PROPOSED RULES
(Nursing Care Quality Assurance Commission)
Original Notice.
Preproposal statement of inquiry was filed as WSR 00-11-158 on May 24, 2000.
Title of Rule: WAC 246-840-910 Purpose, 246-840-920 Definitions, 246-840-930 Criteria for delegation, 246-840-940 Delegation decision tree, 246-840-950 How to make changes to the delegated tasks, 246-840-960 Rescinding delegation, 246-840-970 Accountability, liability, coercion and 246-841-405 Nursing assistant delegation; and repealing WAC 246-840-980 Evaluation of nurse delegation.
Purpose: To protect the public by requiring nurses to adhere to standards for delegating nursing care tasks to registered and certified nursing assistants. These rules safeguard the authority of registered nurses to make independent professional decisions regarding the delegation of a task.
Other Identifying Information: The delegation task list is eliminated from the existing rules.
Statutory Authority for Adoption: Chapters 18.79 and 18.88A RCW, chapter 95, Laws of 2000.
Statute Being Implemented: Chapter 18.79 RCW.
Summary: The statute requires that rules be revised to eliminate the delegation task list in both the nursing and nursing assistant rules. It also requires revision of the process for obtaining patient consent to delegation. These rules are based on the elements of the nursing process and will ensure that the nursing care services will be consistent with the established standard of practice. This will allow better coordination and planning of nursing care for residents in community care settings and ensures the registered professional nurses will direct the assessment and evaluation of the resident and the nursing assistant to accurately carry out the delegated plan of care.
Reasons Supporting Proposal: To protect the public by requiring nurses to adhere to standards for delegating nursing care tasks to registered and certified nursing assistants. These rules safeguard the authority of registered nurses to make independent professional decisions regarding the delegation of a task.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Terry J. West, 1300 S.E. Quince, Olympia, WA 98504, (360) 236-4712.
Name of Proponent: Department of Health, Health Professions Quality Assurance Division, Nursing Care Quality Assurance Commission.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The new nurse delegation rules eliminate the delegated task list in both the nursing rules and nursing assistant rules and reformats the rules to align with the elements of the nursing process. The rule allows the registered nurse to delegate tasks to qualified nursing assistants based on the professional judgment of the nurse. There are three specific tasks which are prohibited from delegation. This rule specifies the requirements for the nurse to obtain informed patient consent for delegation and changes the reevaluation of the delegated nursing care tasks to no less than ninety days. The purpose of these changes is to allow the professional registered nurse to evaluate the comprehensive care needs of a resident and to use professional nursing judgment to determine which parts of the nursing care plan can be safely delegated to nursing assistants. It is expected that the resident care will be better coordinated and the delegating nurse will be directing the assessment and evaluation process of both the resident and nursing assistant to validate the outcomes of the delegated plan of care.
Proposal Changes the Following Existing Rules: The primary change to WAC 246-840-930 is the format in which the delegation criteria are described and expressed. The decision tree in WAC 246-840-940 will help guide the registered nurse and other providers in determining the process for and the appropriateness of delegating nursing tasks. WAC 246-840-950 provides specific instructions on how to make modifications in the delegation and how to transfer the delegation to another registered nurse.
A small business economic impact statement has been prepared under chapter 19.85 RCW.
Necessity of Amendments to Nursing Rules: With the passing of SHB 1218, the current rule needs to reflect the changes to chapters 18.79 and 18.88A RCW. The bill eliminated the delegated task list, which specified what activities could never be delegated, and an informed patient consent process. Instead the bill authorized the registered nurse to use nursing judgment to determine the overall needs of the resident and delegate selected aspects of the nursing care plan to nursing assistants.
What Does the Proposed Rule Amendment Do? The proposed amendments rewrite the entire text of WAC 246-840-930 into a format that is easier to use and remains consistent with the elements of the nursing process.
| The definitions section in WAC 246-840-920 reorders the list by alphabet. | |
| A new section has been added, WAC 246-840-940 offers a delegation decision tree to guide the delegating nurse and other providers on the criteria for nurse delegation. | |
| A section has been added to describe the requirements when the delegation has to be transferred to another nurse or changes to the nursing care plan need to be made. | |
| A registered nurse is allowed to use judgment to define the tasks, which may be delegated. |
Costs to Businesses: There are no new additional costs to a business to comply with the proposed amendments to this existing rule. Each of the bulleted revisions to the rule is expected to reduce costs.
