Overview of the FAQs Related to the Nursing Practice
The broadly written laws and rules allow nurses to practice to their full scope of practice in any setting. It is impossible for the WA Board of Nursing (WABON) to provide a comprehensive listing of the duties that licensed nurses are permitted to perform since nursing practice is reflective of the dynamic changes occurring in healthcare and society.
The Revised Code of Washington (RCW) 18.79 and Washington Administrative Code (WAC) 246-840 provide the statutory and legal basis of nursing practice. The nursing board provides advisory opinions and interpretive statements about specific areas of nursing practice.
FAQs Based on Role:
The practicing nurse should use the Scope of Practice Decision Tree to determine if the activity is within their legal and individual scope of practice. Standing orders may be used. See WABON's Neonatal Intubation and Related Procedures Advisory Opinion for additional information.
FAQs are currently going through a review and rewriting process.
Advanced Registered Nurse Practitioner (ARNP)
The nursing commission recognizes and licenses 4 ARNP designations in accordance with WAC 246-840-302 which include:
- Nurse practitioner (NP)
- Certified nurse-midwife (CNM)
- Certified registered nurse anesthetist (CRNA)
- Clinical nurse specialist (CNS)
- Patient Abandonment
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- What is the legal definition of patient abandonment?
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The Washington State nursing laws and rules don't define patient abandonment.
The Washington State Board of Nursing (WABON) has investigated and disciplined nurses for issues surrounding the concept of abandonment as it relates to the nurse’s duty to a patient.
The WABON’s position applies to the licensed practical nurse, registered nurse, and advanced registered nurse practitioner.
Some behavior may be considered an employer-employment issue and not patient abandonment.
The American Nurses Association (ANA) defines patient abandonment as “a unilateral severance of the established nurse-patient relationship without giving reasonable notice to the appropriate person so that arrangements can be made for the continuation of nursing care by others…”
- What does the Washington State Board of Nursing (WABON) consider as patient abandonment?
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The nurse’s duty is not defined by any single event, such as clocking in or taking a report.
From the WABON standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.
The primary concern is whether the nurse's actions compromised patient safety or caused patient abandonment. The nurse must:
- Have first accepted the patient assignment, thus establishing a nurse-patient relationship, and then,
- Severed that nurse-patient relationship without giving reasonable notice to the appropriate person (e.g., supervisor, patient, contractor) so that arrangements can be made for the continuation of nursing care by others.
Failure to fulfill a nursing responsibility may result in unsafe nursing care. Failure to practice with reasonable skill and safety is a ground for disciplinary action by the WABON.
The decision to take disciplinary action is based on the facts of the individual case, and the unique circumstances of each situation, and their application to grounds for disciplinary action in the nursing laws and rules.
The concept of the nurse’s duty to promote patient safety also serves as the basis for determining behavior that could be considered unprofessional conduct.
The Board believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.
Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse’s license.
- Is it considered patient abandonment if a nurse is the sole provider of care of the patient, and no other care provider is available to relieve the nurse?
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There are some unique circumstances about which at may be considered patient abandonment.
An example is a registered nurse with a private practice or a contract to provide care to a patient who does not arrange for another qualified care provider to continue the care, may be considered patient abandonment.
A complaint should be reported to the Washington State Board of Nursing (WABON) for possible disciplinary action.
Conduct that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.
- What is the nurse’s responsibility specific to patient abandonment?
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The Washington State Board of Nursing (WABON) holds nurses accountable to the minimum standard of care, which requires the nurse to fulfill a patient care assignment or transfer responsibility to another qualified person once a nurse has accepted an assignment.
- What are some examples of an employee-employment issue vs. patient abandonment?
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The Washington State Board of Nursing (WABON) has no jurisdiction over employers, employment-related issues or disputes.
Other laws regulating facility licensure may apply certain responsibilities to the employer for patient safety, such as developing effective patient care systems or providing adequate numbers of qualified staff.
Specific requirements for a given facility may be obtained by contacting the applicable licensing authority for the institution.
WABON believes that the following are examples of employment issues that would not typically involve violations of nursing laws and rules:
- Resignation without advance notice, assuming the nurse’s current patient care assignment and work shift have been completed.
- Refusal to work additional shifts, either “doubles” or extra shifts on days off.
