WSR 02-06-117

PERMANENT RULES

DEPARTMENT OF HEALTH


(Nursing Care Quality Assurance Commission)

[ Filed March 6, 2002, 9:46 a.m. ]

Date of Adoption: January 11, 2002.

Purpose: Amend WAC 246-840-700 Standards of nursing conduct or practice, 246-840-705 Functions of a licensed practical nurse and 246-840-710 Violations of standards of nursing conduct or practice; and repealing WAC 246-840-715 Standards/competencies.

Citation of Existing Rules Affected by this Order: Repealing WAC 246-840-715; and amending WAC 246-840-700, 246-840-705, and 246-840-710.

Statutory Authority for Adoption: RCW 18.79.110.

Adopted under notice filed as WSR 01-21-135 on October 24, 2001.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, Repealed 1.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 1.
Effective Date of Rule: Thirty-one days after filing.

January 11, 2002

Joanna Boatman, RN

Chair, Nursing Commission

OTS-3427.7


AMENDATORY SECTION(Amending WSR 97-13-100, filed 6/18/97, effective 7/19/97)

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 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 ((pursuant to)) 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((:


FOR REGISTERED NURSES:


(1) Nursing process:

(a) The registered nurse shall collect pertinent objective and subjective data regarding the health status of the client.

(b) The registered nurse shall plan and implement nursing care which will assist the client to maintain or return to a state of health or will support a dignified death.

(c) The registered 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.

(d) The registered nurse shall document, on essential client records, the nursing care given and the client's response to that care.

(2) Delegation and supervision: The registered nurse shall be accountable for the safety of clients receiving nursing service by:

(a) Delegating selected nursing functions to others in accordance with their education, credentials, and demonstrated competence.

(b) Supervising others to whom he/she has delegated nursing functions.

(3) Other responsibilities:

(a) The registered 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 shall be responsible and accountable for practice based on and limited to the scope of her/his education, demonstrated competence, and nursing experience.

(c) The registered nurse shall obtain instruction, supervision, and consultation as necessary before implementing new or unfamiliar techniques or practices.

(d) The registered nurse shall be responsible for maintaining current knowledge in his/her field of practice.

(e) The registered nurse shall conduct nursing practice without discrimination.

(f) The registered nurse shall respect the client's right to privacy by protecting confidential information.

(g) The registered nurse shall report unsafe nursing acts and practices, and illegal acts as defined in WAC 246-840-730.


FOR PRACTICAL NURSES:


(4) The licensed practical nurse, functioning under the direction and supervision of other licensed health care professionals as provided in RCW 18.79.060, shall be responsible and accountable for his or her own nursing judgments, actions and competence.

(5) The licensed practical nurse shall practice practical nursing in the state of Washington only with a current Washington license.

(6) The licensed practical nurse shall not permit his or her license to be used by another person for any purpose.

(7) The licensed practical nurse shall have knowledge of the statutes and rules governing licensed practical nurse practice and shall function within the legal scope of licensed practical nurse practice.

(8) The licensed practical nurse shall not aid, abet or assist any other person in violating or circumventing the laws or rules pertaining to the conduct and practice of licensed practical nursing.

(9) The licensed practical nurse shall not disclose the contents of any licensing examination or solicit, accept or compile information regarding the contents of any examination before, during or after its administration.

(10) The licensed practical nurse shall delegate activities only to persons who are competent and qualified to undertake and perform the delegated activities, and shall not delegate to unlicensed persons those functions that are to be performed only by licensed nurses.

(11) The licensed practical nurse, in delegating functions, shall supervise the persons to whom the functions have been delegated.

(12) The licensed practical nurse shall act to safeguard clients from unsafe practices or conditions, abusive acts, and neglect.

(13) The licensed practical nurse shall report unsafe acts and practices, unsafe practice conditions, and illegal acts to the appropriate supervisory personnel or to the appropriate state disciplinary board or commission.

(14) The licensed practical nurse shall respect the client's privacy by protecting confidential information, unless required by law to disclose such information.

(15) The licensed practical nurse shall make accurate, intelligible entries into records required by law, employment or customary practice of nursing, and shall not falsify, destroy, alter or knowingly make incorrect or unintelligible entries into client's records or employer or employee records.

