PROPOSED RULES
(Nursing Care Quality Assurance Commission)
Supplemental Notice to WSR 00-14-062.
Preproposal statement of inquiry was filed as WSR 98-23-071.
Title of Rule: Standards of conduct or practice for nurses, WAC 246-840-700; functions of registered nurse (RN) and licensed practical nurse (LPN) practice, WAC 246-840-705; and violations of standards of nursing conduct or practice, WAC 246-840-710.
Repealing standards/competencies, WAC 246-840-715.
Purpose: To protect the public by requiring nurses to adhere to standards of competency and delineation of violations of the practice standards for nurses.
Other Identifying Information: The primary components identified in standards/competencies WAC 246-840-715 are combined into WAC 246-840-700, thereby eliminating the need for WAC 246-840-715 (repeal).
Statutory Authority for Adoption: Chapter 18.79 RCW.
Statute Being Implemented: Chapter 18.79 RCW.
Summary: The proposal clarifies the scope of practice standards for registered nurses and licensed practical nurses by combining the standards and competencies for nurses into one rule, WAC 246-840-700 and repealing a redundant rule, WAC 246-840-715. The revisions to WAC 246-840-705 add a description of the functions of the registered nurse. WAC 246-840-710 uniformly outlines RN and LPN violations of nursing standards.
Reasons Supporting Proposal: The restructuring of the rules provide clearer guidance to nurses about the scope of practice requirements and a consistent description of the violations of the practice standards.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Terry J. West, 1300 S.E. Quince, Olympia, WA 98504, (360) 236-4712.
Name of Proponent: Department of Health, Health Professions Quality Assurance Division, Nursing Care Quality Assurance Commission, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The rule revisions are intended to eliminate redundancies in the current WACs. The reformatting of the standards of practice will enable the practitioner to examine the differences in the scope of practice for registered nurses and licensed practical nurses in the context of the nursing process. Combining the LPN competencies under one rule which describes nursing standards will clarify the expectations and streamline the chapter. By expanding the rule related to the functions of a nurse to include a description of the RN function will make the section consistent with the table format to enable side-by-side comparison of the RN and LPN functions. The revised rule relating to violations of the nursing standards help simplify the requirements and to apply the same language to both the RN and LPN.
Proposal Changes the Following Existing Rules: The primary change to WAC 246-840-700 is the format in which the standards are described and expressed. The LPN competencies in WAC 246-840-715 are modified and reordered into the "700" rule. WAC 246-840-715 is repealed as a result. WAC 246-840-705 adds the function of the RN and again expresses the functions in a table format to allow side-by-side comparison. WAC 246-840-710 describes violations of the standards uniformly for both RN and LPN practice, thereby eliminating differences in violations for RN and LPN practice.
A small business economic impact statement has been prepared under chapter 19.85 RCW.
A copy of the statement may be obtained by writing to Department of Health, Nursing Care Quality Assurance Commission, P.O. Box 47864, Olympia, WA 98504-7864, Attn: Terry West, phone (360) 236-4712, fax (360) 236-4738.
RCW 34.05.328 applies to this rule adoption. Violator will be subject to penalty or sanction.
Hearing Location: Center Point Corporate Park, Creekside One at CenterPoint, 20415 72nd Avenue South, Suite 150, Kent, WA, on March 9, 2001, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Kris McLaughlin by March 2, 2001, TDD (360) 664-0064, or (360) 236-4713.
Submit Written Comments to: Terry J. West, P.O. Box 47864, Olympia, WA 98504-7864, fax (360) 236-4738, by March 7, 2001.
Date of Intended Adoption: March 9, 2001.
