Responsible for the development, oversight, coordination, and evaluation of the facility’s Restorative Nursing and Wound Care Programs. This position functions in a leadership capacity, providing oversight of restorative services, wound management, preventive practices, interdisciplinary collaboration, documentation integrity, and quality improvement initiatives. Performance to reflect such of a clinical leader and program owner, ensuring high-quality, evidence-based care that promotes skin integrity, wound healing, functional maintenance, and regulatory compliance in accordance with federal, state, and JCAHO standards governing the facility.

1. In addition to the duties, essential functions, and performance expectations of the Restorative/Treatment Nurse position, the duties, essential functions, and performance expectations outlined in the LPN (Charge Nurse) job description apply to this position and are expected to be performed when assigned.
   1. The nurse is expected to assume charge responsibilities as needed, including supervision of nursing assistants, coordination of resident care, medication administration, treatments, assessments, documentation, and response to changes in resident condition.
   2. The nurse will support daily nursing operations and staffing needs, maintaining flexibility to assist with admissions, condition changes, emergency response, and direct resident care.
   3. This role does not exempt the nurse from routine clinical responsibilities; rather, it adds specialized program oversight responsibilities in restorative and wound care.
   4. When operational needs require, the nurse will prioritize resident safety and nursing department workflow, performing all assigned clinical duties consistent with the LPN (Charge Nurse) role.
2. The Restorative/Treatment Nurse plans, develops, organizes, implements, and directs restorative and wound care services for residents requiring such services.

Services include, but are not limited to:

• Assesses residents to determine restorative nursing and skin integrity needs.
• Develops, documents, and updates individualized care plans with measurable objectives and defined interventions.
• Provides ongoing oversight of restorative programs and wound management plans.
• Conducts regular (weekly/monthly) evaluations of resident progress and adjusts interventions as clinically indicated.
• Ensures restorative and wound documentation is accurate, timely, and reflective of resident status.
• Maintains current program caseload lists, including lists for residents receiving restorative services, residents requiring splints or braces, restorative dining participants, and residents with active wounds or high risk for skin breakdown.