- Other work-related issues, such as frequent absenteeism, tardiness, or conflicts between staff/employees.
- Not showing up for work or not calling in.
- Refusing to work all remaining scheduled shifts after resigning.
- Refusing an assignment for religious, cultural, legal, or ethical reasons.
- Not returning from a leave of absence.
- Refusing to work in an unsafe situation.
- Refusing to delegate to an unsafe caregiver.
- Refusing to give care that may harm the patient.
- Refusing to accept an assignment or a nurse-patient relationship.
- Refusing to work mandatory overtime beyond the regularly scheduled number of hours.
- Refusing to work in an unfamiliar, specialized, or “high-tech” practice area when there has been no orientation, educational preparation, or employment experience.
- Refusing to “float” to an unfamiliar unit to accept a patient assignment.
Examples of abandonment:
- Accepting the assignment and then leaving the unit without notifying a qualified person.
- Leaving without reporting to the on-coming shift.
- Leaving patients without licensed supervision (especially at a long-term care facility with no licensed person coming on duty).
- Sleeping on duty.
- Going off the unit without notifying a qualified person and arranging coverage of patients.
- Leaving in an emergency.
- Overlooking or failing to report abuse or neglect.
- Giving care while impaired.
- Giving incompetent care.
- Delegating care to an unqualified caregiver.
- Failure to perform assigned responsibilities.
- Closing a private practice without making reasonable arrangements for the patient to transfer care.
- If a nurse is assigned to see a home-bound patient daily, but did not show up for a week, notify anyone, and did not arrange for another nurse to see the patient, is this patient abandonment?
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It is important to consider what the nurse-patient assignment involves.
Acceptance of a patient assignment may vary from setting to setting and requires a clear understanding of the workload and the agreement to provide care.
In this situation, since the nurse failed to see the patient for a week and failed to request another nurse visit, this may be considered patient abandonment.
A complaint should be reported to the Washington State Board of Nursing (WABON).
Conduct, that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.
- If it is unsafe for the nurse to provide care during an emergency or disaster, is this patient abandonment?
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A nurse may have to choose between the duty to provide safe patient care and protecting the nurse's own life during an emergency, including but not limited to disasters, infectious disease outbreaks, acts of terrorism, active shooter incidents, and workplace violence.
All nurses must adhere to nursing laws and rules regardless of practice setting, position title, or role.
There is also no routine answer to the question, "When does the nurse's duty to a patient begin?"
The nurse's duty is not defined by any single event, such as clocking in or taking a report.
From a Washington State Board of Nursing (WABON) standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.
WABON believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.
The nurse should take steps to protect patients if there is time and use a method that does not jeopardize the nurse’s safety or interfere with law enforcement personnel.
An example is an active shooter incident. This scenario may include evacuating the area or preventing entry to a place where the active shooter is located. However, a nurse may find insufficient time to do anything but ensure their own safety during the situation, In this case, as soon as the situation has been resolved the nurse should promptly resume care of patients.
In accordance with FBI active shooter training provides, the safe and ethical response would be to maintain the safety of oneself instead of rushing to an injured party in a dangerous situation. When the immediate danger to self is over, a nurse would go to any injured person and assist in the most informed and efficient way possible.
Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse's license.The Washington State Board of Nursing (WABON) recommends that employers develop and periodically review policies and procedures to provide nurses with clear guidance and direction so patients can receive safe and effective care.
- What do I do if my employer requires me to work a double shift during a disaster, and I am already physically exhausted?
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A nurse must accept only assignments that consider patient safety and are commensurate with the nurse’s educational preparation, experience, knowledge, physical, and emotional ability.
This is an employer-employment issue that the Washington State Board of Nursing does not have authority over.
- How does the Washington State Board of Nursing (WABON) decide whether a complaint is patient abandonment or an employee-employment issue?
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Complaints of “patient abandonment” when it is evident from the allegation that it is an employment issue will not be investigated by WABON.
Some general factors that would be considered in investigating a complaint alleging a nurse left an assignment would include, but not be limited to:
- The extent of dependency or disability of the patient.
- Stability of the patient.
- The length of time the patient was deprived of care.
- Any harm to the patient/level of risk of harm to the patient.
