Assessment Nurse

February 23, 2021

Assists in planning, implementing, and evaluating nursing care with the Resident Assessment
Instrument (RAI) coordinator. If a Registered Nurse may be designated as RAI coordinator.
Assists with the pre-admission screening process, admission process and administration for therapy and nursing interventions. Is responsible for clinical documentation to include observing, recording, and reporting to the appropriate person the signs and symptoms that may be indicative of a change in the resident. Assists RAI Coordinator in communicating with the physician / nurses / CNA’s / coworkers / interdisciplinary team members and families as to resident’s condition or response to treatment. Follows and completed the RAI process including documentation requirements, Minimum Data Set (MDS), Care Area Assessment process, care plan development, and care plan implementation.

The Assessment nurse is responsible to the RN RAI Coordinator. (DON or RN Assessment
Nurse may act as RN RAI Coordinator)

EDUCATION:

Must be a graduate of an accredited school of nursing currently registered with the state agency for nursing licensure and hold a valid Nurse’s License in the state he/she is employed.

QUALIFICATIONS:

 Maintains current licensure as a Licensed Nurse. Demonstrates experience in geriatric nursing and long term care. Experience with nursing documentation, Minimum Data Set
(MDS) coding, and Case Management experience preferred. Demonstrates completion of on-going continuing education on subjects related to case management, regulatory requirements, restorative nursing, medical records documentation, legal aspects of documentation, etc. Demonstrates an attitude for providing a high degree of patient satisfaction and services. Demonstrates experience working in a positive collaborative relationship with members of the community, residents, families, and co-workers.

Job Responsibilities:

Demonstrated competency in the following area:

 Knowledgeable of federal, state, and local government regulations and legislation.
 Knowledge of the Minimum Data Set (MDS), Care Area Assessment process, care plan development, Discharge Plan and documentation requirements per state and federal regulations.

 Performs resident care responsibilities as required considering needs specific to the standard of care for the patient’s age.

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 Interacts with discharge planners and staff from referring facilities, agencies and hospitals to pre-screen potential residents for admission and readmission to the facility as directed by supervisor.

 Assists/performs screenings and/or evaluations of new admissions, pre-admissions, and re-admissions utilizing data collection and recording.

 Assist with the management and collaborates with the MDS Team on pre-admission screening, assignment of observation and look-back periods for the MDS completion including the implementation of a “significant change” MDS/plan of care processes.

 Performs data collection for the MDS process on residents and reassessments as per the
MDS scheduled requirements unless these are assigned to other clinical disciplines for completion.

 Assists in development and revision of plan of care as indicated by the resident’s response to treatment and the effectiveness of the overall plan of care in collaboration with the interdisciplinary team.

 Demonstrates the ability to directly perform treatments and provide services to the level of licensure.

 Knowledge of medication and their correct administration based on the age of the patient and their clinical condition.

 Communicates appropriately and clearly to the RAI Coordinator and other interdisciplinary team members (IDT) regarding the resident’s plan of care.

 Consults other departments as appropriate to provide for an interdisciplinary approach to the patient’s care.

 Demonstrates an ability to be flexible, organized, and functions under stressful situations.
 Treats residents and their families with respect and dignity; ensures resident confidentiality and privacy.
 Interacts professionally with resident/family and involves resident/family in the formation of the resident-centered plan of care.
 Works closely with DON to implement and coordinate all aspects of the facilities

Nursing Restorative Program.
 Assist with other job duties as directed.
 Provides job related staff teaching as necessary.
 Maintains a good working relationship both with all departments and with contacts from referring facilities and agencies.

Professional Requirements:

 Adheres to dress code, appearance is neat and clean.
 Completes educational requirements per policy.
 Maintains regulatory requirements.
 Reports to work on time and as scheduled. Completes work within designated time.
 Wears identification while on duty.
 Completes inservices and returns to work in a timely manner.

Language Skills:

 Ability to read and communicate effectively in English.

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Skills:

 Current knowledge of nursing theory and practice.
 Ability to develop resident-centered plans of care.
 Ability to document resident care outcomes.
 Ability to organize and implement RAI schedules.