Cost Minimizing Features of the Rule: Each of the bulleted items in section "Necessity of amendments to nursing rules" is expected to reduce the cost of the rules. Allowing the registered nurse to use judgment to define the tasks, which may be delegated, will reduce costs. The services provided by a registered nurse cost from $18-$25 per hour. A nursing assistant costs from $6-$10 per hour. This will result in approximately $12-$15 per hour cost savings. The rules will be easier to understand and use.
Is There a Disproportionate Impact? The rule reduces costs therefore, there is no disproportionate cost for small businesses.
DOH Costs to Administer the Regulation: There are no new additional costs to the Department of Health to regulate these amendments. These rules require that individual nurses comply with the minimum standards and delineates the commission's interpretation of violations of those standards. The nurse delegation criteria are an extension of the standard of practice. No additional review time and no additional analyses are required as a result of these amendments.
How the Department of Health Will Notify Businesses: When the rules are adopted these rules will be made available to businesses that involve nurses in a number of ways.
| Available on the nursing web site. | |
| Copy sent to all businesses that have asked to be placed on the interested persons mailing list. | |
| Included in the next updated law book which is sent upon request to businesses. | |
| Available at the front counter for businesses. | |
| Copy will be mailed to all community based care settings. | |
| Copy of rule is available through the Code Reviser's Office, which is available to all businesses. |
During the three rule-writing workshops the Nursing Commission heard from a lot of nurses, Directors of Nursing, and business owners who had many comments on the draft rules. The majority of their comments have been incorporated into the draft.
A copy of the statement may be obtained by writing to the Department of Health, Nursing Care Quality Assurance Commission, P.O. Box 47864, Olympia, WA 98504-7864, phone (360) 236-4712, fax (360) 236-4738.
RCW 34.05.328 applies to this rule adoption. Violators will be subject to penalty or sanction.
Hearing Location: Center Point Corporate Park, Creekside Three at Center Pointe, 20435 72nd Avenue South, Suite 200, Kent, WA 98032, on November 9, 2001, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Kris McLaughlin by November 2, 2001, (360) 236-4713.
Submit Written Comments to: Terry J. West, P.O. Box 47864, Olympia, WA 98504-7864, fax (360) 236-4738, by November 5, 2001.
Date of Intended Adoption: November 9, 2001.
August 22, 2001
Paula R. Meyer, RN, MSN
Executive Director
OTS-4440.4
REGISTERED NURSE DELEGATION IN COMMUNITY CARE SETTINGS
AMENDATORY SECTION(Amending WSR 96-05-060, filed 2/19/96,
effective 3/21/96)
WAC 246-840-910
Purpose.
The purpose of this delegation
protocol is to ensure that nursing care services have a
consistent standard of practice upon which the public and
profession may rely and to safeguard the authority of the
((nurse)) registered nurse delegator to make independent
professional decisions regarding the delegation of a nursing
task. ((According to Public Law 1908,)) A licensed registered
nurse may delegate specific nursing care tasks to nursing
assistants who meet certain requirements and provide care to
individuals ((in)) served by certified community residential
programs for the developmentally disabled, to residents in
licensed adult family homes, and to residents of licensed
boarding homes ((contracting to provide assisted living
services)). Before delegating a task, the registered nurse
delegator must determine that specific criteria described in the
protocol are met and ensure that the patient is in a stable and
predictable condition. Registered nurses delegating tasks are
accountable to the Washington state nursing care quality
assurance commission. The registered nurse delegator and nursing
assistant are accountable for their own individual actions in the
delegation process. No person may coerce a registered nurse into
compromising patient safety by requiring the registered nurse to
delegate if the ((nurse)) registered nurse delegator determines
it is inappropriate to do so. ((These specific care tasks as
defined by the nursing commission include:
(1) Oral and topical medications and ointments;
(2) Nose, ear, eye drops, and ointments;
(3) Dressing changes and urinary catheterization using clean techniques;
(4) Suppositories, enemas, and ostomy care in established and healed condition;
(5) Blood glucose monitoring; and
(6) Gastrostomy feedings in established and healed condition)) Registered nurse delegators cannot delegate the following care tasks under any circumstances:
(1) Administration of medications by injection (intramuscular, intradermal, subcutaneous, intraosseous and intravenous).
(2) Sterile procedures.
(3) Central line maintenance.
[Statutory Authority: Chapter 18.79 RCW. 96-05-060, 246-840-910, filed 2/19/96, effective 3/21/96.]
(1) (("Delegation" means the licensed registered nurse
transfers the performance of selected nursing tasks to competent
individuals in selected situations. The licensed registered
nurse delegating the task retains the responsibility and
accountability for the nursing care of the patient.
