7/1/2014 DELEGATION FOR LAY CAREGIVERS PURPOSE & KEY TERMS OBJECTIVES

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1 DELEGATION FOR LAY CAREGIVERS June 2012 DHS Office of Licensing and Regulatory Oversight 1 PURPOSE & KEY TERMS The purpose of this section is to help the learner understand the basics of RN delegation and the role and responsibilities of the AFH provider when a task of nursing is delegated. Lay caregiver Periodic inspection Rescinding RN delegation Supervisory visits Written instructions June 2012 DHS Office of Licensing and Regulatory Oversight 2 OBJECTIVES The learner will be able to: Understand the basic RN delegation process; Describe why an RN must provide periodic inspection and supervisory visits; Describe the role and responsibility of the lay caregiver once a task of nursing has been delegated; List the types of situations/conditions when an RN may rescind a delegated task; Know what documents the RN must leave at the AFH when a task has been delegated. June 2012 DHS Office of Licensing and Regulatory Oversight 3 1

2 INTRODUCTION AFH residents frequently require nursing tasks such as insulin injections. RN delegation is a tool that allows a caregiver to perform a specific nursing task: Not all nursing tasks can be delegated; It is the sole responsibility of the RN to decide if a nursing task can be delegated; and RN delegation will not work in all situations June 2012 DHS Office of Licensing and Regulatory Oversight 4 INTRODUCTION CONTINUED RN delegation is process that requires a team approach between the RN and the AFH caregiver(s): While the RN is responsible for understanding rules of RN delegation, it is important the AFH caregiver understands the RN delegation process and what to expect from an RN when a nursing task is delegated. June 2012 DHS Office of Licensing and Regulatory Oversight 5 WHAT IS RN DELEGATION RN delegation is a legally defined process that allows an RN to authorize a caregiver (nonlicensed caregiver) to perform a nursing task for a resident without the RN being in the foster home each time the task is performed: The Oregon Nurse Practice Act only authorizes the RN to delegate the performance of the physical task. The RN cannot delegate assessment or evaluation of the person s health status. June 2012 DHS Office of Licensing and Regulatory Oversight 6 2

3 IMPORTANT NOTE RN delegation requirements do not apply to family members performing nursing tasks for family members. June 2012 DHS Office of Licensing and Regulatory Oversight 7 RN delegation is a: Task; Person; and Setting specific process. What this means is the RN must provide detailed teaching and written instructions for each task for each resident in each setting and observe each caregiver performing the nursing task on the resident June 2012 DHS Office of Licensing and Regulatory Oversight 8 The RN can teach several caregivers at the same time about the resident s condition: However, for delegation to occur, the RN must evaluate each individual caregiver; and Observe each individual caregiver perform the nursing task from start to finish for each resident. June 2012 DHS Office of Licensing and Regulatory Oversight 9 3

4 What tasks of nursing must be delegated: There is no list of what nursing tasks must be delegated. It is the individual RN s responsibility to determine if a nursing task can be delegated. The following list is a sample of common delegations seen in AFH settings: Subcutaneous injections such as insulin; Providing nutrition, fluids and oral medications through a gastrostomy tube (g tube) or other feeding tubes; Routine trach care and suctioning; Straight urinary catheterization. June 2012 DHS Office of Licensing and Regulatory Oversight 10 Other nursing tasks may be appropriate to delegate: Additionally, the RN may determine a commonly delegated nursing task cannot be delegated in a specific situation. The RN is solely responsible for making the final decision if the delegation of a nursing task can safely occur in your AFH. June 2012 DHS Office of Licensing and Regulatory Oversight 11 What cannot be delegated: An RN cannot delegate: Assessment, evaluation or decision making; Any nursing task if the resident s condition is unstable or requires the RN to assess before and/or after the task is performed; The administration of intramuscular (IM) injections; The administration of intravenous (IV) medications. June 2012 DHS Office of Licensing and Regulatory Oversight 12 4

