Delegation–Authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is directly assisting a RN by carrying out nursing tasks in the presence of a RN. Unlicensed person–An individual, not licensed as a health care provider Verifies that the unlicensed person can properly and adequately perform the delegated task without jeopardizing the client’s welfare; and The following standards must be met before the RN delegates nursing tasks to unlicensed persons. These criteria apply to all instances of RN delegation. Additional criteria, if appropriate to the particular task being delegated, may also be found in §224.8(b)(1) of this title (relating to Discretionary Delegation Tasks). (1) The RN must make an assessment of the client’s nursing care needs. The RN should, when the client’s status allows, consult with the client, and when appropriate the client’s family and/or significant other(s), to identify the client’s nursing needs prior to delegating nursing tasks. (2) The nursing task must be one that a reasonable and prudent RN would find is within the scope of sound nursing judgment to delegate.
The RN should consider the five rights of delegation: the right task, the right person to whom the delegation is made, the right circumstances, the right direction and communication by the RN, and the right supervision as determined by the RN. (3) The nursing task must be one that, in the opinion of the delegating RN, can be properly and safely performed by the unlicensed person involved without jeopardizing the client’s welfare. (4) The nursing task must not require the unlicensed person to exercise professional nursing judgment; however, the unlicensed person may take any action that a reasonable, prudent non-health care professional would take in an emergency situation. (5) The unlicensed person to whom the nursing task is delegated must be adequately identified. The identification may be by individual or, if appropriate, by training, education, and/or certification/permit of the unlicensed person. (6) The RN shall have either instructed the unlicensed person in the delegated task, or verified the unlicensed person’s competency to perform the nursing task.
The verification of competence may be done by the RN making the decision to delegate or, if appropriate, by training, education, experience and/or certification/permit of the unlicensed person. (7) The RN shall adequately supervise the performance of the delegated nursing task in accordance with the requirements of §224.7 of this title (relating to Supervision). (8) If the delegation continues over time, the RN shall periodically evaluate the delegation of tasks. For example, the evaluation would be appropriate when the client’s Nursing Care Plan is reviewed and revised. The RN’s evaluation of a delegated task(s) will be incorporated into the client’s Nursing Care Plan. (a) Tasks Which are Most Commonly Delegated. By way of example, and not in limitation, the following nursing tasks are ones that are most commonly the type of tasks within the scope of sound professional nursing practice to be considered for delegation, regardless of the setting, provided the delegation is in compliance with §224.6 of this title (relating to General Criteria for Delegation) and the level of supervision required is determined by the RN in accordance with §224.7 of this title (relating to Supervision):
(1) non-invasive and non-sterile treatments;
(2) the collecting, reporting, and documentation of data including, but not limited to: (A) vital signs, height, weight, intake and output, capillary blood and urine test for sugar and hematest results, (B) environmental situations;
(C) client or family comments relating to the client’s care; and (D) behaviors related to the plan of care;
(3) ambulation, positioning, and turning;
(4) transportation of the client within a facility;
(5) personal hygiene and elimination, including vaginal irrigations and cleansing enemas; (6) feeding, cutting up of food, or placing of meal trays; (7) socialization activities;
(8) activities of daily living; and
(9) reinforcement of health teaching planned and/or provided by the registered nurse
Discuss delegation rules pertinent to “independent living” environments for stable conditions. (a)The RN is responsible for proper performance of the assessment required by §225.6 of this title (relating to RN Assessment of the Client) and for the RN’s decisions made as a result of that assessment including determining that performance of a particular ADL or HMA for a particular client qualifies as not requiring delegation. (a) Activities of daily living (ADLs), as defined in this chapter, that do not fall within the practice of professional nursing may be performed by an unlicensed person in accordance with this section without being delegated. The Board has determined that in situations governed by this chapter ADLs do not fall within the practice of professional nursing when: (1) performed for a person with a functional disability and the client would perform the task(s) but for the functional disability; and (2) the RN determines, based on an assessment under §225.6 of this title (relating to RN Assessment of the Client) that the task(s) is such that it could be performed by any unlicensed person without RN supervision. (a)(b) If the above criteria cannot be met, an ADL may still be performed as a delegated task if it meets the criteria of §225.9 of this title (relating to Delegation Criteria). (b) Health Maintenance Activities (HMAs), as defined in this chapter that do not fall within the practice of professional nursing, may be performed by an unlicensed person in accordance with this section without being delegated. The Board has determined that in situations governed by this chapter HMAs do not fall within the practice of professional nursing when: (1) performed for a person with a functional disability