(2) "Nursing assistant" means a nursing assistant-registered under chapter 18.88A RCW or a nursing assistant-certified under chapter 18.88A RCW, who provides care to individuals in certified community residential programs for the developmentally disabled, to individuals residing in licensed adult family homes, and to individuals residing in licensed boarding homes contracted to provide assisted living services.
(3) "Patient" means the individual recipient of nursing actions. In the community residential settings, the patient may also be referred to as client or consumer.
(4) "Protocol" means an explicit, detailed written plan specifying the procedures to be followed in providing care for a particular condition.
(5) "Procedure" means a series of steps by which a desired result is obtained; a particular course of action or way of doing something.
(6) "Outcome" means the end result or consequence of an action after following an established plan of care.
(7) "Supervision" means the provision of guidance and evaluation by a qualified registered nurse for the accomplishment of a nursing task or activity, as outlined in this protocol, including the initial direction of the task or activity; periodic inspection at least every sixty days of the actual act of accomplishing the task or activity; and the authority to require corrective action.
(8) "Immediate supervision" means the licensed registered nurse is on the premises and is within audible and visual range of the patient and the patient has been assessed by the licensed registered nurse prior to the delegation of duties to any care giver.
(9) "Direct supervision" means the licensed registered nurse is on the premises, is quickly and easily available and the patient has been assessed by the licensed registered nurse prior to the delegation of the duties to any care giver.
(10) "Indirect supervision" means the licensed registered nurse is not on the premises but has previously given written instructions for the care and treatment of the patient and the patient has been assessed by the licensed registered nurse prior to the delegation of duties to any care giver. If oral clarification of the written instructions is required, it must be documented.
(11) "Coercion" means to force or compel another, by authority, to do something that he/she would not otherwise choose to do.
(12) "Stable and predictable condition" means a situation in which the patient's clinical and behavioral status is known through the registered nurse's assessment to be nonfluctuating and consistent, including a terminally ill patient whose deteriorating condition is predictable. The registered nurse determines that the patient does not require their frequent presence and evaluation.
(13) "Medication prescribed" means an order for drugs issued by a practitioner duly authorized by law or rule in the state of Washington to prescribe drugs.
(14) "Over-the-counter medication" means a drug that can be obtained without a prescription and is not restricted to use by prescribing practitioners.
(15) "PRN medication" means a medication that has been ordered to be given as needed.
(16) "Oral medication" means any medication that can be ingested through the mouth or administered directly into a gastrostomy tube.
(17) "Topical medication" means any medication that is applied to the outer skin, nose, ear, or eye as drops or ointments.
(18) "Suppository" means a semisolid medication for insertion into the rectum or vagina where it dissolves, releasing the drug for absorption.
(19) "Dressing change using clean technique" means using a clean, nonsterile technique to change the protective covering over a wound or injured body part.
(20) "Urinary catheterization using clean technique" means using a clean, nonsterile technique to insert a catheter through the urethra and into the urinary bladder to withdraw urine.
(21) "Ostomy care" means caring for the stoma, the skin, and the ostomy device or tube for the patient having a gastrostomy, colostomy, ileostomy, or urostomy that is in an established and healed condition.
(22) "Enema" means the introduction of solution into the rectum to promote evacuation of feces from the colon.
(23) "Blood glucose monitoring" means regular testing of blood obtained by fingerstick to measure the blood glucose level.
(24) "Gastrostomy feeding" means administering a nutritional tube feeding through a tube directly into the stomach which is in an established and healed condition.
(25) "Complex task" means that a nursing task may become more complicated because of the interrelationship between the following criteria:
(a) The patient's condition;
(b) The setting;
(c) The nursing care task(s) and involved risks; and
(d) The skill level required to perform the task.
The delegating nurse must identify and facilitate additional training of the nursing assistant prior to delegation in these situations. The delegating nurse may decide the task is not delegatable. In no case, may delegation go beyond the list of specific care tasks authorized by this chapter.
(26))) "Authorized representative" means a person authorized to provide informed consent for health care on behalf of a patient who is not competent to consent. Such person shall be a member of one of the classes of persons as directed in RCW 7.70.065.
(2) "Coercion" means to force or compel another, by authority, to do something that he/she would not otherwise choose to do.
(3) "Complex task" means that a nursing task may become more complicated because of the interrelationship between the following criteria:
(a) The patient's condition;
(b) The setting;
(c) The nursing care task(s) and involved risks; and
(d) The skill level required to perform the task.
