Other Findings Required by Other Provisions of Law as Precondition to Adoption or Effectiveness of Rule: The commission is setting an early effective date for this rule under RCW 34.04.380 (3)(a) [34.05.380 (3)(a)] because there was an emergency clause in chapter 140, Laws of 2003. The requirements in this rule have been in place under emergency rules and will expire July 2, 2004.

     Purpose: Adopt rules to implement chapter 140, Laws of 2003, allowing registered nurses employed by a home health or hospice agency to delegate application, instillation or insertion of medications to a nursing assistant under a plan of care and allowing delegation of specific nursing care tasks to nursing assistants in an in-home care setting. Emergency rules currently in place are due to expire on July 2, 2004.

     Citation of Existing Rules Affected by this Order: Amending WAC 246-840-700, 246-840-910, 246-840-930, and 246-840-940.

     Statutory Authority for Adoption: RCW 18.79.110, 18.79.260 (3)(f) and 18.88A.210, chapter 140, Laws of 2003.

      Adopted under notice filed as WSR 04-10-078 on May 4, 2004.

     Changes Other than Editing from Proposed to Adopted Version: WAC 246-840-930 (8)(c) now requires the registered nurse to check for an actual certificate of completion rather than simply to assure that the course has been completed. This makes the rule consistent with RCW 18.88A.210(3) which requires the nursing assistant to present the certificate to the registered nurse.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 4, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 4, Repealed 0.

     Date Adopted: July 2, 2004.

June 8, 2004

Cheryl Payseno, Chair

Nursing Care Quality

Assurance Commission

OTS-6412.5

AMENDATORY SECTION(Amending WSR 02-06-117, filed 3/6/02, effective 4/6/02)

WAC 246-840-700   Standards of nursing conduct or practice.   (1) The purpose of defining standards of nursing conduct or practice through WAC 246-840-700 and WAC 246-840-710 is to identify responsibilities of the professional registered nurse and the licensed practical nurse in health care settings and as provided in the Nursing Practice Act, chapter 18.79 RCW. Violation of these standards may be grounds for disciplinary action under chapter 18.130 RCW. Each individual, upon entering the practice of nursing, assumes a measure of responsibility and public trust and the corresponding obligation to adhere to the professional and ethical standards of nursing practice. The nurse shall be responsible and accountable for the quality of nursing care given to clients. This responsibility cannot be avoided by accepting the orders or directions of another person. The standards of nursing conduct or practice include, but are not limited to the following;

     (2) The nursing process is defined as a systematic problem solving approach to nursing care which has the goal of facilitating an optimal level of functioning and health for the client, recognizing diversity. It consists of a series of phases: Assessment and planning, intervention and evaluation with each phase building upon the preceding phases.

(a) Registered Nurse:	(b) Licensed Practical Nurse:
Minimum standards for registered nurses include the following:	Minimum standards for licensed practical nurses include the following:
(i) Standard I Initiating the Nursing Process:	(i) Standard I - Implementing the Nursing Process: The practical nurse assists in implementing the nursing process;
(A) Assessment and Analysis: The registered nurse initiates data collection and analysis that includes pertinent objective and subjective data regarding the health status of the clients. The registered nurse is responsible for ongoing client assessment, including assimilation of data gathered from licensed practical nurses and other members of the health care team;	(A) Assessment: The licensed practical nurse makes basic observations, gathers data and assists in identification of needs and problems relevant to the clients, collects specific data as directed, and, communicates outcomes of the data collection process in a timely fashion to the appropriate supervising person;
(B) Nursing Diagnosis/Problem Identification: The registered nurse uses client data and nursing scientific principles to develop nursing diagnosis and to identify client problems in order to deliver effective nursing care;	(B) Nursing Diagnosis/Problem Identification: The licensed practical nurse provides data to assist in the development of nursing diagnoses which are central to the plan of care;
(C) Planning: The registered nurse shall plan nursing care which will assist clients and families with maintaining or restoring health and wellness or supporting a dignified death;	(C) Planning: The licensed practical nurse contributes to the development of approaches to meet the needs of clients and families, and, develops client care plans utilizing a standardized nursing care plan and assists in setting priorities for care;
(D) Implementation: The registered nurse implements the plan of care by initiating nursing interventions through giving direct care and supervising other members of the care team; and	(D) Implementation: The licensed practical nurse carries out planned approaches to client care and performs common therapeutic nursing techniques; and
(E) Evaluation: The registered nurse evaluates the responses of individuals to nursing interventions and is responsible for the analysis and modification of the nursing care plan consistent with intended outcomes;	(E) Evaluation: The licensed practical nurse, in collaboration with the registered nurse, assists with making adjustments in the care plan. The licensed practical nurse reports outcomes of care to the registered nurse or supervising health care provider;
(ii) Standard II Delegation and Supervision: The registered nurse is accountable for the safety of clients receiving nursing service by:	(ii) Standard II Delegation and Supervision: Under direction, the practical nurse is accountable for the safety of clients receiving nursing care:
(A) Delegating selected nursing functions to others in accordance with their education, credentials, and demonstrated competence as defined in WAC 246-840-010(10);	(A) The practical nurse may delegate selected nursing tasks to competent individuals in selected situations, in accordance with their education, credentials and competence as defined in WAC 246-840-010(10);
(B) Supervising others to whom he/she has delegated nursing functions as defined in WAC 246-840-010(10);	(B) The licensed practical nurse in delegating functions shall supervise the persons to whom the functions have been delegated;
(C) Evaluating the outcomes of care provided by licensed and other paraprofessional staff; ((and))	(C) The licensed practical nurse reports outcomes of delegated nursing care tasks to the RN or supervising health care provider; and
(D) The registered nurse may delegate certain additional acts to certain individuals in community-based long-term care and in-home settings as provided by WAC 246-840-910 through ((246-840-980)) WAC 246-840-970 and WAC 246-841-405; and	(D) In community based long-term care and in-home settings as provided by WAC 246-840-910 through ((246-840-980)) WAC 246-840-970 and WAC 246-841-405, the practical nurse may delegate only personal care tasks to qualified care givers;
(E) In a home health or hospice agency regulated under chapter 70.127 RCW, a registered nurse may delegate the application, instillation, or insertion of medications to a registered or certified nursing assistant under a plan of care pursuant to chapter 246-335 WAC;
(iii) Standard III Health Teaching. The registered nurse assesses learning needs including learning readiness for patients and families, develops plans to meet those learning needs, implements the teaching plan and evaluates the outcome.	(iii) Standard III Health Teaching. The practical nurse assists in health teaching of clients and provides routine health information and instruction recognizing individual differences.