5 Certain nursing tasks used for anticipatory emergencies cannot be delegated but are taught by an RN, pharmacist or the resident s primary care practitioner: Glucagon for diabetics; Epi pens for allergies. June 2012 DHS Office of Licensing and Regulatory Oversight 13 The RN must evaluate five components of the RN delegation process before deciding if a nursing task can be delegated: RN must consider: Their own expertise with the delegation process and the nursing task being considered. Does the RN have time to complete the delegation process in a timely manner? Is the RN able to provide the required ongoing supervision of the delegated nursing task? June 2012 DHS Office of Licensing and Regulatory Oversight 14 The RN must evaluate the resident s health condition related to the nursing task being considered for delegation. The resident s condition must be stable and predictable. To determine if the resident is stable and predictable, the RN will do a focused assessment of the resident related to the nursing task being considered. A RN cannot delegate a nursing task if the resident has an unknown health condition. The RN must determine if the task being considered for delegation is appropriate in this specific situation. June 2012 DHS Office of Licensing and Regulatory Oversight 15 5

6 The RN must assess each caregiver individually and determine if the caregiver is able: And willing to perform the task (includes physical ability); To follow written instructions and to communicate; AND To routinely perform the task: The RN cannot delegate a nursing task if the lay caregiver cannot perform the nursing task frequently enough to maintain the necessary skills. The RN must decide if the environment where the nursing task will be performed is appropriate. June 2012 DHS Office of Licensing and Regulatory Oversight 16 Once the RN has decided to delegate the RN must provide the caregiver with information before delegating the nursing task: Basic information about the resident s chronic condition including why the resident needs a particular nursing task performed; Any potential risks associated with the nursing task and possible side effects the resident may experience when performing the nursing task; Any signs and symptoms you need to observe or any action you need to take and document; How to perform the task. June 2012 DHS Office of Licensing and Regulatory Oversight 17 The RN must observe the caregiver perform the nursing task from start to finish. The RN can provide teaching about the task to several caregivers at one time, the RN must observe each caregiver perform the task from start to finish on the resident. Depending on the frequency of the nursing task, the RN may need to return to the AFH to finish delegating to all caregivers. June 2012 DHS Office of Licensing and Regulatory Oversight 18 6

7 The RN is required to document in the resident s record the name of each caregiver the RN has delegated the nursing task: The RN must provide a nursing plan of care that identifies the delegation; and When the RN will return to review the delegation. The RN is responsible for providing clear written step by step instructions including when to call 9 1 1, the resident s health care practitioner and the RN who has delegated the nursing task. June 2012 DHS Office of Licensing and Regulatory Oversight 19 The RN is not on call for emergencies. However, it is the AFH s responsibility to notify the RN anytime there is a change in the resident s medical orders or condition. The RN will need to determine if the changes affect the delegated nursing task. June 2012 DHS Office of Licensing and Regulatory Oversight 20 Once a nursing task has been delegated, the RN has mandated ongoing periodic inspection, supervision and evaluation: Oregon s Nurse Practice Act requires the following frequencies: A new delegation requires the RN to evaluate the lay caregiver and resident between one and 60 days from the date the nursing task was delegated. Thereafter, the RN is required to evaluate each lay caregiver and resident no less than every 180 days from the last visit. June 2012 DHS Office of Licensing and Regulatory Oversight 21 7

8 Supervision of RN delegation is limited to the delegated task and is not general supervision of the caregiver(s). The AHF owner and/or resident manager must routinely review caregiver records to assure the caregivers are following the RNs directions as written. June 2012 DHS Office of Licensing and Regulatory Oversight 22 The RN may decide to evaluate the caregiver more frequently. The decision to review more frequently is based on the complexity of the nursing task, the resident s needs, and the skill and confidence of the caregiver: Frequency of the RN s supervisory visits should be documented in the nurse s plan of care; If the resident s health support needs have changed or medical orders have changed, the RN may need to return and review the delegation to assure it is still appropriate or make any necessary changes to the instructions. June 2012 DHS Office of Licensing and Regulatory Oversight 23 When the RN returns to your AFH for the supervision visit, he or she will: Assess the current condition of the resident; Review the procedures and written directions established; Ensure the AFH documentation demonstrates the RN s written instructions are being followed; Observe each caregiver(s) whom the RN has delegated to perform the nursing task. June 2012 DHS Office of Licensing and Regulatory Oversight 24 8

