Z-0094.5  _______________________________________________

 

                          HOUSE BILL 1218

          _______________________________________________

 

State of Washington      56th Legislature     1999 Regular Session

 

By Representatives Cody and Parlette; by request of Department of Health

 

Read first time 01/19/1999.  Referred to Committee on Health Care.

Modifying provisions related to nurse delegation of tasks.


    AN ACT Relating to department of health recommendations for improving nurse delegation in community settings; amending RCW 18.88A.210, 18.88A.230, and 18.79.260; and repealing RCW 18.88A.220 and 18.88A.240.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

 

    Sec. 1.  RCW 18.88A.210 and 1998 c 272 s 10 are each amended to read as follows:

    (1) A ((nurse may delegate specific care tasks to)) nursing assistant((s)) meeting the requirements of this section ((and)) who provides care to individuals in ((community residential programs for the developmentally disabled certified by the department of social and health services under chapter 71A.12 RCW, to individuals residing in adult family homes licensed under chapter 70.128 RCW, and to individuals residing in boarding homes licensed under chapter 18.20 RCW contracting with the department of social and health services to provide assisted living services pursuant to RCW 74.39A.010)) community-based care settings, as defined in RCW 18.79.260(3), may accept delegation of nursing care tasks by a registered nurse as provided in RCW 18.79.260(3).

    (2) For the purposes of this section, "nursing assistant" means a nursing assistant-registered or a nursing assistant-certified.  Nothing in this section may be construed to affect the authority of nurses to delegate nursing tasks to other persons, including licensed practical nurses, as authorized by law.

    (3) Before commencing any specific nursing care tasks authorized under this chapter, the nursing assistant must (a) provide to the delegating nurse a certificate of completion issued by the department of social and health services indicating the completion of basic core nurse delegation training ((as provided in this section)), (b) be regulated by the department of health pursuant to this chapter, subject to the uniform disciplinary act under chapter 18.130 RCW, and (c) meet any additional training requirements identified by the nursing care quality assurance commission ((and authorized by this section)).  Exceptions to these training requirements must adhere to RCW 18.79.260(3)(d)(iii).

    (((4) A nurse may delegate the following care tasks:

    (a) Oral and topical medications and ointments;

    (b) Nose, ear, eye drops, and ointments;

    (c) Dressing changes and catheterization using clean techniques as defined by the nursing care quality assurance commission;

    (d) Suppositories, enemas, ostomy care;

    (e) Blood glucose monitoring;

    (f) Gastrostomy feedings in established and healed condition.

    (5) On or before September 1, 1995, the nursing care quality assurance commission, in conjunction with the professional nursing organizations, shall develop rules for nurse delegation protocols and by December 5, 1995, identify training beyond the core training that is deemed necessary for the delegation of complex tasks and patient care.

    (6) Nursing task delegation protocols are not intended to regulate the settings in which delegation may occur but are intended 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 to make independent professional decisions regarding the delegation of a task.  Protocols shall include at least the following:

    (a) Ensure that determination of the appropriateness of delegation of a nursing task is at the discretion of the nurse;

    (b) Allow delegation of a nursing care task only for patients who have a stable and predictable condition.  "Stable and predictable condition" means a situation, as defined by rule by the nursing care quality assurance commission, in which the patient's clinical and behavioral status is known and does not require frequent presence and evaluation of a registered nurse;

    (c) Assure that the initial delegating nurse obtains written consent to the nurse delegation process from the patient or a person authorized under RCW 7.70.065.  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.  The written consent must include at a minimum the following:

    (i) A list of the tasks that could potentially be delegated per RCW 18.88A.210; and

    (ii) A statement that a nursing assistant through the nurse delegation process will be performing a task that would previously have been performed by a registered or licensed practical nurse;

    (d) Verify that the nursing assistant has completed the core training;

    (e) Require assessment by the nurse of the ability and willingness of the nursing assistant to perform the delegated nursing task in the absence of direct nurse supervision and to refrain from delegation if the nursing assistant is not able or willing to perform the task;

    (f) Require the nurse to analyze the complexity of the nursing task that is considered for delegation and determine the appropriate level of training and any need of additional training for the nursing assistant;

    (g) Require the teaching of the nursing care task to the nursing assistant utilizing one or more of the following:  (i) Verification of competency via return demonstration; (ii) other methods for verification of competency to perform the nursing task; or (iii) assurance that the nursing assistant is competent to perform the nursing task as a result of systems in place in the community residential program for the developmentally disabled, adult family home, or boarding home providing assisted living services;

