencies.
• Work with the Interdisciplinary Care Plan Team in completing a comprehensive resident assessment and care plan for each resident.
• Evaluate each resident's condition and pertinent medical data to determine any need for special assessment activities or a need to amend the admission assessment.
• Assist in scheduling participation by outside members of the care plan team, including the resident's representative and/or other interested family members. Ensure that care provided is in accordance with the resident's wishes and interests.
• Develop and participate in the planning, conducting, and scheduling of timely in service training classes that include assessment skills or techniques needed to complete the assessment functions of the facility.
• Assist in developing any training activities needed concerning resident assessment/care plan skills (including, but not limited to initial or refresher courses relative to techniques for interviewing residents, rehabilitation principles, commonly used psychotropic drugs, care plan functions, etc.).
• Assist in the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care. Ensure that appropriate health professionals are involved in the assessment. Assist the nursing staff in encouraging the resident and his/her family to participate in the development and review of the resident's plan of care.

Required Knowledge, Skills and Abilities

Must possess the ability to make independent decisions, follow instructions, and accept constructive criticism. Must be able to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public. Must be able to work with ill, disabled, elderly, and emotionally upset people within the facility. Must be able to speak, write and understand English in a manner that is sufficient for effective communication with supervisors, employees, residents, and families.

Education and Experience

• Minimum of 1 year experience as an RN
• Prefer two years experience in a clinical capacity within a long-term care facility.
• Must have experience in supervision and principles, practice of teaching, etc.
• Must possess skills in leadership and communication.
• Must possess creativity, integrity, and initiative. 
• Must be able to provide critical thinking skills to address clinical issues.
• Must be proficient in Microsoft Word.

Licensing/Certifications

Must possess a current and active license to practice as an RN in this state.

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