The registered nurse delegator must identify and facilitate additional training of the nursing assistant prior to delegation in these situations. The registered nurse delegator may decide the task is not delegable. In no case, may administration of medications by injection, sterile procedures and central line maintenance be delegated.
(4) "Medication assistance" as defined in chapter 246-888 WAC does not require delegation by a licensed nurse.
(5) "Nursing assistant" means a nursing assistant-registered under chapter 18.88A RCW or a nursing assistant-certified under chapter 18.88A RCW, who provides care to individuals served by certified community residential programs for the developmentally disabled, to individuals residing in licensed adult family homes, and to individuals residing in licensed boarding homes.
(6) "Outcome" means the end result or consequence of an action after following an established plan of care.
(7) "Patient" means the individual recipient of nursing actions. In the community residential settings, the patient may also be referred to as client, consumer, or resident.
(8) "Personal care services" as defined in WAC 388-15-202 do not require delegation by a licensed nurse.
(9) "Procedure" means a series of steps by which a desired result is obtained; a particular course of action or way of doing something.
(10) "Protocol" means an explicit, detailed written plan specifying the procedures to be followed in providing care for a particular condition.
(11) "Registered nurse delegation" means the registered nurse transfers the performance of selected nursing tasks to competent nursing assistants in selected situations. The registered nurse delegating the task retains the responsibility and accountability for the nursing care of the patient.
(12) "Supervision" means the provision of guidance and evaluation by a registered nurse delegator for the accomplishment of a nursing task or activity, as outlined in this protocol, including the initial direction of the task or activity; periodic inspection at least every ninety days of the actual act of accomplishing the task or activity; and the authority to require corrective action.
(13) "Immediate supervision" means the registered nurse delegator is on the premises and is within audible and visual range of the patient and the patient has been assessed by the registered nurse delegator prior to the delegation of duties to any care giver.
(14) "Direct supervision" means the registered nurse delegator is on the premises, is quickly and easily available and the patient has been assessed by the registered nurse delegator prior to the delegation of the duties to any care giver.
(15) "Indirect supervision" means the registered nurse delegator is not on the premises but has previously given written instructions for the care and treatment of the patient and the patient has been assessed by the registered nurse delegator prior to the delegation of duties to any care giver. If oral clarification of the written instructions is required, it must be documented.
(16) "Stable and predictable condition" means a situation in which the patient's clinical and behavioral status is known through the registered nurse delegator's assessment to be nonfluctuating and consistent, including a terminally ill patient whose deteriorating condition is predictable. The registered nurse delegator determines that the patient does not require their frequent presence and evaluation.
[Statutory Authority: Chapter 18.79 RCW. 96-05-060, 246-840-920, filed 2/19/96, effective 3/21/96.]
(1) Determine that the setting allows delegation because it is a certified community residential program for the developmentally disabled, a licensed adult family home, or a licensed boarding home contracted to provide assisted living services.
(2) Determine that the task to be delegated is within the nurse's area of responsibility and that it is a specific care task that has been approved for delegation.
(3) Determine that the task to be delegated can be properly and safely performed by the nursing assistant-certified or nursing assistant-registered. The registered nurse shall assess the potential risk of harm for the individual patient. Potential harm may include, but is not limited to, infection, hemorrhage, hypoxemia, nerve damage, physical injury, or psychological distress.
(4) Assess the patient's nursing care needs and determine that the patient is in a stable and predictable condition.
(5) Analyze the complexity of the nursing task and determine the required training or additional training needed by the nursing assistant to competently accomplish the task. The registered nurse shall consider the psychomotor and cognitive skills required to perform the nursing task. More complex tasks may require additional training and supervision for the nursing assistant. The nurse must identify and facilitate any additional training of the nursing assistant that is needed prior to delegation. The nurse must ensure that the task to be delegated can be properly and safely performed by the nursing assistant.
(6) Assess the level of interaction required, considering language or cultural diversity that may affect communication or the ability to accomplish the task to be delegated, as well as methods to facilitate the interaction.
(7) Verify that the nursing assistant:
(a) Is currently registered or certified as a nursing assistant in Washington state and is in good standing without restriction;
(b) Has a certificate of completion issued by the department of social and health services indicating completion of core delegation training for nursing assistants; and
(c) Is willing to perform the task in the absence of direct or immediate nurse supervision and accept responsibility for their actions.
(8) Assess the ability of the nursing assistant to competently perform the delegated nursing task in the absence of direct or immediate nurse supervision to ensure that the nursing task can be properly and safely performed by the nursing assistant.
(9) Discuss the delegation with the patient or authorized representative, including the level of training of the nursing assistant delivering care. The patient, or authorized representative, must give written, informed consent to the delegation under chapter 7.70 RCW.