    (h) Require a plan of nursing supervision and reevaluation of the delegated nursing task.  "Nursing supervision" means that the registered nurse monitors by direct observation or by whatever means is deemed appropriate by the registered nurse the skill and ability of the nursing assistant to perform delegated nursing tasks.  Frequency of supervision is at the discretion of the registered nurse but shall occur at least every sixty days;

    (i) Require instruction to the nursing assistant that the delegated nursing task is specific to a patient and is not transferable;

    (j) Require documentation and written instruction related to the delegated nursing task be provided to the nursing assistant and a copy maintained in the patient record;

    (k) Ensure that the nursing assistant is prepared to effectively deal with the predictable outcomes of performing the nursing task;

    (l) Include in the delegation of tasks an awareness of the nature of the condition requiring treatment, risks of the treatment, side effects, and interaction of prescribed medications;

    (m) Require documentation in the patient's record of the rationale for delegating or not delegating nursing tasks.

    (7) A basic core training curriculum on providing care for individuals in community residential programs for the developmentally disabled certified by the department of social and health services under chapter 71A.12 RCW shall be in addition to the training requirements specified in subsection (5) of this section.  Basic core training shall be developed and adopted by rule by the secretary of the department of social and health services.  The department of social and health services shall appoint an advisory panel to assist in the development of core training comprised of representatives of the following:

    (a) The division of developmental disabilities;

    (b) The nursing care quality assurance commission;

    (c) Professional nursing organizations;

    (d) A state-wide organization of community residential service providers whose members are programs certified by the department under chapter 71A.12 RCW.

    (8) A basic core training curriculum on providing care to residents in residential settings licensed under chapter 70.128 RCW, or in assisted living pursuant to RCW 74.39A.010 shall be mandatory for nursing assistants prior to assessment by a nurse regarding the ability and willingness to perform a delegated nursing task.  Core training shall be developed and adopted by rule by the secretary of the department of social and health services, in conjunction with an advisory panel.  The advisory panel shall be comprised of representatives from, at a minimum, the following:

    (a) The nursing care quality assurance commission;

    (b) Professional nurse organizations;

    (c) A state-wide association of community residential service providers whose members are programs certified by the department under chapter 71A.12 RCW;

    (d) Aging consumer groups;

    (e) Associations representing homes licensed under chapters 70.128 and 18.20 RCW; and

    (f) Associations representing home health, hospice, and home care agencies licensed under chapter 70.127 RCW.))

 

    Sec. 2.  RCW 18.88A.230 and 1998 c 272 s 11 are each amended to read as follows:

    (1) The ((nurse and)) nursing assistant shall be accountable for their own individual actions in the delegation process.  ((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.))  Nursing assistants following written delegation instructions from registered nurses performed in the course of their accurately written, delegated duties shall be immune from liability.

    (2) ((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.))  Nursing assistants shall not be subject to any employer reprisal or disciplinary action by the ((nursing care quality assurance commission)) secretary for refusing to accept delegation of a nursing task based on patient safety issues.  No ((community residential program, adult family home, or boarding home contracting to provide assisted-living services)) community-based care setting as defined in RCW 18.79.260(3)(d) may discriminate or retaliate in any manner against a person because the person made a complaint or cooperated in the investigation of a complaint.

    (((3) The department of social and health services may impose a civil fine of not less than two hundred fifty dollars nor more than one thousand dollars on a community residential program, adult family home, or boarding home under chapter 18, Laws of 1995 1st sp. sess. that knowingly permits an employee to perform a nursing task except as delegated by a nurse pursuant to chapter 18, Laws of 1995 1st sp. sess.))

 

    Sec. 3.  RCW 18.79.260 and 1995 1st sp.s. c 18 s 51 are each amended to read as follows:

    (1) A registered nurse under his or her license may perform for compensation nursing care, as that term is usually understood, of the ill, injured, or infirm((, and in the course thereof, she or he may do the following things that shall not be done by a person not so licensed, except as provided in RCW 18.79.270 and 18.88A.210:)).

