ENSURING QUALITY CARE RN DELEGATION September 2019 Safety, - - PowerPoint PPT Presentation

ENSURING QUALITY CARE

RN DELEGATION

September 2019 Safety, Oversight and Quality Unit 1

PURPOSE AND 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 licensee when a task of nursing is delegated.

• Lay caregiver
• Periodic inspection
• Rescinding
• RN delegation
• Supervisory visits
• Written instructions

September 2019 Safety, Oversight and Quality Unit 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 or 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.

September 2019 Safety, Oversight and Quality Unit 3

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. Remember:

• Not all nursing tasks can be delegated
• It is the sole responsibility of the RN to decide if a nursing task can be

delegated

• RN delegation will not work in all situations

September 2019 Safety, Oversight and Quality Unit 4

INTRODUCTION CONTINUED

RN delegation is a process that requires a team approach between the RN and all caregivers in the AFH. While the RN is responsible for understanding the rules of RN delegation, it is important the AFH caregiver understand the delegation process as well as what to expect from an RN when a nursing task is delegated.

September 2019 Safety, Oversight and Quality Unit 5

WHAT IS RN DELEGATION?

RN delegation is a legally defined process that allows an RN to authorize a caregiver (non-licensed 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 resident’s health

status

September 2019 Safety, Oversight and Quality Unit 6

IMPORTANT NOTE

RN delegation requirements do not apply to family members performing nursing tasks for family members.

September 2019 Safety, Oversight and Quality Unit 7

RN DELEGATION PROCESS

RN delegation is a:

• Specific task
• For a specific resident
• That sets a specific process

What this means is that the RN must provide detailed written instructions for each task and each resident in each setting and observe each caregiver performing the nursing task on the resident.

September 2019 Safety, Oversight and Quality Unit 8

RN DELEGATION PROCESS CONTINUED

The RN can teach several caregivers about the resident’s condition at the same time.

• However, for delegation to occur the RN must evaluate each individual

caregiver as they perform the nursing task from start to finish.

September 2019 Safety, Oversight and Quality Unit 9

RN DELEGATION PROCESS CONTINUED

Types of nursing tasks that 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 or should be delegated. The following list is a sample of common delegations that are 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

September 2019 Safety, Oversight and Quality Unit 10

RN DELEGATION PROCESS CONTINUED

Other nursing tasks may be appropriate to delegate, however, 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 as to whether the delegation of a nursing task can safely occur in your AFH.

September 2019 Safety, Oversight and Quality Unit 11

RN DELEGATION PROCESS CONTINUED

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

September 2019 Safety, Oversight and Quality Unit 12

RN DELEGATION PROCESS CONTINUED

Certain nursing tasks used for anticipatory emergencies cannot be delegated but are taught by an RN, pharmacist or the resident’s primary care practitioner. These include:

• Glucagon for diabetics
• Epi-pens for allergies

September 2019 Safety, Oversight and Quality Unit 13

RN DELEGATION PROCESS CONTINUED

The RN must evaluate five components of the RN delegation process before deciding if a nursing task can be delegated.

• 1. RN must consider:
• Their own expertise with the delegation process and the nursing task

being considered

• If there is time to complete the delegation process in a timely manner
• If the RN has the time to provide on-going supervision of the delegated

nursing task(s)

September 2019 Safety, Oversight and Quality Unit 14

RN DELEGATION PROCESS CONTINUED

• 2. 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

• An RN cannot delegate if the resident is displaying symptoms that may be

signaling a possible unknown health condition

• 3. The RN must determine if the task being considered for delegation is

appropriate in this specific situation.

September 2019 Safety, Oversight and Quality Unit 15

RN DELEGATION PROCESS CONTINUED

• 4. The RN must assess each caregiver individually and determine if the

caregiver is:

• Able and willing to perform the task (includes physical ability)
• Able follow written instructions and communication; AND
• Is able 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

• 5. The RN must decide if the environment where the nursing task will

be performed is appropriate.

September 2019 Safety, Oversight and Quality Unit 16

RN DELEGATION PROCESS CONTINUED

Once the RN has decided to delegate, the RN must provide the caregiver with information before delegating the nursing task, which includes:

• 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 the nursing task is performed

• Any signs and symptoms the caregiver needs to observe and/or any actions

that need to be taken and documented

• How to correctly perform the task

September 2019 Safety, Oversight and Quality Unit 17

RN DELEGATION PROCESS CONTINUED

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,

however the RN must observe each caregiver as they perform the nursing task on the resident.