(10) Document in the patient's record the rationale for delegating or not delegating nursing tasks.
(11) Discuss the process for continuing, rescinding, or adding medications to the delegation list when the health care provider changes medication orders:
(a) The registered nurse must verify the change in medication or a new medication order with the health care provider;
(b) If a change is made in the medication dosage or if a change is made in the type of medication for the same problem (i.e., one medication is deleted by the health care provider and another is substituted) and the patient remains in a stable and predictable condition, delegation can continue at the registered nurse's discretion; and
(c) If a new medication is added, the registered nurse must review the criteria and process for delegation prior to delegating the administration of the new medication to the nursing assistant. The registered nurse maintains the authority to decide if the new medication can be added to the delegated task list immediately, if a site visit is warranted prior to delegation, or if delegation is no longer appropriate. If delegation is to be rescinded, the nurse must initiate and participate in developing an alternative plan to assure the needs of the patient are met.)) elements of the nursing process: ASSESS, PLAN, IMPLEMENT, EVALUATE:
ASSESS
(2) Determine that the setting allows delegation because it
is a certified community residential program for the
developmentally disabled, a licensed adult family home, or a
licensed boarding home.
(3) Assess the patient's nursing care needs and determine that the patient is in a stable and predictable condition.
(4) Determine that the task to be delegated is within the delegating nurse's area of responsibility.
(5) Determine that the task to be delegated can be properly and safely performed by the nursing assistant. The registered nurse delegator shall assess the potential risk of harm for the individual patient. Potential harm may include, but is not limited to, infection, hemorrhage, hypoxemia, nerve damage, physical injury, or psychological distress.
(6) Analyze the complexity of the nursing task and determine the required training or additional training needed by the nursing assistant to competently accomplish the task. The registered nurse delegator shall consider the psychomotor and cognitive skills required to perform the nursing task. More complex tasks may require additional training and supervision for the nursing assistant. The registered nurse delegator must identify and facilitate any additional training of the nursing assistant that is needed prior to delegation. The registered nurse delegator must ensure that the task to be delegated can be properly and safely performed by the nursing assistant.
(7) Assess the level of interaction required, considering language or cultural diversity that may affect communication or the ability to accomplish the task to be delegated, as well as methods to facilitate the interaction.
(8) Verify that the nursing assistant:
(a) Is currently registered or certified as a nursing assistant in Washington state and is in good standing without restriction;
(b) Has a certificate of completion issued by the department of social and health services indicating completion of nurse delegation for nursing assistants; and
(c) Is willing to perform the task in the absence of direct or immediate nurse supervision and accept responsibility for their actions.
(9) Assess the ability of the nursing assistant to competently perform the delegated nursing task in the absence of direct or immediate nurse supervision to ensure that the nursing task can be properly and safely performed by the nursing assistant.
(10) If the registered nurse delegator determines delegation is appropriate, the nurse must:
(a) Discuss the delegation process with the patient or authorized representative, including the level of training of the nursing assistant delivering care.
(b) Obtain patient consent. The patient, or authorized representative, must give written, informed consent to the delegation process under chapter 7.70 RCW. Documented verbal consent of patient or authorized representative may be acceptable if written consent is obtained within thirty days; electronic consent is an acceptable format.
(c) Written consent is only necessary at the initial use of the nurse delegation process for each patient and is not necessary for task additions or changes or if a different nurse or nursing assistant will be participating in the process.
PLAN
(11) Document in the patient's record the rationale for
delegating or not delegating nursing tasks.
(12) Provide specific, written delegation instructions to the nursing assistant with a copy maintained in the patient's record that include:
(a) The rationale for delegating the nursing task;
(b) That the delegated nursing task is specific to one patient and is not transferable to another patient;
(c) That the delegated nursing task is specific to one nursing assistant and is not transferable to another nursing assistant;
(d) The nature of the condition requiring treatment and purpose of the delegated nursing task;
(e) A clear description of the procedure or steps to follow to perform the task;
(f) The predictable outcomes of the nursing task and how to effectively deal with them;
(g) The risks of the treatment;
(h) The interactions of prescribed medications;
(i) How to observe and report side effects, complications, or unexpected outcomes and appropriate actions to deal with them, including specific parameters for notifying the registered nurse delegator, health care provider, or emergency services;
(j) The action to take in situations where medications and/or treatments and/or procedures are altered by health care provider orders, including:
(i) How to notify the registered nurse delegator of the change;
(ii) The process the registered nurse delegator will use to obtain verification from the health care provider of the change in the medical order; and
(iii) The process to notify the nursing assistant of whether administration of the medication or performance of the procedure and/or treatment is delegated or not;
(k) How to document the task in the patient's record;
(l) Document what teaching was done and that a return demonstration, or other method for verification of competency, was correctly done; and
(m) A plan of nursing supervision describing how frequently the registered nurse will supervise the performance of the delegated task by the nursing assistant and reevaluate the delegated nursing task. Supervision shall occur at least every ninety days.
