Position Summary

The primary responsibility of the MDS Nurse is to organize, complete and evaluate resident assessment and plan of care in accordance with current applicable state, federal guidelines/ regulations and as may be directed by the Director of Nursing to ensure each resident is encouraged to attain the highest possible level of functioning.

Essential Functions, Key Duties, & Responsibilities

• Assume the authority, responsibility and accountability of coordinating the MDS, CAAS and care planning process for each resident upon admission.
• Complete triple check at beginning of month for all Medicare, Managed care and outpatient therapies.
• Observe and report changes in residents’ physical and emotional condition to the Unit Nurse
• Weekly management and update of the 672/802 as needed.
• Establish care plan dates within 7 days of completion of MDS or Quarterly review, in accordance with state and federal regulations/guidelines.
• Ensure that nursing documentation reflects the care plan being followed when administering nursing care or treatment.
• Document information obtained in the assessment process.
• Establish Assessment Reference Dates (ARD) for residents and communicate with the interdisciplinary team on the ARDs.
• Interview and observe residents and families to obtain a complete and accurate assessment before completing the MDS.
• Consult with resident’s physician in providing the resident’s care, treatment, rehabilitation, etc. as necessary.
• Participate in the community’s Quality Improvement and Quality Assurance program for the nursing service department.
• Participate in community surveys (inspections) made by authorized governmental agencies as requested.
• Report and assist in investigation of allegations of resident abuse, neglect and/or misappropriation of resident property as needed.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting etc., as needed.
• Create and maintain a professional atmosphere while demonstrating a positive attitude and caring demeanor under all conditions.
• Provide information for forecasting future revenue projections based on past utilization of service, case mix history, and industry trends.
• Develop and implement training on required supportive documentation for the MDS and the electronic health records.
• Promote and respect the dignity and well-being of each resident.
• Encourage resident and/or family to participate in the assessment and care planning process and to attend care plan conference via telephone and written correspondence.
• Provide administration with information regarding quality of care issues.
• Serve as a resource to other department personnel regarding resident assessment and care plan development.
• Mentor MDS Nurses so as to foster their professional growth and expand their knowledge of the assessment and care planning process.
• Respond immediately to all crises or calls for assistance as needed.
• Perform other duties as assigned.
• Comply with all policies and procedures and any updates.

Position Requirements

Education: A nursing degree from an accredited college or university

Licenses/Certifications: Current unrestricted license as a Licensed Practical Nurse (LPN) or Registered Nurse (RN) in practicing state

Experience: 2+ years of MDS experience

Skills & Abilities:

• The ability to anticipate needs of residents/clients and co-workers in a pro-active fashion seeking to meet those needs even before a formal request is made.
• Excellent verbal and written communication skills.

Travel: N/A

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