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; and boarding homes licensed under chapter 18.20 RCW.
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 injection, sterile procedures, and central line maintenance may
never be delegated.
(iii)
The registered nurse shall verify that the nursing assistant has completed the
required core nurse delegation training required in chapter 18.88A RCW prior to
authorizing delegation.
(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, 2001, 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.