- Steps taken by the nurse to notify a supervisor of the inability to provide care.
- Previous history of leaving a patient care assignment.
- Emergencies that require nurses to respond, including but not limited to disasters, disease outbreaks, and bioterrorism.
- Workplace violence, including but not limited to an active shooter situation.
- Other unprofessional conduct concerning the practice of nursing.
- The nurse's general competency regarding adherence to minimum nursing standards.
As with all allegations received by WABON, the alleged conduct by a nurse will be thoroughly investigated to determine what, if any, violations of the nursing laws and rules have occurred.
Depending upon the case analysis, actions may range from the case being closed with no findings or action, to suspension or revocation, or voluntary surrender of the nurse’s license.
If evidence of violations exists, WABON must determine what sanction is appropriate for the nurse’s license and what specific stipulation requirements will be applied.
- Can the nurse invoke “Safe Harbor” in Washington State if asked to accept an assignment that could cause the nurse to violate their duty to a patient?
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Washington State does not have a “Safe Harbor” law.
Safe Harbor is a means by which a nurse can request a peer review committee determination of a specific situation concerning the nurse’s duty to a patient, affording nurse immunity from the board action against the nurse’s license.
- Portable Orders for Life Sustaining Treatment
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- What is a Portable Order for Life Sustaining Treatment (POLST) form?
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POLST is a set of portable medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals.
POLST is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year. Advanced care planning is thoughtful conversations between health care professionals, the patient and/or surrogate.
It is within the scope of the appropriately prepared and competent LPN to discuss end-of-life care with the patient or surrogate under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse (RN).
For more information and resources on POLST, go to:
- Advisory Opinion: Portable Order for Life Sustaining Treatment (POLST) (PDF)
- DOH: Portable Orders for Life Sustaining Treatment (POLST)
- WSMA: Advance Care Planning
- WSMA: POLST Form & Brochure
- How should the decisions in a POLST be made?
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The patient (or surrogate decision-maker) and the health care provider should discuss information to assure the POLST reflects the patient's wishes, as expressed in an advance directive or through communications with family or others. The patient's most recent communications, made in the context of their current medical condition, are the most likely to reflect their current wishes. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. RCW 7.70.065(1)(c).
- Is it within the scope of practice for an ARNP to sign POLST orders?
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Yes. A licensed ARNP, physician or physician assistant may sign a POLST. The health care practitioner signing the form assumes full responsibility for obtaining informed consent from the patient or surrogate decision-maker. The form must also be signed by the patient or surrogate to be valid. Verbal orders are acceptable with a follow-up signature following facility policy.
The ARNP should periodically review the POLST instructions with the individual or family for any treatment preference changes and consistency with any advance directive, especially if there are substantial changes in the person's health status. The Washington State Medical Association provides many resources and references in helping individuals receive the end-of-life care they specify.
- Is it within the scope of practice of an ARNP to sign a POLST?
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Yes.
The licensed ARNP, physician, or physician assistant may sign POLST.
- The health care practitioner signing the form assumes full responsibility for obtaining informed consent from the patient or surrogate decision-maker.
- The form must also be signed by the patient or surrogate to be valid.
- Verbal orders are acceptable with a follow-up signature following facility policy.
The ARNP should periodically review the POLST instructions with the individual or family for any treatment preference changes and consistency with any advance directive, especially if there are substantial changes in the person's health status or if there are substantial revisions to the form.
For more information and resources on POLST:
- Advisory Opinion: Portable Order for Life Sustaining Treatment (POLST) (PDF)
- DOH: Portable Orders for Life Sustaining Treatment (POLST)
- WSMA: Advance Care Planning
- WSMA: POLST Form & Brochure
Licensed Practical Nurse (LPN)
- Cardiology and Respiratory Procedures
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- Can a licensed practical nurse assist in performing a needle decompression for a tension pneumothorax?
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It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner, or a registered nurse, to perform needle decompression for a tension pneumothorax, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse change or reposition a tracheostomy tube?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform routine and non-complex tracheostomy care under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards including:
- Suctioning of a non-established or established tracheostomy stoma. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in suctioning a fresh tracheostomy stoma;
- Changing, repositioning, or reinserting a tracheostomy tube in an established tracheostomy tract, (Decannulation before a mature tract is an emergency situation as well as a complex procedure and is not within the scope of the licensed practical nurse. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in reinsertion of a tracheostomy tube if the decannulation occurs before the tract is established.);
- Tracheostomy site care and dressing changes; and
- Inflation and deflation of cuff in a healed and established stoma.
