WSR 09-06-006

PERMANENT RULES

DEPARTMENT OF HEALTH


(Nursing Care Quality Assurance Commission)

[ Filed February 18, 2009, 4:10 p.m. , effective March 21, 2009 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: Nursing delegation rules already exist. Legislation was passed in 2008 (E2SHB 2668, chapter 146, Laws of 2008) that adds insulin injection as a health care task that can be delegated by a registered nurse (RN) to a nursing assistant. The rule amendments allow for the delegation of insulin injections and establishes the training standards and the process that must be followed in order to delegate.

Citation of Existing Rules Affected by this Order: Amending WAC 246-840-910, 246-840-920, 246-840-930, 246-840-940, 246-840-950, 246-840-960, 246-840-970, and 246-841-405.

Statutory Authority for Adoption: RCW 18.79.110, 18.79.260, 18.88A060 [18.88A.060], and 18.88A.210.

Adopted under notice filed as WSR 09-01-001 on December 3, 2008.

A final cost-benefit analysis is available by contacting Terry West, Department of Health, P.O. Box 47864, Olympia, WA 98504, phone (360) 236-4712, fax (360) 236-4738, e-mail terry.west@doh.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 8, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 8, Repealed 0.

Date Adopted: January 27, 2009.

Paula R. Meyer, RN, MSN

Executive Director

OTS-1861.4


AMENDATORY SECTION(Amending WSR 04-14-065, filed 7/2/04, effective 7/2/04)

WAC 246-840-910   Purpose.   ((The purpose of)) This ((delegation protocol is to ensure that nursing care services have)) rule defines a consistent standard of ((practice upon which the public and profession may rely and to safeguard the authority of)) nursing care with the delegation of nursing tasks to nursing assistants. The registered nurse delegator ((to)) makes independent professional decisions ((regarding)) of the delegation of a nursing task. A licensed registered nurse may delegate specific nursing care tasks to nursing assistants ((who meet)) meeting certain requirements and ((provide)) providing care to individuals in a community-based care setting ((as)) defined by RCW 18.79.260 (3)(e)(i) and to individuals in an in-home care setting ((as)) defined by RCW 18.79.260 (3)(e)(ii). Before delegating a task, the registered nurse delegator ((must)) determines 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 shall not delegate the following care tasks:

(1) Administration of medications by injection (by intramuscular, intradermal, subcutaneous, intraosseous, intravenous, or otherwise) with the exception of insulin injections.

(2) Sterile procedures.

(3) Central line maintenance.

(4) Acts that require nursing judgment.

[Statutory Authority: RCW 18.79.110, 18.79.260 (3)(f), 18.88A.210, 2003 c 140. 04-14-065, 246-840-910, filed 7/2/04, effective 7/2/04. 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.]


AMENDATORY SECTION(Amending WSR 02-02-047, filed 12/27/01, effective 1/27/02)

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)) allowed to provide ((informed)) written 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)) identifies and facilitates additional training of the nursing assistant prior to delegation in these situations. The registered nurse delegator ((may)) decides if the task is not delegable. In no case, may administration of medications by injection with the exception of insulin injections, 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)) providing support and care to individuals served by certified community residential programs for the developmentally disabled, to individuals residing in licensed adult family homes, to in-home care and to individuals residing in licensed boarding homes.

(6) "Outcome" means the end result or consequence of an action after following ((an established)) a plan of care.

(7) "Patient" means the individual ((recipient of)) receiving nursing ((actions)) care tasks. In the community residential settings, the patient may ((also)) be ((referred to as)) a client, consumer, or resident.

(8) "Personal care services" as defined in WAC ((388-15-202)) 388-106-0010 do not require delegation by a licensed nurse.

(9) "Procedure" means a series of steps ((by which)) with 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))) (11) "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))) (12) "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)) assessment by the registered nurse delegator occurs prior to the delegation of duties to any care giver.

(((14))) (13) "Direct supervision" means the registered nurse delegator ((is)) on the premises, ((is)) quickly and easily available and the patient ((has been assessed)) assessment by the registered nurse delegator occurs prior to the delegation of the duties to any care giver.

(((15))) (14) "Indirect supervision" means the registered nurse delegator is not on the premises ((but has previously given)). The registered nurse delegator previously provided 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)). The registered nurse delegator documents in the patient record the instruction to the nursing assistant, observation of the delegated task, and confirmation of the nursing assistant understanding the directions.

(((16))) (15) "Stable and predictable condition" means ((a situation in which)) the registered nurse delegator determines the patient's clinical and behavioral status is ((known through the registered nurse delegator's assessment to be)) nonfluctuating and consistent((, including)). Stable and predictable may include a terminally ill patient whose deteriorating condition is ((predictable)) expected. Stable and predictable may include a patient with sliding scale insulin orders. The registered nurse delegator determines ((that)) the patient does not require ((their)) frequent nursing 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.]