(a) A RN may delegate to medication aides the administration of medication to clients in long term care facilities and home health agencies if: (1) the medication aide holds a valid permit issued by the appropriate state agency to administer medications in that facility or agency; (2) the RN assures that the medication aide functions in compliance with the laws an regulations of the agency issuing the permit; and (3) the route of administration is oral, via a permanently placed feeding tube, sublingual or topical including eye, ear or nose drops and vaginal or rectal suppositories. (b) The following tasks may not be delegated to the Medication Aide Permit Holder unless allowed and in compliance with Chapter 225 of this title (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions): (1) calculation of any medication doses except for measuring a prescribed amount of liquid medication and breaking a tablet for administration, provided the RN has calculated the dose; (2) administration of the initial dose of a medication that has not been previously administered to the client; (3) administration of medications by an injectable route except as permitted for administration of insulin under §225.11 of this title (relating to Delegation of Administration of Medications From Pill Reminder Container and Administration of Insulin); (4) administration of medications used for intermittent positive pressure breathing or other methods involving medication inhalation treatments except as permitted in §225.10(10)(E) of this title (relating to Tasks That May Be Delegated). (5) administration of medications by way of a tube inserted in a cavity of the body except as stated in §225.11 of this title. (6) responsibility for receiving verbal or telephone orders from a physician, dentist, or podiatrist; and (7) responsibility for ordering a client’s medication from the pharmacy.
RNs in independent living environments such as, home and community-based settings or school health must utilize the rules in Chapter 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions when making decisions that pertain to delegation. The RN depending on the assessment of the client and the delegation criteria may decide to: designate a task a HMA that does not require delegation; delegate a task to an unlicensed person; or have a nurse perform the task. HMAs are defined as “tasks that enable the client to remain in an independent living environment and that go beyond activities of daily living (ADLs) because of the higher skill level required to perform”, [See Board Rule 225.4(8)]. The Board believes that expanding the list of HMAs will foster a client’s independence and further supports a client or the client’s responsible adult (CRA) who is able to train and supervise unlicensed personnel in the performance of a HMA, thus enabling the client to remain in the least restrictive environment as possible. For a complete list of tasks that can be designated as HMAs please refer to Board Rule 225.4(8) (A-E). The additional tasks that may be designated as HMAs are: •Noninvasive ventilation (NIV) such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) therapy •Routine administration of a prescribed dose of oxygen
•Unit dose medication administration by way of inhalation (MDIs) including medications administered as nebulizer treatments for prophylaxis and/or maintenance
•Topically applied medications
•Insulin administration subcutaneously, nasally, or via an insulin pump Because all nurses are required to promote a safe environment for their clients and others [See Board Rule 217.11(1)(B)], the RN must always consider what is safest for the client when making decisions to designate a task a HMA that does not require delegation. Nurses are reminded to document their decisions concerning delegation in the client’s record RN may delegate in emergency situations for clients in independent living environments, provided the RN has an order to administer or perform the following and the client has received a diagnosis that required a prescription for:
•Glucagon injections for treatment of severe hypoglycemia in unconscious clients or clients who are unable to swallow oral glucose
•Epinephrine injections from a single-dose pre-filled automatic injection device for severe allergic anaphylactic reactions
•Diazepam rectal gel in a pre-filled syringe for episodes of increased seizure activity •Nitroglycerin tablet(s) administered sublingually for the acute relief of an attack of angina pectoris •Use of a hand held magnet to activate a vagus nerve stimulator to prevent or control seizure activity •Metered dose inhalers or nebulizer treatments for the relief of acute respiratory symptoms
•Oxygen administration for the relief of acute respiratory symptoms Planning for emergencies in independent living environments requires the RN to utilize both Chapter 224, Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments and Chapter 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions. RNs must use their nursing judgment to decide when it is safe and appropriate to delegate life-sustaining medications and treatments to unlicensed personnel in independent living environments such as community-based settings, client homes or schools.