The licensed practical nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse's legal and individual scope of practice. Standing orders may be used. See the Nursing Care Quality Assurance Commission's Neonatal Intubation and Related Procedures Advisory Opinion for additional information.
- Can the licensed practical nurse perform cardiac stress testing?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform a routine and non-complex cardiac stress test under the direction of an authorized health care practitioner, or under the direction and supervision of a registered nurse, following clinical practice standards. A prescription or order from an authorized health care practitioner is required.
The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
There may be other regulations, such as Centers for Medicare and Medicaid Services (CMS) who defines the requirements for supervision (general or direct), and other parameters, for reimbursement of the procedure.
- Can the licensed practical nurse perform endotracheal intubation or other resuscitative procedures?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse due to the complexity of the activity to perform endotracheal intubation. The licensed practical nurse may be a member of the team and assist in performing individual activities during resuscitation based on the Scope of Practice Decision Tree under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. See the Nursing Care Quality Assurance Commission's for additional information.
- Can the licensed practical nurse perform pulmonary functioning testing?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform routine and non-complex pulmonary functioning testing under the direction of an authorized health care practitioner, or under the direction and supervision of a registered nurse, following clinical practice standards.
A prescription or order from an authorized health care practitioner is required. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
There may be other regulations, such as Centers for Medicare and Medicaid Services (CMS) who defines the requirements for supervision (general or direct), and other parameters for reimbursement of the procedure.
- Can the licensed practical nurse perform respiratory therapy procedures?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform routine and non-complex respiratory therapy procedures under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. It may be within the scope of practice for the licensed practical nurse to perform respiratory therapy procedures and activities such as administering or adjusting oxygen settings, adjusting ventilator settings, nebulizer treatments, suctioning, chest physical therapy, nebulizer treatments, intermittent positive pressure breathing therapy, or pulmonary function testing. Medical regimens require a prescription or order from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The licensed practical nurse may not use the title of respiratory therapist unless the nurse is dually licensed.
- Can the licensed practical nurse pull an intra-aortic balloon pump (IABP) and temporary pacer wires?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to remove an IABP or temporary pacing wires due to the complexity of the procedure and concerns about the stability of the patient. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing this activity.
The licensed practical nurse should use the Scope of Practice Decision Tree to determine if any of the activities the licensed practical nurse is assisting with, is within the nurse's legal and individual scope of practice.
- Is it with the scope of the licensed practical nurse to perform pulmonary artery pressure monitoring procedures?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to perform pulmonary artery pressure monitoring procedures due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing this activity. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Is it within the scope of practice of a licensed practical nurse to administer the OSHA Respirator Medical Evaluation Questionnaire in accordance with the OSHA Respirator Protection Standard (29 CFR 1910.134) and perform a respiratory fit test?
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It is within the scope of the appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner, or the registered nurse, in performing the OSHA Respirator Medical Evaluation Questionnaire and perform a respiratory fit test, following clinical practice standards.
The licensed practical nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse's legal and individual scope of practice.
Please see the regulations for OSHA Respirator Medical Evaluations.
The licensed practical nurse may initiate the evaluation and/or respiratory fit testing following standing orders. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion and Verbal Orders provides additional guidance and recommendations.
- Is it within the scope of the licensed practical nurse to assist in removing trans-thoracic (epicardial) pacing wire following open-heart surgery?
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It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner, or the registered nurse, in removing trans-thoracic (epicardial) pacing wire following open-heart surgery, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Is the licensed practical nurse required to have a current first aid certification and cardiopulmonary resuscitation certification (CPR), and if so, does it have to be the health care provider CPR?