9 AFH providers sometimes complain if the RN wants to come to the AFH during busy times such as meals or during the morning. If the delegated nursing task is scheduled during a busy time, the RN must visit during the time the nursing task will be performed. June 2012 DHS Office of Licensing and Regulatory Oversight 25 RESCINDING A DELEGATION If any of the five components are not met, the RN cannot delegate a nursing task: Additionally, if there are changes to any one of the five components after the task has been delegated, the RN may be required to rescind a delegation. June 2012 DHS Office of Licensing and Regulatory Oversight 26 RESCINDING A DELEGATION CONTINUED Common reasons for rescinding a delegation: The resident s condition has changed and is not stable; The nursing task is no longer needed; The caregiver(s) is not able to follow the instructions for any reason; The RN is not able to provide adequate supervision of a caregiver; The caregiver quits; There are frequent changes in caregivers and the RN is unable to evaluate new caregivers in a timely manner; The resident moves to another setting or dies. June 2012 DHS Office of Licensing and Regulatory Oversight 27 9

10 RESCINDING A DELEGATION CONTINUED No matter why the RN needs to rescind a delegation, it must be documented in the resident s record. Documentation needs to include the date the delegation was rescinded; the name of each caregiver for whom the delegation is rescinded; and the reason why the RN needs to rescind the delegation. June 2012 DHS Office of Licensing and Regulatory Oversight 28 HOME HEALTH AND HOSPICE A resident receiving home health services or on hospice may have delegation needs for a chronic ongoing condition such as diabetes: In this case, you must discuss the resident s needs with each RN to determine who is doing what and when: This should all be documented in the resident s record: Clear communication in the beginning will assure the resident s health care needs are fully supported. June 2012 DHS Office of Licensing and Regulatory Oversight 29 MISCELLANEOUS GUIDANCE Information regarding oral medications may need to be taught by a qualified health professional but does not require RN delegation: The RN consultant, the resident s pharmacist or primary care practitioner can provide information regarding oral medications; An informational document about the drug is provided for each medication dispensed from the pharmacy. It contains important information about the medication. June 2012 DHS Office of Licensing and Regulatory Oversight 30 10

11 MISCELLANEOUS GUIDANCE CONTINUED An RN may need to rescind a delegation if a caregiver: Does not follow instructions or Is unable to perform the task for any reason; however, it is the responsibility of the AFH provider to address performance issues with the staff. RN delegation is not transferable. What this means is you cannot perform the same task on another resident without the nursing task being delegated for that resident. June 2012 DHS Office of Licensing and Regulatory Oversight 31 MISCELLANEOUS GUIDANCE CONTINUED You cannot perform a nursing task prior to having it delegated even if a nurse is scheduled to delegate the task later. The RN is responsible for any forms or documents needed to delegate a nursing task. Any staff member with a medication aide or nursing assistant certificate must have nursing tasks delegated by an RN. June 2012 DHS Office of Licensing and Regulatory Oversight 32 MISCELLANEOUS GUIDANCE CONTINUED AFH rules require that you have all the necessary supports in place before accepting a resident: If a hospital, nursing home or anyone else wants you to admit a resident who has RN delegation needs, you cannot accept the resident unless you have made arrangements for RN delegation. June 2012 DHS Office of Licensing and Regulatory Oversight 33 11

12 MISCELLANEOUS GUIDANCE CONTINUED If an RN is unavailable, consider asking: For a referral for home health to either perform the task or to delegate the task; If a family member has experience performing the nursing task and if that person is willing to perform the nursing task until an RN is available to delegate the task to the AFH caregiver; The resident s primary care practitioner to perform the task. June 2012 DHS Office of Licensing and Regulatory Oversight 34 DISCUSSION/QUESTIONS June 2012 DHS Office of Licensing and Regulatory Oversight 35 12