    (((1))) (2) A registered nurse may, at or under the general direction of a licensed physician and surgeon, dentist, osteopathic physician and surgeon, naturopathic physician, podiatric physician and surgeon, physician assistant, osteopathic physician assistant, or advanced registered nurse practitioner acting within the scope of his or her license, administer medications, treatments, tests, and inoculations, whether or not the severing or penetrating of tissues is involved and whether or not a degree of independent judgment and skill is required.  Such direction must be for acts which are within the scope of registered nursing practice((;

    (2) Delegate to other persons the functions outlined in subsection (1) of this section in accordance with chapter 18.88A RCW;)).

    (3) A registered nurse may delegate tasks of nursing care to other individuals where the registered nurse determines that it is in the best interest of the patient.

    (a) The delegating nurse shall:

    (i) Determine the competency of the individual to perform the tasks;

    (ii) Evaluate the appropriateness of the delegation;

    (iii) Supervise the actions of the person performing the delegated task; and

    (iv) Delegate only those tasks that are within the registered nurse's scope of practice.

    (b) A registered nurse may not delegate acts requiring substantial skill, the administration of medications, or piercing or severing of tissues except to registered or certified nursing assistants who provide care to individuals in community-based care settings as authorized under (d) of this subsection.  Acts that require nursing judgment shall not be delegated.

    (c) No person may coerce a nurse into compromising patient safety by requiring the nurse to delegate if the nurse determines that it is inappropriate to do so.  Nurses shall not be subject to any employer reprisal or disciplinary action by the 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.

    (d) For delegation in community-based care settings, a registered nurse may delegate nursing care tasks only to registered or certified nursing assistants.  Simple care tasks such as blood pressure monitoring, personal care service, or other tasks as defined by the nursing care quality assurance commission are exempted from this requirement.  "Community-based care settings" includes:  Community residential programs for the developmentally disabled, certified by the department of social and health services under chapter 71A.12 RCW; adult family homes licensed under chapter 70.128 RCW; boarding homes licensed under chapter 18.20 RCW; and other community-based settings as authorized by the nursing care quality assurance commission by rule.  Community-based care settings do not include acute care or skilled nursing facilities.

    (i) Delegation of nursing care tasks in community-based care settings is only allowed for individuals who have a stable and predictable condition.  "Stable and predictable condition" means a situation in which the individual's clinical and behavioral status is known and does not require the frequent presence and evaluation of a registered nurse.

    (ii) The determination of the appropriateness of delegation of a nursing task is at the discretion of the registered nurse.  However, the administration of medications by the intravenous or intramuscular route, sterile procedures, and central line maintenance may never be delegated.

    (iii) The registered nurse is responsible for ensuring that the nursing assistant has completed the required core nurse delegation training required in chapter 18.88A RCW prior to authorizing delegation.  On a case-by-case basis, the registered nurse may delegate tasks to nursing assistants prior to the nursing assistant completing the training if the registered nurse determines that it is appropriate to do so, provides all necessary one-on-one training specific to that task and resident, and ensures that the nursing assistant receives the core delegation training within the first sixty days of the delegation process.  The registered nurse shall immediately rescind the delegation process if the nursing assistant has not completed the core training within this time frame.

    (iv) The nurse is accountable for his or her own individual actions in the delegation process.  Nurses acting within the protocols of their delegation authority are immune from liability for any action performed in the course of their delegation duties.

    (v) On or before June 30, 2000, the nursing care quality assurance commission, in conjunction with the professional nursing organizations and the department of social and health services, shall make any needed revisions or additions to nurse delegation protocols by rule, including standards for nurses to obtain informed consent prior to the delegation of nursing care tasks.  Nursing task delegation protocols are not intended to regulate the settings in which delegation may occur, but are intended to ensure that nursing care services have a consistent standard of practice upon which the public and the profession may rely, and to safeguard the authority of the nurse to make independent professional decisions regarding the delegation of a task.

    (e) The nursing care quality assurance commission may adopt rules to implement this section.

    (4) Only a person licensed as a registered nurse may instruct nurses in technical subjects pertaining to nursing((;)).

    (((4))) (5) Only a person licensed as a registered nurse may hold herself or himself out to the public or designate herself or himself as a registered nurse.

 

    NEW SECTION.  Sec. 4.  The following acts or parts of acts are each repealed:

    (1) RCW 18.88A.220 and 1995 1st sp.s. c 18 s 47; and

    (2) RCW 18.88A.240 and 1995 1st sp.s. c 18 s 49.

 


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