AMENDATORY SECTION(Amending WSR 04-14-065, filed 7/2/04, effective 7/2/04)

WAC 246-840-930   Criteria for delegation.   (1) Before delegating a nursing task, the registered nurse delegator ((must determine that it)) decides the task is appropriate to delegate based on the elements of the nursing process: ASSESS, PLAN, IMPLEMENT, EVALUATE((:)).


ASSESS


(2) ((Determine that)) The setting allows delegation because it is 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).

(3) Assess the patient's nursing care needs and determine ((that)) the patient's condition is ((in a)) stable and predictable ((condition)). A patient may be stable and predictable with an order for sliding scale insulin or terminal 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)) assesses 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)) identifies and facilitates any additional training of the nursing assistant ((that is)) needed prior to delegation. The registered nurse delegator ((must)) ensures ((that)) the task to be delegated can be properly and safely performed by the nursing assistant.

(7) Assess the level of interaction required((, considering)). Consider language or cultural diversity ((that may affect)) affecting communication or the ability to accomplish the task ((to be delegated, as well as methods)) and 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)) have completed 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 training; ((and))

(d) Has a certificate of completion issued by the department of social and health services indicating completion of diabetes training when providing insulin injections to a diabetic client; and

(e) Is willing and able 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)) Discusses the delegation process with the patient or authorized representative, including the level of training of the nursing assistant delivering care.

(b) Obtains ((patient)) written 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 includes:

(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)) uses 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. With delegation of insulin injections, the supervision occurs at least weekly for the first four weeks, and may be more frequent.

(13) The administration of medications may be delegated at the discretion of the registered nurse delegator ((but never by)), including insulin injections. Any other injection (((by)) intramuscular, intradermal, subcutaneous, intraosseous, intravenous, or otherwise) is prohibited. The registered nurse delegator ((must)) provides to the nursing assistant written ((parameters)) directions 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)) monitors the performance of the task(s) to assure compliance ((to)) with established standards of practice, policies and procedures and ((to ensure)) appropriate documentation of the task(s).


EVALUATE


(16) The registered nurse delegator ((must)) evaluates 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)) supervises and evaluates 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)) reevaluates 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)) ensures safe and effective services are provided. Reevaluation and documentation ((must)) occurs at least every ninety days. Frequency of supervision is at the discretion of the registered nurse delegator and may be more often based upon nursing assessment.

(19) The registered nurse must supervise and evaluate the performance of the nursing assistant with delegated insulin injection authority at least weekly for the first four weeks. After the first four weeks the supervision shall occur at least every ninety days.

[Statutory Authority: RCW 18.79.110, 18.79.260 (3)(f), 18.88A.210, 2003 c 140. 04-14-065, 246-840-930, filed 7/2/04, effective 7/2/04. 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.]


AMENDATORY SECTION(Amending WSR 04-14-065, filed 7/2/04, effective 7/2/04)

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


(1) Does the patient reside in one of the following settings? 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 ↓
(5) Is the task within the registered nurse's scope of practice? No -> Do not delegate
Yes
(6) Is the nursing assistant registered or certified and properly trained in the nurse delegation for nursing assistants? Is the nursing assistant trained in diabetes care and insulin injections when delegating insulin? No -> Do not delegate
Yes
(7) Does the delegation exclude the administration of medications by injection other than insulin, sterile procedures or central line maintenance? No -> Do not delegate
Yes
(8) Can the task be performed without requiring judgment based on nursing knowledge? No -> Do not delegate
Yes
(9) Are the results of the task reasonably predictable? No -> Do not delegate
Yes
(10) Can the task be safely performed according to exact, unchanging directions? No -> Do not delegate
Yes
(11) Can the task be performed without a need for complex observations or critical decisions? No -> Do not delegate
Yes
(12) Can the task be performed without repeated nursing assessments? No -> Do not delegate
Yes
(13) Can the task be performed ((improperly without life-threatening consequences)) properly? No -> Do not delegate
Yes
(14) Is appropriate supervision available? With insulin injections, the supervision occurs at least weekly for the first four weeks. No -> Do not delegate
Yes
(15) There are no specific laws or rules prohibiting the delegation? No -> Do not delegate
Yes
(16) Task is delegable

[Statutory Authority: RCW 18.79.110, 18.79.260 (3)(f), 18.88A.210, 2003 c 140. 04-14-065, 246-840-940, filed 7/2/04, effective 7/2/04. 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.]


