Ratings:

3 = Exceeds Expectations

2 = Meets Expectations

1 = Needs Improvement

Annual

Evaluation

Date:

____/___/____

Notes:

Make rounds at the beginning and end of shift.

Perform Admission Assessments on new and re-admissions.

Consult with a resident’s physician in providing the resident’s care, treatment and rehabilitation as necessary.

Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.

Report all complaints and grievances made by a resident immediately.

Participate in and receive the nursing report upon reporting for duty.

Follow established policies concerning exposure to blood/body fluids.

Review each resident’s records for specific treatment, medication orders, diets, etc.

Review lab reports and notify physicians of results to determine appropriate follow-up.

Notify and provide an accurate assessment to the attending physician when a resident has an accident or incident or when there is a change in the resident’s condition.

Notify resident’s family and/or responsible party when a resident has an accident or incident or when there is a change in the resident’s condition.

Administer professional services such as medication administration, catheterization, tube feeding, suctioning, applying and changing dressings/bandages, packs, colostomy and drainage bags, taking vital signs, transferring residents, feeding, toileting, etc. as required. Document the provision of services accurately and on a timely basis.

Obtain sputum, urine, stool and other specimens for lab tests as ordered.

Monitor seriously ill residents as necessary

Assess resident’s skin for signs of breakdown and take immediate action for treatment when indicated.

Institute and maintain preventative measures for skin breakdown.

Ensure that residents with decubitus ulcers receive appropriate treatment such as daily inspection of wounds turning and positioning, nutritional support and maintaining a clean/dry bed.

Ensure that the GNA’s and CMA’s are providing direct care to the residents and are providing such care in accordance with each resident’s care plan and wishes.

Meet with residents and/or family members as necessary.

Inform the family member of the death of a resident; contact the funeral home when requested by the family; follow policy for postmortem care.

Medication Administration

Ratings:

3 = Exceeds Expectations

2 = Meets Expectations

1 = Needs Improvement

Annual

Evaluation

Date:

____/____/____

Notes:

Prepare and administer medications as ordered by the physician within the specified time frames and according to established policy.

Document acceptance and/or refusal of medications per policy.

Administer medications orally, topically, by feeding tube, intramuscularly, subcutaneously or rectally as specified per physician’s order.

Administer all physician ordered nourishments.

Assess and observe residents for drug interactions and adverse reactions.

Assess need for PRN medications; assess and record effectiveness of administered dose.

Verify the identity of the resident before administering medication.

Ensure that prescribed medication for one resident is not administered to another.

Ensure that an adequate supply of medications for assigned residents, floor stock medications, supplies and equipment are on hand to meet the nursing needs of the residents.

Maintain medicine cart in a neat, clean and orderly manner.

Order prescribed medications, supplies and equipment as necessary and in accordance with Fahrney-Keedy and pharmacy policies.

Count narcotics accurately for the shift and document.

Dispose of drugs and narcotics as required and in accordance with established procedures.

Treatment Administration

Ratings:

3 = Exceeds Expectations

2 = Meets Expectations

1 = Needs Improvement

Annual

Evaluation

Date:

____/____/____

Notes:

Perform sterile and clean dressing changes as ordered and per facility policy; label, date and initial dressings.

Assess wound appearance, stage, drainage, size and document on skin grid per policy.

Administer tube feedings per physician’s orders (continuous or bolus) and flushes per physician’s order and policy.

Insert/change urinary catheters (Foley and suprapubic) per physician’s orders and policy.

Irrigate Foley catheters per physician’s orders and policy.

Insert/change gastric tubes per physician’s orders and policy.

Administer oxygen and respiratory treatments.

Change oxygen tubing and other respiratory equipment per policy.

Perform Colostomy Care as ordered.

Administer douches and enemas as ordered.

Assess and document resident’s response to treatments and procedures.

Charting & Documentation

Ratings:

3 = Exceeds Expectations

2 = Meets Expectations

1 = Needs Improvement

Annual

Evaluation

Date:

____/____/____

Notes:

Complete required electronic documentation upon resident’s admission, transfer and discharge.

Ensure that attending physicians review, record and sign their progress notes and orders in accordance with policies.

Receive telephone orders from physicians and record accurately.

Transcribe physician’s orders to residents’ electronic charts, MAR, TAR, ADL and Lab books accurately.

Electronically 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 care. Review previous nurses’ notes to assure continuity and follow-up.

Electronically chart all reports of accidents, incidents and change of condition.

Complete incident report for all accidents and injuries – witnessed or unwitnessed; initiate unwitnessed injury investigation when indicated.

Electronically record new or changed diet orders and forward information to Dietary Department.

Report all discrepancies noted concerning physician’s orders, diet changes, charting errors, etc. Complete Medication Error Reports as indicated.

Electronically document medication and treatment administration and refusal and response to drugs per facility policy. Report refusal of medications to physicians.

Notify the scheduler when you will be late or absent from work – at least two hours prior to your shift start time.

Report work-related injuries or illnesses and/or occupational exposures to blood, body fluids, infectious materials and hazardous chemicals to the supervisor.

Report known or suspected incidents of fraud to the supervisor.

Administrative Functions

Ratings:

3 = Exceeds Expectations

2 = Meets Expectations

1 = Needs Improvement

Annual

Evaluation

Date:

____/____/____

Notes:

Participate in employee performance evaluations, providing information on the performance of GNA’s and CMA’s to the Director of Nursing.

Develop and maintain a good working rapport with intradepartmental and interdepartmental staff to ensure that Nursing Services can be adequately maintained to meet the needs of the residents.

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 supervisor.

Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the supervisor.

Report any known or suspected unauthorized attempts to access the facility’s information system to the supervisor.

Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.

Safety & Infection Control

Ratings:

3 = Exceeds Expectations

2 = Meets Expectations

1 = Needs Improvement

Annual

Evaluation

Date:

____/____/____

Notes:

Observe and follow established infection control policies and procedures; ensure that staff follows procedures and that par levels of personal protective devices are available.

Ensure that the nursing unit is maintained in a clean and sanitary manner.

Ensure that residents’ rooms and common areas are maintained in a clean, safe, sanitary manner.

Participate in all fire safety and disaster preparedness drills in a safe and professional manner.

Follow established safety regulations for the use of equipment and supplies and ensure that staff follow established policies for their use.

Report broken or damaged equipment and supplies and complete online TELS work orders as indicated.

Participate in Fall Risk Management program and other specialty programs and ensure GNA’s and CMA’s are aware of residents at risk.

Institute appropriate infection control procedures when residents require specific precautions and/or isolation.

Practice appropriate handwashing and use of hand sanitizer at all times.