December 1, 2000
Paula R. Meyer, RN, MSN
Executive Director
OTS-3427.4
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 expected of registered nurses include the following: | Minimum standards expected of 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: The registered nurse initiates data collection and analysis that includes pertinent objective and subjective data regarding the health status of the client. | (A) Assessment: The licensed practical nurse makes basic observations, gathers data and assists in identification of needs and problems relevant to the client. Collects specific data as directed and identifies major deviation from normal. Communicates outcomes of the assessment process in a timely fashion. Reports variances immediately. |
| (B) 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. | (B) Planning: The licensed practical nurse contributes to the development of approaches to meet the needs of clients and families. Develops client care plans utilizing a standardized nursing care plan and assists in setting priorities for care. |
| (C) Implementation: The registered nurse shall implement the plan of care by initiating nursing interventions through giving direct care and/or assisting with care through responsible assignment and supervision. | (C) Implementation: The licensed practical nurse carries out planned approaches to client care; performs common therapeutic nursing techniques. |
| (D) 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. | (D) Evaluation: Utilizing a standard plan for nursing care, the licensed practical nurse in collaboration with the registered nurse, appraises the effectiveness of client care. Assists with making adjustments in the care plan and reports outcome of care to the registered nurse. |
| (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 responsible and accountable for own actions by using common techniques of problem solving and decision making to plan and organize own assignment. Problem solving and decision making include utilization of available resources to secure a desired result. 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. |
| (A) Delegating selected nursing functions to others in accordance with their education, credentials, and demonstrated competence as provided by 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 provided by WAC 246-840-010 (10). |
| (B) Supervising others to whom he/she has delegated nursing functions as provided by WAC 246-840-010(10). | (B) The 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. | (C) In community long-term care settings, the practical nurse may delegate only personal care tasks to qualified care givers. |
| (D) Differentiating delegation activities in community long-term care settings as provided by WAC 246-840-910. | |
| (iii) Standard III Health Teaching. The registered nurse assesses learning needs 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. Health teaching is defined as facilitating learning and instructing clients and significant others in preventive and therapeutic measures. |
(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, or behaviors that serves as both a means of gathering information and of influencing the behavior, actions, attitudes, and feelings of others.
(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.
(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 their practice based on and limited to the scope of her/his education, demonstrated competence, and nursing experience consistent with the scope of practice set forth in this document.
(c) The registered nurse and the licensed practical nurse shall obtain instruction, supervision, and consultation as necessary before implementing new or unfamiliar techniques or practices.
(d) The registered nurse and the licensed practical nurse shall be responsible for maintaining current knowledge in his/her field of practice.
(e) The registered nurse and the licensed practical nurse shall conduct nursing practice without discrimination.
(f) 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.
(g) The registered nurse and the licensed practical nurse shall make mandatory reports in a timely fashion to the Nursing Care Quality Assurance Commission concerning unsafe or unprofessional conduct as required in WAC 246-840-730.
[Statutory Authority: Chapter 18.79 RCW. 97-13-100, 246-840-700, filed 6/18/97, effective 7/19/97.]
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, physiological, behavioral, and sociological and nursing sciences. Such acts are grounded in the elements of the nursing process which include the observation, assessment, analysis, diagnosis, planning, implementation and evaluation of nursing care and health teaching in the maintenance 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. | The licensed practical nurse performs services requiring knowledge, skill and judgment necessary for carrying out selected aspects of the designated nursing regimen under the direction and supervision of the registered nurse, advanced registered nurse practitioner, licensed physician and surgeon, dentist, osteopathic physician and surgeon, naturopathic physician, physician assistant, osteopathic physician assistant, and podiatric physician and surgeon. 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. The clinical and behavioral state of the client is relatively stable and 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. |
| (3) Registered Nurses: | (4) Licensed Practical Nurses: |
| The registered nurse functions in an independent role when utilizing unique skills, knowledge and judgment based on the biopsychosocial and health sciences to meet the complex needs of the client. | The licensed practical
nurse functions in an
interdependent role to
deliver care as directed and
revises care plans in
collaboration with the
registered nurse. The licensed practical nurse functions in a dependent role when under the direction of a registered nurse, advanced registered nurse practitioner, licensed physician and surgeon, dentist, osteopathic physician and surgeon, physician assistant, osteopathic physician assistant, podiatric physician and surgeon, and naturopathic physician and performs delegated elements of the nursing process. |
| 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. | These functions of practical nursing create a distinct occupation within the profession of nursing. 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 while under the direction and supervision of the health care professionals listed in RCW 18.79.270. |
| The registered nurse functions in a dependent role when executing a medical regimen under the direction of an advanced registered nurse practitioner, licensed physician and surgeon, dentist, osteopathic physician and surgeon, physician assistant, osteopathic physician assistant, podiatric physician and surgeon, and naturopathic physician. | 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.]
(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 intelligibly.
(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.
(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 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.
(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.
(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. Nor shall the nurse 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.
(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.
(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.
(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.]
The following section of the Washington Administrative Code is repealed:
| WAC 246-840-715 | Standards/competencies. |