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The nursing laws and rules do not require the licensed practical nurse to maintain first aid certification, CPR or stipulate whether the licensed practical nurse needs to have Basic Cardiac Life Support (BLS) or have BLS for health care providers. The laws and rules require the licensed practical nurses to demonstrate competence and accountability in all areas of practice in which the nurse is engaged. The licensed practical nurse should consider the area of practice in which the nurse is working. Competent practice may require the administration of first aid and/or CPR. Employers or facilities may require the licensed practical nurse to maintain first aid and/or CPR certification. Some facility laws and rules require nurses to have a CPR certification. For example, WAC 246-320 Hospital Licensing Regulations require at least one nurse to have CPR and at least one nurse to have advanced cardiac life support (ACLS) in recovery areas and in critical care units. In neonatal and pediatric services in hospitals, at least one registered nurse or physician must be trained in infant/pediatric resuscitation; in obstetrics, at least one registered nurse must be trained in neonatal resuscitation when infants are present. WAC 246-330 Ambulatory Surgical Facilities require at least one registered nurse to have current ACLS certification. WAC 388-112-0260 Adult Family Homes and Assisted Living Facilities also have specific requirements for CPR and first aid training. The Centers for Medicaid and Medicare Services (CMS) and accreditation organizations (such as the Joint Commission) may have specific requirements. It is the employer's decision as to the first aid and CPR requirements including and what type (BCLS or BLS for Health Care Providers) in the absence of accreditation or facility regulations. The employer may also decide whether they want to require an in-person course or on-line course and other parameters.
- What activities can the licensed practical nurse perform when caring for a patient with a chest tube?
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It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to perform the following tasks related to chest tube care under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards:
- Chest tube insertion site and dressing change.
- Clamp the tube in an emergency.
- Administer medications via a chest tube.
- Monitor patency of the draining system.
- Assist an authorized health care practitioner or the registered nurse in removing a chest tube.
- Changing bottles and/or disposable collection system.
It is not within the scope of the licensed practical nurse to perform the following tasks:
- Independently remove a chest tube.
- Manipulate, advance, irrigate, milk, or remove a chest tube.
The licensed practical nurse must demonstrate the following competencies:
- Demonstrate knowledge and ability to apply critical thinking and evidence-informed inquiry throughout the nursing process to care for a patient with a chest draining system.
- Demonstrate knowledge and understanding of the indications and contraindications for chest tube insertion.
- Hemothorax
- Spontaneous or traumatic pneumothorax
- Tension pneumothorax
- Spontaneous or traumatic pneumothorax
- Tension pneumothorax
- Pleural effusion
- Cardiac tamponade
- Diaphragmatic hernia
- Hepatic hydryothorax
- Refractory coagulopathy
- Demonstrate knowledge and ability to identify and describe purpose of pleural or mediastinal chest tubes.
- Demonstrate knowledge and ability to assist with insertion and removal of chest tubes
- Demonstrate knowledge and ability to setup, manage, and access a chest tube system.
- Demonstrate knowledge and ability to identify potential complications for patients with chest drainage systems such as:
- Compromise in system patency
- Discussion or malfunction
- Incorrect placement, dislodgement, or occlusion
- Hemorrhage
- Pulmonary Edema
- Infection
- Subcutaneous emphysema
The licensed practical nurse should use the Nursing Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Delegation in Community-Based and In-Home Care Settings During the COVID-19 Emergency
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- Can the registered nurse delegator use telehealth services to initiate and provide ongoing evaluation, and supervision of delegated tasks to UAP in community-based or in-home care settings during the COVID-19 emergency?
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The nursing and nursing assistant laws and rules do not prohibit the registered nurse delegator from using telehealth services to initiate or provide ongoing evaluation, or supervision of delegated tasks to UAP. The nurse must use nursing judgment and consider what aspects of the initial and ongoing assessment, supervision, and evaluation need to be done face-to-face. Telehealth may not be appropriate in some circumstances. The most important consideration is whether it is safe for the patient to perform the initial and ongoing assessment, evaluation, or supervision using telehealth services following the nursing and delegation laws and rules (RCW 18.79, WAC 246-840, RCW 18.88A, WAC 246-841).