     (3) The following standards apply to registered nurses and licensed practical nurses:

     (a) The registered nurse and licensed practical nurse shall communicate significant changes in the client's status to appropriate members of the health care team. This communication shall take place in a time period consistent with the client's need for care. Communication is defined as a process by which information is exchanged between individuals through a common system of speech, symbols, signs, and written communication or behaviors that serves as both a means of gathering information and of influencing the behavior, actions, attitudes, and feelings of others; and

     (b) The registered nurse and licensed practical nurse shall document, on essential client records, the nursing care given and the client's response to that care; and

     (c) The registered nurse and licensed practical nurse act as client advocates in health maintenance and clinical care.

     (4) Other responsibilities:

     (a) The registered nurse and the licensed practical nurse shall have knowledge and understanding of the laws and rules regulating nursing and shall function within the legal scope of nursing practice;

     (b) The registered nurse and the licensed practical nurse shall be responsible and accountable for his or her practice based upon and limited to the scope of his/her education, demonstrated competence, and nursing experience consistent with the scope of practice set forth in this document; and

     (c) The registered nurse and the licensed practical nurse shall obtain instruction, supervision, and consultation as necessary before implementing new or unfamiliar techniques or procedures which are in his/her scope of practice.

     (d) The registered nurse and the licensed practical nurse shall be responsible for maintaining current knowledge in his/her field of practice; and

     (e) The registered nurse and the licensed practical nurse shall respect the client's right to privacy by protecting confidential information and shall not use confidential health care information for other than legitimate patient care purposes or as otherwise provided in the Health Care Information Act, chapter 70.02 RCW.

[Statutory Authority: RCW 18.79.110. 02-06-117, § 246-840-700, filed 3/6/02, effective 4/6/02. Statutory Authority: Chapter 18.79 RCW. 97-13-100, § 246-840-700, filed 6/18/97, effective 7/19/97.]

     (1) Administration of medications by injection (by intramuscular, intradermal, subcutaneous, intraosseous ((and)), intravenous, or otherwise).

     (2) Sterile procedures.

     (3) Central line maintenance.

     (4) Acts that require nursing judgment.

[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.]

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)) community-based care setting as defined by RCW 18.79.260 (3)(e)(i) or an in-home care setting as defined by RCW 18.79.260 (3)(e)(ii).

     (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) 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;

     (c) Has a certificate of completion issued by the department of social and health services indicating completion of the required core nurse delegation ((for nursing assistants)) training; and

     (d) 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 but never by injection (by intramuscular, intradermal, subcutaneous, intraosseous, intravenous, or otherwise). 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.

[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.]

(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)) A community-based care setting as defined by RCW 18.79.260 (3)(e)(i) or an in-home care setting as defined by RCW 18.79.260 (3)(e)(ii).	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)	Does the patient have a stable and predictable condition?	No ->	Do not delegate
Yes ↓
(((4))) (5)	Is the task within the registered nurse's scope of practice?	No ->	Do not delegate
Yes ↓
(((5))) (6)	Is the nursing assistant registered or certified and properly trained in the nurse delegation for nursing assistants?	No ->	Do not delegate
Yes ↓
(7)	Does the delegation exclude the administration of medications by injection, sterile procedures or central line maintenance?	No ->	Do not delegate
Yes ↓
(((6))) (8)	Can the task be performed without requiring judgment based on nursing knowledge?	No ->	Do not delegate
Yes ↓
(((7))) (9)	Are the results of the task reasonably predictable?	No ->	Do not delegate
Yes ↓
(((8))) (10)	Can the task be safely performed according to exact, unchanging directions?	No ->	Do not delegate
Yes ↓
(((9))) (11)	Can the task be performed without a need for complex observations or critical decisions?	No ->	Do not delegate
Yes ↓
(((10))) (12)	Can the task be performed without repeated nursing assessments?	No ->	Do not delegate
Yes ↓
(((11))) (13)	Can the task be performed improperly without life-threatening consequences?	No ->	Do not delegate
Yes ↓
(((12))) (14)	Is appropriate supervision available?	No ->	Do not delegate
Yes ↓
(((13))) (15)	There are no specific laws or rules prohibiting the delegation?	No ->	Do not delegate
Yes ↓
(((14))) (16)	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.]

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