AMENDATORY SECTION(Amending WSR 02-02-047, filed 12/27/01, effective 1/27/02)

WAC 246-840-950   How to make changes to the delegated tasks.   (1) Medication. The registered nurse delegator ((will discuss)) discusses with the nursing assistant the process for continuing, rescinding, or adding medications to the delegation list when the ((health care provider)) changes ((medication orders)) occur:

(a) The registered nurse delegator ((must verify)) verifies 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 type of medication changes 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)) continues at the registered nurse delegator's discretion; and

(c) If a new medication is added, the registered nurse delegator ((must)) reviews 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)) initiates and participates in developing an alternative plan to ((assure)) meet the needs of the patient ((are met)).

(2) Treatments and/or procedures.

(a) The registered nurse delegator ((must verify)) verifies the change in the medical order with the health care provider.

(b) The registered nurse delegator ((maintains the authority to)) decides 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 rescinding delegation ((is to be rescinded)), the registered nurse delegator ((must)) initiates and participates in developing an alternative plan to ((assure)) meet 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)) may transfer the delegation process((, provided)) to another registered nurse. The registered nurse assuming responsibility ((knows)) assesses 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: 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.]


AMENDATORY SECTION(Amending WSR 02-02-047, filed 12/27/01, effective 1/27/02)

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:

(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)) rescinding the delegation ((be rescinded));

(g) When the facility's license lapsed; or

(h) When caregivers are not currently registered, certified, or have restrictions to practice.

(2) In the event delegation is rescinded, the registered nurse delegator initiates and participates in developing an alternative plan to ((ensure the)) provide continuity ((for the provision)) of the task or assumes responsibility for performing the task.

(3) The registered nurse delegator ((must)) documents the reason for rescinding delegation of the task and the plan for ((ensuring continuity of)) continuing 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.]


AMENDATORY SECTION(Amending WSR 02-02-047, filed 12/27/01, effective 1/27/02)

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. While the delegated task becomes the responsibility of the ((person to whom it is delegated but)) nursing assistant, 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 adult services administration of the department of social and health services or via a toll-free telephone number.

(5) All complaints related to registered nurse ((delegation)) delegators shall be referred to the nursing care quality assurance commission.

(6) All complaints related to nursing assistants performing delegated tasks shall be referred to the secretary of health.

(7) 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))) (8) 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.]

OTS-1862.2


AMENDATORY SECTION(Amending WSR 04-14-064, filed 7/2/04, effective 7/2/04)

WAC 246-841-405   Nursing assistant delegation.   Provision for delegation of certain tasks.

(1) Nursing assistants ((may)) perform tasks ((when)) delegated by a registered nurse for patients in community-based care settings or in-home care settings((,)) each as defined in RCW 18.79.260 (3)(e).

(2) ((Any nursing assistant who receives authority to perform a delegated nursing task must,)) Before performing any delegated task:

(a) ((For)) Nursing assistants-registered((, provide to the delegating nurse)) must show the certificate of completion of both the basic caregiver training and core delegation training ((as established by)) from the department of social and health services to the registered nurse delegator.

(b) ((For)) Nursing assistants-certified((, provide to)) must show the ((delegating nurse the)) certificate of completion of the core delegation training ((as established by)) from the department of social and health services to the registered nurse delegator.

(c) ((For)) All nursing assistants((,)) must comply with all applicable requirements ((and protocol established by)) of the nursing care quality assurance commission in WAC 246-840-910 through 246-840-970.

(d) ((For)) All nursing assistants, registered and certified, who may be completing insulin injections must give a certificate of completion of diabetic training from the department of social and health services to the registered nurse delegator.

(e) All nursing assistants((,)) must meet any additional training requirements identified by the nursing care quality assurance commission. Any exceptions to ((any such)) additional training requirements must ((adhere to)) comply with RCW 18.79.260 (3)(e)(v).

(3) ((Any nursing assistant performing a)) Delegated nursing care tasks ((pursuant to)) described in this section((, shall perform the task)) are:

(a) Only for the specific patient ((who was the subject of the)) receiving delegation;

(b) Only with the patient's consent; and

(c) In compliance with all applicable requirements ((and protocols established by the nursing care quality assurance commission)) in WAC 246-840-910 through 246-840-970.

(4) A nursing assistant may consent or refuse to consent to perform a delegated nursing care task ((and shall be)). The nursing assistant is responsible for their own actions with ((regard to)) the decision to consent or refuse to consent and the performance of the delegated nursing care task.

(5) Nursing assistants shall not accept delegation of, or perform, the following nursing care tasks:

(a) Administration of medication by injection, with the exception of insulin injections;

(b) Sterile procedures;

(c) Central line maintenance;

(d) Acts that require nursing judgment.

[Statutory Authority: RCW 18.88A.060 and 2003 c 140. 04-14-064, 246-841-405, filed 7/2/04, effective 7/2/04. Statutory Authority: Chapter 18.88A RCW. 96-06-029, 246-841-405, filed 2/28/96, effective 3/30/96.]

Washington State Code Reviser's Office