(13) The administration of medications may be delegated at the discretion of the registered nurse delegator. The registered nurse delegator must provide written parameters specific to an individual patient which includes guidelines for the nursing assistant to follow in the decision-making process to administer a medication and the procedure to follow for such administration.
IMPLEMENT
(14) Delegation requires the registered nurse delegator
teach the nursing assistant how to perform the task, including
return demonstration or other method of verification of
competency as determined by the registered nurse delegator.
(15) The registered nurse delegator is accountable and responsible for the delegated nursing task. The registered nurse delegator must monitor the performance of the task(s) to assure compliance to established standards of practice, policies and procedures and to ensure appropriate documentation of the task(s).
EVALUATE
(16) The registered nurse delegator must evaluate the
patient's responses to the delegated nursing care and to any
modification of the nursing components of the patient's plan of
care.
(17) The registered nurse delegator must supervise and evaluate the performance of the nursing assistant, including direct observation or other method of verification of competency of the nursing assistant to perform the delegated nursing task. The registered nurse delegator must also reevaluate the patient's condition, the care provided to the patient, the capability of the nursing assistant, the outcome of the task, and any problems.
(18) The registered nurse delegator must ensure safe and effective services are provided. Reevaluation and documentation must occur at least every ninety days. Frequency of supervision is at the discretion of the registered nurse delegator.
(19) The registered nurse delegator must participate in recordkeeping as required by the secretary of health to facilitate evaluation.
[Statutory Authority: Chapter 18.79 RCW. 97-13-100, 246-840-930, filed 6/18/97, effective 7/19/97; 96-05-060, 246-840-930, filed 2/19/96, effective 3/21/96.]
(1) Obtain the written informed consent of the patient or authorized representative under chapter 7.70 RCW, the delegating nurse, and the nursing assistant.
(2) Delegation requires the nurse teach the nursing assistant how to perform the task, including return demonstration under observation. The nurse shall observe the nursing assistant performing the delegated task to verify their competency to properly perform the task safely and accurately.
(3) Provide specific, written delegation instructions to the nursing assistant with a copy maintained in the patient's record that include:
(a) The rationale for delegating the nursing task;
(b) That the delegated nursing task is specific to one patient and is not transferable to another patient;
(c) That the delegated nursing task is specific to one nursing assistant and is not transferable to another nursing assistant;
(d) The nature of the condition requiring treatment and purpose of the delegated nursing task;
(e) A clear description of the procedure or steps to follow to perform the task;
(f) The predictable outcomes of the nursing task and how to effectively deal with them;
(g) The risks of the treatment;
(h) The interactions of prescribed medications;
(i) How to observe and report side effects, complications, or unexpected outcomes and appropriate actions to deal with them, including specific parameters for notifying the delegating registered nurse, health care provider, or emergency services;
(j) The action to take in situations where medications are altered by health care provider orders, including:
(i) How to notify the registered nurse of the change;
(ii) The process the registered nurse will use to obtain verification from the health care provider of the medication change; and
(iii) The process to notify the nursing assistant of whether administration of the medication is delegated or not;
(k) How to document the task in the patient's record;
(l) Document what teaching was done and that a return demonstration was correctly done; and
(m) A plan of nursing supervision describing how frequently the registered nurse will supervise the performance of the delegated task by the nursing assistant and reevaluate the delegated nursing task. Supervision shall occur at least every sixty days.
(4) The administration of PRN medications may be delegated at the discretion of the registered nurse. The nurse must first assess the patient to determine that on-site patient assessment will not be required prior to the ongoing administration of each PRN medication dose. The registered nurse must provide written parameters specific to an individual patient which includes guidelines for the nursing assistant to follow in the decision-making process to administer the PRN medication and the procedure to follow for such administration.))
