Job Description
POSITION SUMMARY The primary purpose of your job position as MDS Nurse is to provide direct care to residents. In your role as MDS Nurse, you will work to restore or maintain the resident's health and well-being by assisting the MDS Coordinator with health and
wellness problem identification (actual/potential), goal setting within the patient care plan, and establishing appropriate medical interventions.
The MDS Nurse will conduct and coordinate the development and completion of the Resident Assessment in accordance with current federal, state, and local standards that govern the Facility, and as directed by management.
ESSENTIAL DUTIES AND RESPONSIBILITIES - Provide direct care to residents in accordance with their patient care plan including assisting with problem identification (actual/potential), goal setting with the patient care plan, and establishing appropriate medical interventions.
- Assess the resident care planning process completion and accuracy and monitor the level of care changes and determinations.
- Complete charting in medical records, to the extent required, in an accurate and timely manner.
- Implement patient-centered quality improvement initiatives to further the quality of care resident's receive.
- Perform Resident Assessment including, including collecting and documenting medical history, current medications, and functional abilities, to develop an accurate resident patient care plan by interviewing residents and family members. Frequent visits to resident rooms, therapy rooms, and other areas throughout
- the facility to obtain resident records and other information.
- Supervise and assist in the development of individual resident care plans.
- Monitor patient's condition and report any changes in a patient's condition identified by the MDS Assessment to the DON and Physician
- Ensure resident care plan is being followed by IDT and monitor IDT progress in tandem with patient's progress to ensure compliance with the MDS process.
- Ensure that residents' present/potential health and wellness problems are identified and prioritized and that appropriate medical intervention is taken to address any present or potential health and wellness problems or risks.
- Ensure that direct care is provided to residents including, preventive measures, treatments, medications, diet and other health services prescribed by the attending physician are promptly carried out and documented, and recommend and implements changes in the administration of direct care, treatment methods, and care plans.
- Report any changes in a patient's condition identified by the MDS Assessment to the DON and Physician Ensure resident care plan is being followed by IDT and monitor their progress to ensure compliance with the MDS process.
- Complete medical forms, charts, and reports in an accurate and timely manner.
- Ensure that the Minimum Data Set (MDS) form is completed in accordance with State and Federal regulations and medical standards.
- Understand long-term care reimbursement process including PDPM, Managed Care and Medicaid, triple check, etc.
- Participate in resident care conferences.
- Participate in the QAPI process as they relate to direct patient care.
- Monitor Quality Care Indicators as they relate to direct patient care.
- Abide with all facility policies and procedures including not disclosing user ID codes and passwords.
- Report any occupational exposures to blood, body fluids, or other hazardous materials to a supervisor immediately.
- Participate in facility surveys (inspections) when required and assisting with plan of corrections as well as follow up.
- Attend Facility staff meetings and serve on Facility committees as requested
Every effort has been made to identify the essential functions of this position. However, it in no way states or implies these are the only duties you will be required to perform as directed by management. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.
REQUIREMENTS Education / Licensure
- LVN training from an accredited school or college
- Valid LVN license in good standing
- Valid CPR and BLS card
Qualifications / Experience
- Minimum of 1 year of skilled nursing experience preferred
- Must be able to speak, read, write and comprehend the English language
- Ability to use computer/tablet to enter resident data
- Proficiency with PCC a plus
Working Conditions
- May encounter frequent interruptions
- May be involved with residents, family and government agencies
- May be requested to work beyond scheduled working hours at times
- May be exposed to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses
Physical Requirements
- Must be able to move intermittently throughout the day
- Working throughout the nursing areas
- Repetitive hand motion
- Ability to read fine print on tablet, progress notes and/or medical labels
Job Tags
Local area, Immediate start,