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Baylor RN or LPN Licensed Practical Nurse

Company: North Raleigh Universal Healthcare
Location: Raleigh
Posted on: March 18, 2023

Job Description:


Job Summary

The Licensed Practical Nurse (LPN) provides direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision and service must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern our facility to always maintain the highest degree of quality care.

Essential Functions

Every effort has been made to make your job description as complete as possible. 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 a logical assignment to the position.

Residents Rights

Knows and respects patients' rights.

Ensures protected health information is kept confidential. Reports potential issues.

Reports complaints made by residents/patients to supervisor.

Reports all allegations of patient abuse, neglect and/or misappropriation of patient property.

Safety and Sanitation

Follows established safety policies and procedures.

Observes safety needs of patients as indicated in care plan.

Wears and/or uses safety equipment and supplies when indicated and properly trained to use.

Demonstrates job-specific knowledge of fire and disaster preparedness during drills or actual situations.

Staff Development

Attends and participates in scheduled in-service training, educational classes, and meetings to maintain current certification and licensure and as managed by regulatory agencies and company policies.

Serves on, participates in, and attends various other committees of the facility as required, and as appointed by the Executive Director or Director of Health Services.

Completes assigned Relias training.

General Nursing Care Responsibilities

Identifies and participates in process improvement initiatives that improve the customer experience, enhance workflow, and/or improve the work environment.

Directs the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the long-term care industry.

Confirms that all nursing personnel assigned comply with the written policies and procedures established by the facility.

Meets with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs and activities.

Verifies that all nursing personnel comply with organization policies and procedures.

Makes written and oral reports/recommendations concerning the activities of shift, as required.

Cooperates with other resident services when coordinating nursing services to make certain that the resident's total regimen of care is maintained.

Participates in the development, maintenance, and implementation of the facility's quality assurance program for the nursing department.

Periodically reviews the resident's written discharge plan. Participates in the updating of the resident's written discharge plan, as required.

Assist in planning the nursing portion of the resident's discharge plan, as necessary.

Admits, transfers, and discharges residents, as required. Complete admission documentation.

Completes accident/incident reports, as necessary.

Complete and file required forms/charts upon resident's admission, transfer, and/or discharge.

Encourages attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies.

Receives telephone orders from physicians and record on the Physicians' Order Form.

Transcribes physician's orders to resident charts, Kardex, medication cards, and treatment/care plans, as required.

Charts 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.

Records new/changed diet orders. Forwards information to Food & Nutrition Services department.

Reports all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the RN Supervisor, LPN Coordinator, or ADHS/DHS.

Fills out and completes transfer forms in accordance with established procedures.

Enters appropriate documentation concerning unauthorized discharges in the resident's medical record in accordance with established procedures.

Performs routine charting duties as required and in accordance with established charting and documentation policies and procedures.

Signs and dates all entries made in the resident's medical record.

Writes nurses' notes to reflect that the care plan is being followed when administering nursing care or treatment.

Prepares and administers medication as ordered by the physician.

Verifies identity of the resident before administering the medication/treatment.

Verifies prescribed medication for one resident is not administered to another.

Verifies adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Reports needs to the nurse supervisor.

Orders prescribed medications, supplies, and equipment as necessary, and in accordance with established procedures.

Verifies that narcotic records are accurate for your shift.

Notifies the nurse supervisor of all drug and narcotic discrepancies noted on your shift.

Reviews medication cards for completeness of information, accuracy in the transcription of the physician's order and adherence to stop order policies.

Notifies the attending physician of automatic stop orders prior to the last dosage being administered.

Immediately notifies the Nurse Supervisor and attending physician of any medication administration errors.

Delivers and maintains optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.

Promptly responds to call lights and assist with other resident needs.

Makes rounds with physicians, as necessary.

Participates in the orientation of new residents/family members to the facility.

Consults with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary.

Reviews the resident's chart for specific treatments, medication orders, diets, etc., as necessary.

Makes periodic checks to confirm that prescribed treatments are being properly administered by CNA's and to evaluate the resident's physical and emotional status.