(16) The licensed practical nurse shall not sign any record attesting to the wastage of controlled substances unless the wastage was personally witnessed.

(17) The licensed practical nurse shall observe and record the conditions of a client, and report significant changes to appropriate persons.

(18) The licensed practical nurse may withhold or modify client care which has been authorized by an appropriate health care provider, only after receiving directions from an appropriate person, unless in a life threatening situation.

(19) The licensed practical nurse shall leave a nursing assignment only after properly reporting to and notifying appropriate persons and shall not abandon clients.

(20) The licensed practical nurse shall not misrepresent his or her education and ability to perform nursing procedures safely.

(21) The licensed practical nurse shall respect the property of the client and employer and shall not take equipment, materials, property or drugs for his or her own use or benefit nor shall the licensed practical nurse solicit or borrow money, materials or property from clients.

(22) The licensed practical nurse shall not obtain, possess, distribute or administer legend drugs or controlled substances to any person, including self, except as directed by a person authorized by law to prescribe drugs.

(23) The licensed practical nurse shall not practice nursing while affected by alcohol or drugs, or by a mental, physical or emotional condition to the extent that there is an undue risk that he or she, as a licensed practical nurse, would cause harm to him or herself or other persons.

(24) It is inconsistent for a licensed practical nurse to perform functions below the minimum standards of competency as expressed in WAC 246-840-715.));

(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 settings as provided by WAC 246-840-910 through 246-840-980 and WAC 246-841-405; (D) In community based long-term care settings as provided by WAC 246-840-910 through 246-840-980 and WAC 246-841-405, the practical nurse may delegate only personal care tasks to qualified care givers;
(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: Chapter 18.79 RCW. 97-13-100, 246-840-700, filed 6/18/97, effective 7/19/97.]


AMENDATORY SECTION(Amending WSR 97-13-100, filed 6/18/97, effective 7/19/97)

WAC 246-840-705   Functions of a registered nurse and a licensed practical nurse.   ((A licensed practical nurse is one who has met the requirements of the Washington state Nurse Practice Act, chapter 18.79 RCW. The licensed practical nurse recognizes and is able to meet the basic needs of the client, and gives nursing care under the direction and supervision of the registered nurse or licensed physician to clients in routine nursing situations. In more complex situations the licensed practical nurse functions as an assistant to the registered nurse and carries out selected aspects of the designated nursing regimen.

A routine nursing situation is one that is relatively free of scientific complexity. The clinical and behavioral state of the client is relatively stable and requires abilities based upon a comparatively fixed and limited body of knowledge.

In complex situations, the licensed practical nurse facilitates client care by meeting specific nursing requirements to assist the registered nurse in the performance of nursing care.

The functions of the licensed practical nurse makes practical nursing a distinct occupation within the profession of nursing. The licensed practical nurse has specific roles in nursing in direct relation to the length, scope and depth of his or her formal education and experience. In the basic program of practical nursing education, the emphasis is on direct client care.

With additional preparation, through continuing education and practice, the licensed practical nurse prepares to assume progressively more complex nursing responsibilities.))

(1) Registered Nurses: (2) Licensed Practical Nurses:
The registered nurse performs acts that require substantial knowledge, judgment and skill based on the principles of biological, behavioral, health, and nursing sciences. Such acts are grounded in the elements of the nursing process which includes, but is not limited to, the assessment, analysis, diagnosis, planning, implementation and evaluation of nursing care and health teaching in the maintenance and the promotion of health or prevention of illness of others and the support of a dignified death. The registered nurse using specialized knowledge can perform the activities of administration, supervision, delegation and evaluation of nursing practice; and The licensed practical nurse performs services requiring knowledge, skill and judgment necessary for carrying out selected aspects of the designated nursing regimen. The licensed practical nurse recognizes and is able to meet the basic needs of the client, and gives nursing care under the direction and supervision, to clients in routine nursing situations. A routine nursing situation is one that is relatively free of complexity, and the clinical and behavioral state of the client is relatively stable, requires care based upon a comparatively fixed and limited body of knowledge. In complex nursing care situations the licensed practical nurse functions as an assistant to the registered nurse and facilitates client care by carrying out selected aspects of the designated nursing regimen to assist the registered nurse in the performance of nursing care; and
(3) Registered Nurses: (4) Licensed Practical Nurses:
The registered nurse functions in an independent role when utilizing the nursing process as defined in WAC 246-840-700(2) to meet the complex needs of the client. The licensed practical nurse functions in an interdependent role to deliver care as directed and assists in the revision of care plans in collaboration with the registered nurse.