3. Lead and oversee the facility’s Restorative Nursing and Wound Care Programs, ensuring evidence-based, high-quality care that promotes skin integrity, wound healing, functional maintenance, and regulatory compliance.
4. Oversees wound care supply inventory, evaluates cost-effectiveness of wound products, collaborates with vendors and pharmacy to ensure appropriate product selection and availability, and monitors restorative equipment condition and availability.
5. Role in Collaboration with Nursing Leadership:
   1. Collaborates with the Director of Nursing to ensure facility policies and procedures in the development, review, and revision of clinical policies and procedures to ensure alignment with current federal and state regulations, evidence-based practice, and facility standards of care.
   2. Assist in maintaining regulatory compliance by reviewing policies related to restorative nursing, wound care, skin integrity, fall prevention, accident prevention, infection control, and quality of care to ensure consistency with CMS F-Tag guidance and state survey expectations.
   3. Identify practice gaps and recommend policy revisions based on audit findings, QAPI data, incident trends, survey outcomes, and changes in regulatory guidance.
   4. Support implementation of new or revised policies by developing workflows, competency tools, education materials, and communication plans to ensure operational consistency across nursing departments.
   5. Monitor adherence to policies and procedures through routine audits, documentation review, and direct observation; report findings and improvement recommendations to the DON.
   6. Collaborate with the DON in corrective action planning following surveys, audits, or adverse events, ensuring policy updates and staff re-education are completed timely.
   7. Participate in interdisciplinary review of clinical protocols to ensure policies reflect realistic workflows, promote resident-centered care, and support reimbursement integrity.
   8. Assist DON to maintain organized policy documentation and revision logs, ensuring version control, accessibility, and readiness for regulatory review.
   9. Serve as a clinical resource to nursing staff regarding policy interpretation and application, reinforcing consistency, accountability, and adherence to standards of care.
   10. Promote a culture of continuous improvement by working with the DON to evaluate existing processes and proactively revise policies to enhance quality, safety, and operational efficiency.
6. Assist in identifying residents appropriate for restorative nursing programs upon admission, quarterly review, or significant change to support functional maintenance and prevent decline.
7. Assess residents upon admission and with condition changes to determine restorative needs, skin integrity risks, and wound care requirements; develop and update individualized care plans with measurable goals and defined interventions.
8. Direct and monitor restorative nursing services, including range of motion, splint/brace management, bed mobility, transfers, ambulation, ADL retraining, prosthesis care, restorative dining, swallowing support, and communication interventions.
9. Maintain and manage program caseloads, including residents receiving restorative services, splint/brace users, restorative dining participants, and those with active wounds or high skin risk.
10. Perform and oversee comprehensive wound assessments and treatments, including pressure injuries, diabetic ulcers, vascular ulcers, traumatic wounds, and other complex skin conditions, in accordance with physician orders and best-practice standards.
11. Complete and document weekly wound evaluations (or more frequently as clinically indicated), accurately recording staging, measurements, healing progression, and treatment effectiveness.
12. Monitor and ensure implementation of preventive measures, including repositioning schedules, offloading techniques, pressure-relieving devices, nutrition/hydration support, and incontinence management.
13. Supervise day-to-day facility operations and assist in validating staff competencies related to restorative techniques, wound treatments, pressure injury prevention, body mechanics, and adaptive equipment use.
14. Review restorative and wound documentation for accuracy, compliance, and reimbursement integrity, ensuring alignment with Medicare/Medicaid and regulatory standards.
15. Collaborate with the interdisciplinary team (IDT) including therapy, physicians, dietary, nursing, and social services to coordinate care plans and promote continuity of care.
16. Provide education to staff, residents, and families regarding wound prevention, healing strategies, restorative goals, and functional maintenance.
17. Track, trend, and report quality indicators, including pressure injury prevalence/incidence, wound healing outcomes, functional decline patterns, and any areas based on the needs of the facility and system areas identified in need of improvement.
18. Participate in QAPI initiatives and regulatory survey preparation, ensuring compliance with federal and state regulations.
19. Report significant changes in resident condition promptly to the physician, RN Supervisor, and Director of Nursing, and provide routine wound status updates to nursing leadership.
20. Promote a proactive, prevention-focused culture centered on skin integrity, fall prevention, functional preservation, and measurable clinical outcomes.
21. Support survey readiness and corrective action planning, maintaining organized documentation and audit data to demonstrate compliance and program effectiveness.
22. Role in MDS (Minimum Data Set):
    1. The Restorative/Treatment Nurse is responsible for completing and validating MDS Sections G, H, M, and O0500 in accordance with CMS RAI guidelines, ensuring documentation accurately reflects ADL function, continence status, skin integrity, and restorative services provided. This role collaborates with the interdisciplinary team to ensure regulatory compliance, care plan alignment, and accurate PDPM reimbursement support.
    2. Collaborate with the MDS Coordinator and interdisciplinary team (IDT) to ensure accurate coding of restorative nursing services, skin conditions, wound treatments, and functional status.
    3. Provide timely clinical documentation to support MDS coding, including restorative program participation qualifying restorative services per RAI guidelines.
    4. Validate restorative program eligibility by ensuring services meet regulatory definitions and are distinct from routine nursing care.
    5. Ensure accurate documentation of pressure injuries and other skin conditions, including stage, size, treatment, and healing progression, consistent with MDS Section M requirements.
    6. Participate in Medicare PPS and OBRA assessment reviews, ensuring restorative and wound-related services are reflected appropriately for PDPM reimbursement.
    7. Monitor and report changes in resident functional status (ADLs, mobility, transfers, swallowing, communication) that may impact MDS coding in Sections G, GG, K, and O.
    8. Review MDS drafts as requested to ensure consistency between clinical documentation, physician orders, care plans, and coded data.
    9. Communicate condition changes promptly to the MDS coordinator, including new pressure injuries, wound deterioration or healing, significant functional decline or improvement, initiation or discontinuation of restorative services.
    10. Ensure restorative and wound documentation supports skilled criteria and reflects medical necessity, measurable goals, and ongoing evaluation.
    11. Assist with audit preparedness and survey readiness related to MDS accuracy, restorative qualification standards, and pressure injury coding compliance.
    12. Support QAPI initiatives related to MDS accuracy, including trending restorative participation rates, pressure injury prevalence, and functional decline patterns.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Current Alabama LPN license in good standing.  One (1) or more year of experience as LPN in long-term care or sub-acute rehabilitation. BLS certification required within 150 days of employment. Must be able to read, write, speak, and comprehend English. Computer skills for general knowledge of facility computers preferred. Demonstrates good communication skills for all population served. Must have positive attitude toward the elderly.

Leadership and Professional Skills

• Demonstrates strong leadership, sound clinical judgment, and accountability.
• Effectively delegates tasks in accordance with scope of practice and resident needs.
• Manages conflict and stressful situations with professionalism and composure.
• Communicates effectively with diverse personalities in face-to-face, phone, and electronic formats.
• Maintains professionalism when interacting with difficult or physically aggressive individuals.
• Works collaboratively within interdisciplinary teams.
• Performs effectively under time constraints and meets established deadlines.

Technology and Communication

• Proficient in electronic medical record systems and routine use of email, telephone, and text communication.
• Maintains professional interpersonal relationships and communication at all times.

Work Environment and Physical Requirements

• Medium work: exert up to 50 lbs. occasionally, 30 lbs. frequently, and 10 lbs. constantly
• Prolonged standing and walking
• Ability to bend, kneel, stoop, sit, reach, and lift
• Ability to reposition and transfer residents safely
• Ability to run/respond quickly in emergencies
• Manual dexterity sufficient for clinical tasks; able to perceive temperature, texture, and shape
• Hearing and vision normal or corrected
• Possible exposure to body fluids, infectious materials, and hazardous substances; PPE required
• Physical presence onsite required
• Ability to perform essential duties with or without reasonable accommodation