• Depending on the frequency of the nursing task, the RN may need to return

to the AFH to finish delegating all caregivers

September 2019 Safety, Oversight and Quality Unit 18

RN DELEGATION PROCESS CONTINUED

The RN is required to document in the resident’s record the name of each caregiver the RN has delegated to perform the nursing task.

• The RN must provide a nursing plan of care that identifies the delegation; and
• Details 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 911, the resident’s healthcare practitioner and/or the RN who has delegated the nursing task.

September 2019 Safety, Oversight and Quality Unit 19

RN DELEGATION PROCESS CONTINUED

The RN is not on call for emergencies however, it is the AFH licensee’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.

September 2019 Safety, Oversight and Quality Unit 20

RN DELEGATION PROCESS CONTINUED

Once the task has been delegated, the RN has a responsibility for on- going 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 sixty days from the date the nursing task was delegated.

• Thereafter, the RN is required to evaluate each caregiver and resident no

less than 180 days from the last visit.

September 2019 Safety, Oversight and Quality Unit 21

RN DELEGATION PROCESS CONTINUED

Supervision of RN delegation is limited to the delegated task and is not general supervision of the caregivers or their work. The AFH licensee and/or resident manager must routinely review caregiver records to ensure the caregivers are following the RNs directions as written.

September 2019 Safety, Oversight and Quality Unit 22

RN DELEGATION PROCESS CONTINUED

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 ensure it is still appropriate or make any necessary changes to the instructions.

September 2019 Safety, Oversight and Quality Unit 23

RN DELEGATION PROCESS CONTINUED

When the RN returns to the AFH for the supervision visit, they 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

September 2019 Safety, Oversight and Quality Unit 24

RN DELEGATION PROCESS CONTINUED

AFH providers can find it challenging if the RN wants to visit the AFH during busy times such as mealtime or first thing in the morning. However, if the delegated nursing task is to be performed at these busy times, the RN must visit during that time the task will be performed.

September 2019 Safety, Oversight and Quality Unit 25

RESCINDING A DELEGATION

If any of the five components are not met, the RN cannot delegate the 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 the delegation.

September 2019 Safety, Oversight and Quality Unit 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 is not able to follow the instructions for any reason
• The RN is not able to provide adequate supervision of the 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 passes away

September 2019 Safety, Oversight and Quality Unit 27

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 was rescinded, and the reason why the RN needs to rescind the delegation.

September 2019 Safety, Oversight and Quality Unit 28

HOME HEALTH AND HOSPICE

A resident that is receiving home health services or is on hospice may have delegation needs for a chronic on-going 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

• The list of responsibilities should be documented in the resident’s record
• Clear communication in the beginning will ensure the resident’s care needs

are fully supported

September 2019 Safety, Oversight and Quality Unit 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. These documents contain important information about the medication.

September 2019 Safety, Oversight and Quality Unit 30

MISCELLANEOUS GUIDANCE CONTINUED

An RN may need to rescind a delegation if a caregiver:

• Does not follow instructions
• Is unable to perform the task for any reason

However, it is the responsibility of the AFH licensee to address performance issues with the staff. RN delegation is not transferable. This means you cannot perform the same task on another resident without the nursing task being delegated for that resident.

September 2019 Safety, Oversight and Quality Unit 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 of the forms or documents related to delegating a nursing task. Any staff member with a medication aide certificate or nursing assistance certificate must have nursing tasks delegated by an RN.

September 2019 Safety, Oversight and Quality Unit 32

MISCELLANEOUS GUIDANCE CONTINUED

AFH rules require that you have all of the necessary supports in place before accepting a resident. If hospital staff, nursing home staff or any other individuals want you to admit a resident who has RN delegation needs, you cannot accept the resident unless you have made arrangements for RN delegation.

September 2019 Safety, Oversight and Quality Unit 33

MISCELLANEOUS GUIDANCE CONTINUED

If an RN is unavailable, consider asking:

• For a referral for home health to either perform the task or delegate the task

to you and your staff

• If a family member has experience performing the nursing task and if that

individual is willing to perform the nursing task until an RN is available to delegate the task to the AFH caregiver

• If the resident’s primary care practitioner is available to perform the nursing

task

September 2019 Safety, Oversight and Quality Unit 34

DISCUSSION/QUESTIONS

September 2019 Safety, Oversight and Quality Unit