| (1) | Does the patient reside in one of the following settings? A certified community residential program for the developmentally disabled, a licensed adult family home, a licensed boarding home | No -> | Do not delegate |
| Yes ↓ | |||
| (2) | Has the patient or authorized representative given consent to the delegation? | No -> | Obtain the written, informed consent |
| Yes ↓ | |||
| (3) | Is RN assessment of patient's nursing care needs completed? | No -> | Do assessment, then proceed with a consideration of delegation |
| Yes ↓ | |||
| (4) | Is the task within the registered nurse's scope of practice? | No -> | Do not delegate |
| Yes ↓ | |||
| (5) | Is the nursing assistant registered or certified and properly trained in the nurse delegation for nursing assistants? | No -> | Do not delegate |
| Yes ↓ | |||
| (6) | Can the task be performed without requiring judgment based on nursing knowledge? | No -> | Do not delegate |
| Yes ↓ | |||
| (7) | Are the results of the task reasonably predictable? | No -> | Do not delegate |
| Yes ↓ | |||
| (8) | Can the task be safely performed according to exact, unchanging directions? | No -> | Do not delegate |
| Yes ↓ | |||
| (9) | Can the task be performed without a need for complex observations or critical decisions? | No -> | Do not delegate |
| Yes ↓ | |||
| (10) | Can the task be performed without repeated nursing assessments? | No -> | Do not delegate |
| Yes ↓ | |||
| (11) | Can the task be performed improperly without life-threatening consequences? | No -> | Do not delegate |
| Yes ↓ | |||
| (12) | Is appropriate supervision available? | No -> | Do not delegate |
| Yes ↓ | |||
| (13) | There are no specific laws or rules prohibiting the delegation? | No -> | Do not delegate |
| Yes ↓ | |||
| (14) | Task is delegable | ||
[Statutory Authority: Chapter 18.79 RCW. 97-13-100, 246-840-940, filed 6/18/97, effective 7/19/97; 96-05-060, 246-840-940, filed 2/19/96, effective 3/21/96.]
(2) A registered nurse may assume delegating responsibilities from the delegating registered nurse for the delegation process, provided the registered nurse assuming responsibility knows the patient through their assessment, the skills of the nursing assistant, and the plan of care. This may include a reevaluation of the patient by the nurse assuming responsibility for delegation. The nurse assuming the responsibility for delegation from another nurse is accountable and responsible for the delegated task. The nurse must document the following in the patient's record:
(a) The reason and justification for another nurse assuming responsibility for the delegation;
(b) The nurse assuming responsibility must agree, in writing, to perform the supervision; and
(c) That the nursing assistant and patient have been informed of this change.)) Medication. The registered nurse delegator will discuss with the nursing assistant the process for continuing, rescinding, or adding medications to the delegation list when the health care provider changes medication orders:
(a) The registered nurse delegator must verify the change in medication or a new medication order with the health care provider;
(b) If a change is made in the medication dosage or if a change is made in the type of medication for the same problem (i.e., one medication is deleted by the health care provider and another is substituted) and the patient remains in a stable and predictable condition, delegation may continue at the registered nurse delegator's discretion; and
(c) If a new medication is added, the registered nurse delegator must review the criteria and process for delegation prior to delegating the administration of the new medication to the nursing assistant. The registered nurse delegator maintains the authority to decide if the new medication can be delegated immediately, if a site visit is warranted prior to delegation, or if delegation is no longer appropriate. If delegation is to be rescinded, the registered nurse delegator must initiate and participate in developing an alternative plan to assure the needs of the patient are met.
(2) Treatments and/or procedures.
(a) The registered nurse delegator must verify the change in the medical order with the health care provider.
(b) The registered nurse delegator maintains the authority to decide if the new treatment or procedure can be delegated immediately, if a site visit is warranted prior to delegation, or if delegation is no longer appropriate. If delegation is to be rescinded, the registered nurse delegator must initiate and participate in developing an alternative plan to assure the needs of the patient are met.
Transferring delegation to another registered nurse.
(3) A registered nurse may assume delegating responsibilities from the registered nurse delegator for the delegation process, provided the registered nurse assuming responsibility knows the patient through their assessment, the skills of the nursing assistant, and the plan of care. This may include a reevaluation of the patient by the nurse assuming responsibility for delegation. The registered nurse assuming the responsibility for delegation from another registered nurse delegator is accountable and responsible for the delegated task. The registered nurse delegator must document the following in the patient's record.
(a) The reason and justification for another registered nurse assuming responsibility for the delegation;
(b) The registered nurse assuming responsibility must agree, in writing, to perform the supervision; and
(c) That the nursing assistant and patient have been informed of this change.
[Statutory Authority: Chapter 18.79 RCW. 96-05-060, 246-840-950, filed 2/19/96, effective 3/21/96.]
(2) Nurses acting within the protocols of their delegation authority shall be immune from liability for any action performed in the course of their delegation duties.
