5415 DELEGATION OF NURSING INTERVENTIONS

5415.1 Nothing in this section shall be applicable to, restrict, or limit the gratuitous provision of care by self, family, or friends.

5415.2 Only a registered nurse as set forth in the Act and this chapter shall delegate nursing interventions to be performed by trained unlicensed personnel on behalf of the delegating registered nurse. Such delegation shall be in a manner that does not conflict with the Act, this chapter, or with other District and federal laws and regulations which affect the practice of nursing in the District of Columbia. Nothing in this chapter shall be construed as permitting or authorizing an unlicensed person to perform duties beyond the scope permitted, or which are prohibited, by any other District or federal laws or regulations.

5415.3 A supervisor may delegate to a registered nurse the responsibility of directing and assigning nursing interventions to trained unlicensed personnel, once the registered nurse has developed the plan of care and identified those services that can be safely performed by the unlicensed personnel.

5415.4 The delegating registered nurse shall be responsible for the adequacy of care provided and shall retain accountability for the nursing task.

5415.5 The Administrator for Nursing Services, or supervisor, shall be responsible for establishing policies and procedures for nursing practice. The policies and procedures shall include a mechanism for:

(a) Identifying those individuals, by position title and job description, to whom nursing interventions may be delegated based on education, training, and competency measurements; and

(b) Assisting the delegating registered nurse in verifying the competency of the trained unlicensed personnel prior to assigning nursing interventions.

5415.6 If the delegating registered nurse determines that the trained unlicensed personnel cannot safely perform the nursing intervention, the delegating registered nurse shall not delegate the nursing intervention.

5415.7 The delegating registered nurse shall assign and delegate in a manner that protects the health, safety, and welfare of the client and others. The nursing tasks delegated shall:

(a) Be within the area of responsibility of the nurse delegating the act;

(b) Be such that, in the judgment of the nurse, it can be properly and safely performed by the unlicensed personnel without jeopardizing the client welfare; and

(c) Be a task that a reasonable and prudent nurse would find is within the scope of sound nursing judgment.

5415.8 When delegating a nursing intervention the nurse shall:

(a) Assess and evaluate the client's condition, identify the client's specific goals, nursing care needs, and required nursing interventions;

(b) Select and identify nursing interventions which do not require unlicensed trained personnel to exercise critical thinking and independent nursing judgment and which do not require either complex or multi-dimensional application of the nursing

process; and

(c) Select nursing interventions, which frequently recur in the daily care of the client or group of clients, whose results are predictable, whose potential for risk is minimal, and which utilize a standard and unchanging procedure.

5415.9 Trained unlicensed personnel shall practice under general or immediate supervision of a registered nurse.

5415.10 The delegating registered nurse shall be fully responsible for providing supervision to the trained unlicensed personnel. The supervision shall include:

1. (a) Instructing the unlicensed personnel in the delegated nursing intervention(s);
2. (b) Monitoring the performance of the delegated nursing intervention(s);
3. (c) Verifying that the delegated nursing intervention(s) has been implemented; and
4. (d) Evaluating the client's response and the outcome of the delegated nursing intervention(s).

5415.11 The delegating registered nurse shall determine the required degree of supervision after an evaluation of appropriate factors including:

1. (a) The stability of the client's condition;
2. (b) The willingness and ability of the client to be involved in the management of his or her care;
3. (c) The training, experience, and competency of the trained unlicensed personnel implementing the nursing intervention; and
4. (d) The nature of the nursing intervention.

5415.12 Except as provided in § 5415.13, the delegating nurse responsible for nursing care in the client's residence shall make a supervisory visit to the residence at least every two (2) weeks to:

1. (a) Evaluate the client's health status;
2. (b) Evaluate the performance of the delegated nursing acts;
3. (c) Determine whether goals are being met; and
4. (d) Evaluate the continued competence of the trained unlicensed individual to perform the delegated nursing task.

5415.13 If the trained unlicensed person is providing care limited to activities of daily living in the client's residence, then the delegating nurse shall make supervisory visits to the client's home as the nurse determines necessary for safe, effective nursing care of the client.

5415.14 The following nursing interventions shall not be delegated to trained unlicensed personnel:

1. (a) The initial nursing assessment;
2. (b) The ongoing comprehensive nursing assessment of the client in any setting;

(c) Development of the nursing diagnosis;

(d) Establishment of the nursing care goal;

(e) Evaluation of the client's progress, or lack of progress toward goal achievement;

(f) Client counseling and family education, except as it relates to promoting independence in personal care and activities of daily living (ADL's);

(g) Coordination and management of care including triage, collaborating, consulting, and referring;

(h) Providing advice to a client or family member; or

(i) Any nursing task which requires nursing knowledge, judgment, and skill.

5415.15 The delegating registered nurse shall retain full responsibility for medication administration as set forth by the Act.

5415.16 A delegating registered nurse may delegate the intervention of administering medication to trained unlicensed personnel in programs for individuals with mental retardation or other developmental disabilities; public schools; and assisted living residential facilities as authorized under D.C. Official Code § 21-1203; D.C. Official Code § 38-632; and D.C. Official Code § 44-109.05.

5415.17 Unless otherwise authorized under this title, a delegating registered nurse shall not delegate to trained unlicensed personnel any nursing acts or interventions relating to medication administration, including:

(a) Calculation of a medication dose;

(b) Administration of the initial dose of a medication;

(c) Administration of a medication by injection route, except for epipen or ejection system as set forth in 17 DCMR § 6111;

(d) Administration of medication by intravenous route;

(e) Administration of medication used for intermittent positive pressure breathing or other methods involving a mechanical device or equipment for medication inhalation treatment;

(f) Administration of medication by way of tube insertion in a cavity of the body; and

(g) Administration of investigational drug treatment and blood or blood products.

5415.18 Trained unlicensed personnel shall identify himself or herself as such at all times when participating in client care. The individual shall wear a pictured identification badge with lettering clearly visible to the client, bearing the name of the individual and his or her position title. The position title shall not in anyway imply that the individual is licensed or a nurse.

5415.19 The delegating registered nurse shall be responsible at all times for all nursing interventions provided by the trained unlicensed personnel to whom it was delegated, and is subject to disciplinary action for any violation of the Act or this chapter in connection with the nursing intervention by the trained unlicensed personnel.

SOURCE: Final Rulemaking published at 51 DCR 8613 (September 3, 2004).