The licensed practical nurse functions in a dependent role when executing a medical regimen under the direction and supervision of an advanced registered nurse practitioner, licensed physician and/or surgeon, dentist, osteopathic physician and/or surgeon, physician assistant, osteopathic physician assistant, podiatric physician and/or surgeon, or naturopathic physician. A licensed practical nurse may not accept delegation of acts not within his or her scope of practice.

In an interdependent role as a member of a healthcare team, the registered nurse functions to coordinate and evaluate the care of the client and independently revises the plan and delivery of nursing care.
The registered nurse functions in an interdependent role when executing a medical regimen under the direction of an advanced registered nurse practitioner, licensed physician and/or surgeon, dentist, osteopathic physician and/or surgeon, physician assistant, osteopathic physician assistant, podiatric physician and/or surgeon, or naturopathic physician. A registered nurse may not accept delegation of acts not within his or her scope of practice. This shall not be construed as authorizing an independent role for the LPN.

[Statutory Authority: Chapter 18.79 RCW. 97-13-100, 246-840-705, filed 6/18/97, effective 7/19/97.]


AMENDATORY SECTION(Amending WSR 97-13-100, filed 6/18/97, effective 7/19/97)

WAC 246-840-710   Violations of standards of nursing conduct or practice.   ((The following will serve as a guideline for the nurse as to the acts, practices, or omissions that are inconsistent with generally accepted standards of nursing conduct or practice. Such conduct or practice may be grounds for action with regard to the license to practice nursing pursuant to chapter 18.79 RCW and the Uniform Disciplinary Act, chapter 18.130 RCW. Such conduct or practice includes, but is not limited to the following:

(1) Failure to adhere to the standards enumerated in WAC 246-840-700(1) which may include:

(a) Failing to assess and evaluate a client's status or failing to institute nursing intervention as required by the client's condition.

(b) Willfully or repeatedly failing to report or document a client's symptoms, responses, progress, medication, or other nursing care accurately and/or intelligibly.

(c) Willfully or repeatedly failing to make entries, altering entries, destroying entries, making incorrect or illegible entries and/or making false entries in records pertaining to the giving of medication, treatments, or other nursing care.

(d) Willfully or repeatedly failing to administer medications and/or treatments in accordance with policy and procedure.

(e) Willfully or repeatedly failing to follow the policy and procedure for the wastage of medications where the nurse is employed or working.

(f) Willfully causing or contributing to physical or emotional abuse to the client.

(2) Failure to adhere to the standards enumerated in WAC 246-840-700(2) which may include:

(a) Delegating nursing care function or responsibilities to a person who the nurse knows or has reason to know lacks the ability or knowledge to perform the function or responsibility, or delegating to unlicensed persons those functions or responsibilities the nurse knows or has reason to know are to be performed only by licensed persons. This section should not be construed as prohibiting delegation to family members and other caregivers exempted by RCW 18.79.040(3), 18.79.050, 18.79.060 or 18.79.240.

(b) Failure to supervise those to whom nursing activities have been delegated. Such supervision shall be adequate to prevent an unreasonable risk of harm to clients.

(3) Failure to adhere to the standards enumerated in WAC 246-840-700(3) which may include:

(a) Performing or attempting to perform nursing techniques and/or procedures for which the nurse lacks the appropriate knowledge, experience, and education and/or failing to obtain instruction, supervision and/or consultation for client safety.

(b) Violating the confidentiality of information or knowledge concerning the client, except where required by law or for the protection of the client.

(c) Writing prescriptions for drugs unless authorized to do so by the board.

(4) Other violations:

(a) Appropriating for personal use medication, supplies, equipment, or personal items of the client, agency, or institution.

(b) Practicing nursing while impaired by any mental, physical and/or emotional condition to the extent that the person may be unable to practice with reasonable skill and safety.

(c) Willfully abandoning clients by leaving a nursing assignment without transferring responsibilities to appropriate personnel or caregiver when continued nursing care is required by the condition of the client(s).

