AGING AND DISABILITY SERVICES ADMINISTRATION

 

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 registered nurse delegator to make independent professional decisions regarding the delegation of a nursing task. A licensed registered nurse may delegate specific nursing care tasks to nursing assistants who meet certain requirements and provide care to individuals served by certified community residential programs for the developmentally disabled, to residents in licensed adult family homes, and to residents of licensed boarding homes. 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 registered nurse delegator determines it is inappropriate to do so. 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: Chapters 18.79 and 18.88A RCW. 02-02-047, § 246-840-910, filed 12/27/01, effective 1/27/02. Statutory Authority: Chapter 18.79 RCW. 96-05-060, § 246-840-910, filed 2/19/96, effective 3/21/96.]

WAC 246-840-920 Definitions.

For the purposes of this chapter, the definitions in this section apply throughout the protocol.

1. "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:
   1. The patient's condition;
   2. The setting;
   3. The nursing care task(s) and involved risks; and
   4. 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: Chapters 18.79 and 18.88A RCW. 02-02-047, § 246-840-920, filed 12/27/01, effective 1/27/02. Statutory Authority: Chapter 18.79 RCW. 96-05-060, § 246-840-920, filed 2/19/96, effective 3/21/96.]
    

WAC 246-840-930 Criteria for delegation. Before delegating a nursing task, the registered nurse delegator must determine that it is appropriate to delegate based on the elements of the nursing process:
ASSESS, PLAN, IMPLEMENT, EVALUATE.

ASSESS

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.
2. Assess the patient's nursing care needs and determine that the patient is in a stable and predictable condition.
3. Determine that the task to be delegated is within the delegating nurse's area of responsibility.
4. 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.
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 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.
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:
   
   1. Is currently registered or certified as a nursing assistant in Washington state and is in good standing without restriction;
   2. As required in WAC 246-841-405 (2)(a), nursing assistants registered must complete both the basic caregiver training and core delegation training before performing any delegated task;
   3. Has a certificate of completion issued by the department of social and health services indicating completion of nurse delegation for nursing assistants; and
   4. 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. If the registered nurse delegator determines delegation is appropriate, the nurse must:
   1. Discuss the delegation process with the patient or authorized representative, including the level of training of the nursing assistant delivering care.
   2. 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.
   3. 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

1. Document in the patient's record the rationale for delegating or not delegating nursing tasks.
2. Provide specific, written delegation instructions to the nursing assistant with a copy maintained in the patient's record that include:
   1. The rationale for delegating the nursing task;
   2. That the delegated nursing task is specific to one patient and is not transferable to another patient;
   3. That the delegated nursing task is specific to one nursing assistant and is not transferable to another nursing assistant;
   4. The nature of the condition requiring treatment and purpose of the delegated nursing task;
   5. A clear description of the procedure or steps to follow to perform the task;
   6. The predictable outcomes of the nursing task and how to effectively deal with them;
   7. The risks of the treatment;
   8. The interactions of prescribed medications;
   9. 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;
   10. The action to take in situations where medications and/or treatments and/or procedures are altered by health care provider orders, including:
       1. How to notify the registered nurse delegator of the change;
       2. The process the registered nurse delegator will use to obtain verification from the health care provider of the change in the medical order; and
       3. 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;
   11. How to document the task in the patient's record;
   12. Document what teaching was done and that a return demonstration, or other method for verification of competency, was correctly done; and
   13. 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.
3. 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

1. 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.
2. 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

1. 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.
2. 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.
3. 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.

[Statutory Authority: Chapters 18.79 and 18.88A RCW. 02-02-047, § 246-840-930, filed 12/27/01, effective 1/27/02. 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.]

WAC 246-840-940 Washington state nursing care quality assurance commission community care setting delegation decision tree.

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: Chapters 18.79 and 18.88A RCW. 02-02-047, § 246-840-940, filed 12/27/01, effective 1/27/02. 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.]

WAC 246-840-950 How to make changes to the delegated tasks.

1. 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:
   1. The registered nurse delegator must verify the change in medication or a new medication order with the health care provider;
   2. 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
   3. 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.
   1. The registered nurse delegator must verify the change in the medical order with the health care provider.
   2. 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.
   1. The reason and justification for another registered nurse assuming responsibility for the delegation;
   2. The registered nurse assuming responsibility must agree, in writing, to perform the supervision; and
   3. That the nursing assistant and patient have been informed of this change.

[Statutory Authority: Chapters 18.79 and 18.88A RCW. 02-02-047, § 246-840-950, filed 12/27/01, effective 1/27/02. Statutory Authority: Chapter 18.79 RCW. 96-05-060, § 246-840-950, filed 2/19/96, effective 3/21/96.]

WAC 246-840-960 Rescinding delegation.

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:
   1. When the registered nurse delegator believes patient safety is being compromised;
   2. When the patient's condition is no longer stable and predictable as determined by the registered nurse delegator;
   3. When the frequency of staff turnover makes delegation impractical to continue in the setting;
   4. When there is a change in the nursing assistant's willingness or competency to do the task;
   5. When the task is not being performed correctly; or
   6. 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: Chapters 18.79 and 18.88A RCW. 02-02-047, § 246-840-960, filed 12/27/01, effective 1/27/02. Statutory Authority: Chapter 18.79 RCW. 96-05-060, § 246-840-960, filed 2/19/96, effective 3/21/96.]

WAC 246-840-970 Accountability, liability, and coercion.

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. Under 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. Under 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 Disability 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. Under 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. Under 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: Chapters 18.79 and 18.88A RCW. 02-02-047, § 246-840-970, filed 12/27/01, effective 1/27/02. Statutory Authority: Chapter 18.79 RCW. 96-05-060, § 246-840-970, filed 2/19/96, effective 3/21/96.]