(3) Nursing assistants following written delegation instructions from registered nurses for delegated tasks shall be immune from liability.
(4) The nursing care quality assurance commission shall take no disciplinary action against nurses following delegation protocols appropriately.
(5) Complaints regarding delegation of specific nursing tasks may be reported to the aging and adult services administration of the department of social and health services or via a toll-free telephone number.
(6) All complaints specifically related to nurse-delegation shall be referred to the nursing care quality assurance commission.
(7) No certified community residential program for the developmentally disabled, licensed adult family home, or licensed boarding home contracting to provide assisted living services may discriminate or retaliate in any manner against a person because the person made a complaint or cooperated in the investigation of a complaint.
(8) No person may coerce a nurse into compromising patient safety by requiring the nurse to delegate if the nurse determines it is inappropriate to do so. Nurses shall not be subject to any employer reprisal or disciplinary action by the Washington nursing care quality assurance commission for refusing to delegate tasks or refusing to provide the required training for delegation if the nurse determines delegation may compromise patient safety.
(9) Nursing assistants shall not be subject to any employer reprisal or disciplinary action for refusing to accept delegation of a nursing task.)) (1) The registered nurse delegator may rescind delegation of the nursing task based on the following circumstances which may include, but are not limited to:
(a) When the registered nurse delegator believes patient safety is being compromised;
(b) When the patient's condition is no longer stable and predictable as determined by the registered nurse delegator;
(c) When the frequency of staff turnover makes delegation impractical to continue in the setting;
(d) When there is a change in the nursing assistant's willingness or competency to do the task;
(e) When the task is not being performed correctly; or
(f) When the patient or authorized representative requests that the delegation be rescinded.
(2) In the event delegation is rescinded, the registered nurse delegator initiates and participates in developing an alternative plan to ensure the continuity for the provision of the task or assumes responsibility for performing the task.
(3) The registered nurse delegator must document the reason for rescinding delegation of the task and the plan for ensuring continuity of the task.
[Statutory Authority: Chapter 18.79 RCW. 96-05-060, 246-840-960, filed 2/19/96, effective 3/21/96.]
(a) When the nurse believes patient safety is being compromised;
(b) When the patient's condition is no longer stable and predictable;
(c) When the frequency of staff turnover makes delegation impractical to continue in the setting;
(d) When there is a change in the nursing assistant's willingness or competency to do the task;
(e) When the task is not being performed correctly; or
(f) When the patient or authorized representative requests that the delegation be rescinded.
(2) In the event delegation is rescinded, the delegating registered nurse assumes responsibility for performing the task or initiating and participating in developing an alternative plan to ensure the continuity for the provision of the task.
(3) The delegating registered nurse must document the reason for rescinding delegation of the task and the plan for ensuring continuity of the task.)) (1) The registered nurse delegator and nursing assistant are accountable for their own individual actions in the delegation process. The delegated task becomes the responsibility of the person to whom it is delegated but the registered nurse delegator retains overall accountability for the nursing care of the patient, including nursing assessment, evaluation, and assuring documentation is completed.
(2) Pursuant to RCW 18.79.260 (3)(d)(iv), delegating nurses acting within the protocols of their delegation authority shall be immune from liability for any action performed in the course of their delegation duties.
(3) Pursuant to RCW 18.88A.230(1), nursing assistants following written delegation instructions from registered nurse delegators for delegated tasks shall be immune from liability.
(4) Complaints regarding delegation of nursing tasks may be reported to the aging and adult services administration of the department of social and health services or via a toll-free telephone number.
(5) All complaints related to nurse delegation shall be referred to the nursing care quality assurance commission.
(6) Pursuant to RCW 18.79.260 (3)(c), no person may coerce the registered nurse delegator into compromising patient safety by requiring the nurse to delegate if the registered nurse delegator determines it is inappropriate to do so. Registered nurse delegators shall not be subject to any employer reprisal or disciplinary action by the Washington nursing care quality assurance commission for refusing to delegate tasks or refusing to provide the required training for delegation if the nurse determines delegation may compromise patient safety.
(7) Pursuant to RCW 18.88A.230(2), nursing assistants shall not be subject to any employer reprisal or disciplinary action by the secretary for refusing to accept delegation of a nursing task based on patient safety issues.
[Statutory Authority: Chapter 18.79 RCW. 96-05-060, 246-840-970, filed 2/19/96, effective 3/21/96.]
The following section of the Washington Administrative Code is repealed:
| WAC 246-840-980 | Evaluation of nurse delegation. |