(d) Practicing nursing while impaired by alcohol and/or drugs.

(e) Conviction of a crime involving physical abuse or sexual abuse relating to the practice of nursing.)) The following conduct may subject a nurse to disciplinary action under the Uniform Disciplinary Act, chapter 18.130 RCW:

(1) Engaging in conduct described in RCW 18.130.180;

(2) Failure to adhere to the standards enumerated in WAC 246-840-700 which may include, but are not limited to:

(a) Failing to assess and evaluate a client's status or failing to institute nursing intervention as required by the client's condition;

(b) Willfully or repeatedly failing to report or document a client's symptoms, responses, progress, medication, or other nursing care accurately and/or legibly;

(c) Willfully or repeatedly failing to make entries, altering entries, destroying entries, making incorrect or illegible entries and/or making false entries in employer or employee records or client records pertaining to the giving of medication, treatments, or other nursing care;

(d) Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards;

(e) Willfully or repeatedly failing to follow the policy and procedure for the wastage of medications where the nurse is employed or working;

(f) Nurses shall not sign any record attesting to the wastage of controlled substances unless the wastage was personally witnessed;

(g) Willfully causing or contributing to physical or emotional abuse to the client;

(h) Engaging in sexual misconduct with a client as defined in WAC 246-840-740; or

(i) Failure to protect clients from unsafe practices or conditions, abusive acts, and neglect;

(3) Failure to adhere to the standards enumerated in WAC 246-840-700(2) which may include:

(a) Delegating nursing care function or responsibilities to a person the nurse knows or has reason to know lacks the ability or knowledge to perform the function or responsibility, or delegating to unlicensed persons those functions or responsibilities the nurse knows or has reason to know are to be performed only by licensed persons. This section should not be construed as prohibiting delegation to family members and other caregivers exempted by RCW 18.79.040(3), 18.79.050, 18.79.060 or 18.79.240; or

(b) Failure to supervise those to whom nursing activities have been delegated. Such supervision shall be adequate to prevent an unreasonable risk of harm to clients;

(4)(a) Performing or attempting to perform nursing techniques and/or procedures for which the nurse lacks the appropriate knowledge, experience, and education and/or failing to obtain instruction, supervision and/or consultation for client safety;

(b) Violating the confidentiality of information or knowledge concerning the client, except where required by law or for the protection of the client; or

(c) Writing prescriptions for drugs unless authorized to do so by the commission;

(5) Other violations:

(a) Appropriating for personal use medication, supplies, equipment, or personal items of the client, agency, or institution. The nurse shall not solicit or borrow money, materials or property from clients;

(b) Practicing nursing while affected by alcohol or drugs, or by a mental, physical or emotional condition to the extent that there is an undue risk that he or she, as a nurse, would cause harm to him or herself or other persons; or

(c) Willfully abandoning clients by leaving a nursing assignment, when continued nursing care is required by the condition of the client(s), without transferring responsibilities to appropriate personnel or caregiver;

(d) Conviction of a crime involving physical abuse or sexual abuse including convictions of any crime or plea of guilty, including crimes against persons as defined in chapter 43.830 RCW and crimes involving the personal property of a patient, whether or not the crime relates to the practice of nursing; or

(e) Failure to make mandatory reports to the Nursing Care Quality Assurance Commission concerning unsafe or unprofessional conduct as required in WAC 246-840-730;

Other:

(6) The nurse shall only practice nursing in the state of Washington with a current Washington license;

(7) The licensed nurse shall not permit his or her license to be used by another person;

(8) The nurse shall have knowledge of the statutes and rules governing nursing practice and shall function within the legal scope of nursing practice;

(9) The nurse shall not aid, abet or assist any other person in violating or circumventing the laws or rules pertaining to the conduct and practice of professional registered nursing and licensed practical nursing; or

(10) The nurse shall not disclose the contents of any licensing examination or solicit, accept or compile information regarding the contents of any examination before, during or after its administration.

[Statutory Authority: Chapter 18.79 RCW. 97-13-100, 246-840-710, filed 6/18/97, effective 7/19/97.]


REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 246-840-715 Standards/competencies.

Washington State Code Reviser's Office