Notifies the resident's attending physician when the resident is involved in an accident or incident.

Notifies the resident's attending physician and responsible party when there is a change in the resident's condition.

Administers professional services such as: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required.

Initiates requests for consultation or referral.

Monitors seriously ill residents, as necessary.

Reviews care plans daily to confirm that appropriate care is being rendered.

Confirms that CNAs are aware of the resident care plans. Verifies that the CNA'S refer to the resident's care plan prior to administering daily care to the resident.

Communicates appropriate information to team members, physicians, families, and supervisor.

Demonstrates a caring attitude toward facility's patients, family members, employees, and other company guests as the need arises; Ensures that subordinates are helpful, caring, and responsive to all guests.

Devotes adequate time and attention to personal development and training

Receives and responds to patient/family complaints.

Agrees 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 Executive Director and/or Compliance Department.

Performs any miscellaneous work assignments as may be required.

Food Service Responsibilities

Assists with meal service.

Monitors patients with significant weight loss and gain and reports this to the physician and dietary.

Identifies patients at risk for nutritional problems and implements preventative measures.

Checks items and food that is brought in by family members to assure it complies with patient's orders, dietary needs, and safety. Ensures such items are dated and labeled according to policy.

Documentation Responsibilities

Documents medications, treatments, prn's per facility policy.

Completes 24-hour report daily.

Monitors patient intake and output.

Accurately completes and is familiar with the forms used throughout the patient's chart and the Electronic Health Record (E.H.R.).

Documents in progress notes any exceptions to patient condition, including daily charting on ill patients, 24, 48, or 72-hour follow up charting on patients with infections, incidents, new admissions, or those with a change in condition.

Completes documentation to reflect progress or lack of progress of patients participating in therapy or restorative nursing

Interprets department policies and procedures to personnel, patients, visitors, and government agencies as required.

Ensures that all patient admissions, discharges, and transfers are entered timely in the E.H.R.

Reports any discrepancies noted concerning physician's orders, diet changes, charting errors, etc. to the Nurse Supervisor/Manager.

Care Plan Responsibilities

Assists in completion of the care plans (acute and long term) and is involved in the care conference as deemed necessary.

Ensures that the progress notes are reflective of the care plan and that the approaches on the care plan are being followed.

Assures that assigned nursing assistants are aware of the patient care plans and ensure that the nursing assistant refers to the care plan prior to administering care.

Administrative Responsibilities

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 Executive Director.

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

Report any known or suspected unauthorized attempt to access facility's information system.

Participate in facility surveys (inspections) made by authorized government agencies as requested.

Inform the Nurse Supervisor of staffing needs when assigned personnel fail to report to work; Report absentee call-ins to the supervisor.

Make daily rounds of unit to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to supervisor.


Must be a graduate of an approved LPN program and possess a current, unencumbered, active license to practice as an LPN in the state facility located.

Must have a current/active CPR certification.

Must have knowledge of skilled medical documentation.

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

Customer service oriented with the ability to work well under pressure.

Ability to work with minimal supervision, take initiative and make independent decisions.

Ability to deal with new tasks without the benefit of written procedures.

Approachable, flexible, and adaptable to change.

Persons who have been found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law; or who has a finding in the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, or has had a disciplinary action in effect taken against his/her professional license are not eligible for employment in this position.


One (1) year prior nursing experience preferred but not required.

Physical Demands

Moderate-extensive physical activity. Push, pull, move, and/or lift a minimum of twenty-five (25) pounds to a minimum height of three (3) feet and be able to push, pull, move, and/or carry such weight a minimum distance of fifty (50) feet. Standing and/or walking extensively per day. Bending and/or stooping, sitting, balancing, kneeling, crouching, reaching, handling, fingering, feeling, talking, hearing, tasting, smelling, near acuity, far acuity, depth perception.

Requires writing and/or computer work with repetitive typing and concentrating on computer screen and/or documents for extended periods.

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Keywords: North Raleigh Universal Healthcare, Raleigh , Baylor RN or LPN Licensed Practical Nurse, Healthcare , Raleigh, North Carolina

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