MDS Nurse (Lpn / RN)

Purpose of Your Job Position

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

Delegation of Authority

As Resident Assessment/Care Plan Coordinator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. 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.

Duties and Responsibilities

Administrative Functions

• Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation of RAPs and Triggers.

• Maintain and periodically update written policies and procedures that govern the development, use, and implementation of the resident assessment (MDS) and care plan.

• Perform administrative duties such as completing medical forms, reports, evaluations, studies, etc., as necessary.

• Develop, implement, and maintain an ongoing quality assurance program for the resident assessment/care plans.

• 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.

• Monitor the facility's QI and QM reports to ensure that appropriate corrective action can be implemented when potential problems areas occur.

• Ensure that all assessments are completed and transmitted in a timely manner. Report problem areas to the administrator.

Ensure that a current copy of the MDS Instructor's Manual is available to persons completing portions of the MDS.

• 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.

Committee Functions

• Act as Chairperson of the Interdisciplinary Care Plan Team.

• Work with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident.

• Serve on, participate in, and attend various other committees of the facility (e.g., Policy Advisory, Quality Assessment, and Assurance) as required, and as appointed by the Administrator.

• Provide written and/or oral reports of the resident assessment/care plan functions as requested or directed by committees.

• Participate in functions involving discharge plans as may be necessary.

• Evaluate and implement recommendations from established committees as they may pertain to the assessment and/or care plan functions of the facility.

Personnel Functions

• Maintain an effective, friendly working relationship with health professionals, physicians, consultants, and governmental agencies that may be involved in the resident assessment/care plan functions of the facility.

• Meet with and solicit advice from department supervisors concerning the resident assessment/care plan functions of the facility.

• Report known or suspected incidents of fraud to the Administrator.

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

Nursing Care Functions

• Conduct or coordinate the interviewing of each resident for the resident's assessment.

• 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.

• Develop and implement procedures with the Director of Nursing Services to inform all assessment team members of the arrival of newly admitted residents.

• Assist facility directors and supervisors in scheduling the resident assessment/care plan meetings.

• Contact and 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.

Staff Development

• 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 the In-service Director/Educator 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.).

• Attend and participate in annual facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.)

• Attend and participate in advance directive in-service training programs for the staff and community.

• Attend and participate in continuing education programs designed to help you keep abreast of changes in your profession, as well as to maintain your license on a current status.

• Conduct training programs for appropriate staff on the completion and use of the MDS.

Care Plan and Assessment Function

• Develop preliminary and comprehensive assessments of the nursing needs of each resident, utilizing the forms required by current rules or regulations and facility policies.

• Ensure that appropriate health professionals are involved in the assessment.

• Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the penalties, including civil money penalties, for false certification.

• Coordinate 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 the care plan includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the resident's assessment.

• Ensure that an initial resident assessment is completed within fourteen days of the resident's admission.

• Ensure that a comprehensive care plan is completed within twenty-one days of the resident's admission.

• 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.

• Develop the schedule of activities required for the resident assessment and plan of care.

• Assist the Director of Nursing Services and relevant directors/supervisors of other departments in ensuring that all personnel involved in providing care to the resident are aware of the resident's care plan and that nursing personnel refer to the resident's care plan prior to administering daily care to the resident.

• Ensure that quarterly and annual resident assessments and care plan reviews are made on a timely basis.

• Ensure that a complete resident assessment is conducted within fourteen days of a significant change in the resident's condition.

• Coordinate the review and revision of the resident's care plan by the interdisciplinary team after each quarterly review or other assessment, assuring that the care plan is evaluated and revised each time an assessment is done or when there is a change in the resident's status.

• Assist the Director of Nursing Services and other relevant directors and supervisors in maintaining good rapport and morale between and within departments to ensure that a team effort is achieved in developing and implementing a comprehensive assessment and plan of care.

• Inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).

• Ensure that each portion of the assessment is signed and dated by the person completing that portion of the MDS.

• Sign and date the assessment instrument to certify its completion.

• Ensure that medical and nursing care is administered in accordance with the resident's wishes, including the implementation of advance directives.

Budget and Planning Functions

• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

Resident Rights

• Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information.

• Ensure that all residents are treated fairly, and with kindness, dignity, and respect.

• Ensure that resident interviews are conducted in private.

• Ensure that all members of the assessment team and the interdisciplinary care planning/medical and nursing team are knowledgeable of the residents' responsibilities and rights including the right to refuse treatment.

• Ensure that nursing staff personnel honor the resident's refusal of treatment request. Ensure that such requests are in accordance with the facility's policies governing advance directives.

• Ensure that the facility's policies and procedures governing advance directives are reviewed with the resident and/or representative.

• Report and investigate all allegations of resident abuse and/or misappropriation of resident property.

• Review any complaints or grievances made by residents regarding the resident assessment or care plan.

• Ensure that a written record is made of any resident's complaints or grievances with a full accounting of any actions taken and the current status of the complaint.

Other Duties

• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Working Conditions

• Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses' stations, resident rooms, etc.).

• Moves intermittently during working hours.

• Is subject to frequent interruptions.

• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.

• Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.

• Communicates with the medical staff, nursing personnel, and other department directors.

• Works beyond normal working hours and on weekends and holidays when necessary.

• Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).

• Is involved in community/civic health matters/projects as appropriate.

• Attends and participates in continuing educational programs.

• Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

• May be subject to the handling of and exposure to hazardous chemicals.

• Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents' needs.

Education

• Must possess, as a minimum, a Nursing Degree from an accredited college or university.

Experience

• Must have, as a minimum, two (2) years of experience as a supervisor in a hospital, nursing care facility, or other related health care facility.

• Must have, as a minimum, six (6) months training experience in rehabilitative and restorative nursing practices.

Specific Requirements

• Must possess a current, unencumbered, active license to practice as a Registered Nurse in this state.

• Must be able to read, write, speak, and understand the English language.

• Must demonstrate the knowledge and skills necessary to prove care appropriate to the age-related needs of the residents served.

• Must be a supportive team member, contribute to, and be an example of team work and team concept.

• Must possess the ability to make independent decisions when circumstances warrant such action.

• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.

• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.

• Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.

• Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.

• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.

• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.

• Must be able to relate information concerning a resident's condition.

• Must not pose a direct threat to the health or safety of other individuals in the workplace.