The Washington State Department of Social and Health Services issued the following policies related to COVID-19, telehealth services, and delegation requirements:
- Dermatology and Cosmetic Procedures
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- Can a licensed practical nurse administer Botox® or inject medications for sclerotherapy, asclerotherapy, or dermal fillers?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to administer neuromodulators (such as Botox®, Dysport®, or Xeomin®) or administering medications for sclerotherapy, asclerotherapy, or dermal fillers under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The nursing laws and rules do not require an authorized health care practitioner or registered nurse to be on the premises when a licensed practical nurse provides nursing care or performs medical regimens. However, the Medical Quality Assurance Commission WAC 246-919-606 Nonsurgical Medical Cosmetic Procedures applies to nonsurgical medical cosmetic procedures that involve the injection of a medication or substance for cosmetic purposes, or use of a prescriptive device for cosmetic purposes (except for laser, light, radiofrequency and plasma devices). These rules allow delegation of these procedures to a properly trained licensed practical nurse. The delegating physician need not be on the premises during the procedure, but the physician must be reachable by telephone to be able to respond within thirty minutes to treat complications. The Nursing Care Quality Assurance Commission recommends following the WAC 246-919-606 for physicians.
- Can a licensed practical nurse administer Botox® or dermal fillers under the direction of a dentist?
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The nursing laws and rules allow a licensed practical nurse to take direction for a medical regimen from a dentist or other authorized health care practitioners practicing within their scope of practice. A dentist may prescribe neuromodulators (such as Botox®) or dermal fillers when it is used to treat functional esthetic dental conditions and their direct esthetic consequences. See the Dentist Scope of Practice - Use of Botulinum Toxin Injections/Dermal Fillers Interpretive Statement for more information.
- Can a licensed practical nurse administer laser treatment for cosmetic purposes?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse from performing laser therapy for cosmetic purposes under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. Laser treatment requires a prescription from an authorized health care practitioner. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The nursing laws and rules do not require an authorized health care practitioner or RN to be on the premises when a LPN provides nursing care or performs medical regimens. However, the Medical Quality Assurance Commission WAC 246-919-605 Use of Laser, Light, Radiofrequency, and Plasma (LLRP) Devices as Applied to the Skin includes language and requirements for physicians. The physician rules allow delegation to a properly trained and licensed professional and require a physician to be on the immediate premises during the patient's initial treatment. The authorized health care practitioner may provide treatment following an established treatment plan during temporary absences of the prescribing physician provided there is a local back-up physician who will be available by telephone and see the patient within sixty minutes. The Nursing Care Quality Assurance Commission recommends the nurse follow the WAC 246-919-605 for physicians when carrying out laser treatment procedures under the direction of an authorized health care practitioner.
- Does a licensed practical nurse require an esthetician's license to perform laser treatment for cosmetic purposes?
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A licensed practical nurse does not require additional licensure as an esthetician to perform laser therapy for cosmetic purposes.
- Does a licensed practical nurse require a special certificate to perform cosmetic procedures such as administering Botox® or performing laser treatments?
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The laws and rules do not require a special certificate to perform cosmetic procedures. The nurse must be competent and getting a certificate may be one method to demonstrate training, knowledge, skills, and abilities. A facility or employer may require a specific certification or training program.
- Can a licensed practical nurse apply eyelash extensions?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to apply eyelash extensions under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The Food and Drug Administration (FDA) approves cosmetics. No color additives are approved by the FDA for permanent dyeing or tinting of eyelashes or eyebrows. False eyelashes and extensions, as well as their adhesives, must meet the safety and labeling requirements for cosmetics. See the Food and Drug Administration's website, Using Eye Cosmetics Safely, for more information.
- Can a licensed practical nurse apply Latisse® for eyelash growth?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to apply medications, such as Latisse®, used for eyelash growth under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. This procedure requires a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse apply chemical peels and microdermabrasion?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to apply superficial chemical peels or microdermabrasion under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse perform medical tattooing, body piercing, electrolysis, or application of permanent makeup?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform medical tattooing, permanent makeup application, body piercing, and electrolysis under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse perform body sculpting using cold methods (such as CoolSculpting®) or heat methods (such as Vanquish™) for fat removal?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to apply cold therapy (cryotherapy) or heat therapy for fat removal under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse perform wart removal using liquid nitrogen (cryotherapy) or topical medications?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform wart removal using liquid nitrogen or topical medications under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse administer phototherapy?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform phototherapy such as Type B Ultraviolet (UVB), Grenz Ray, or Psoralen and Long-Wave Ultraviolet Radiation (PUVA) under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. This procedure requires a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse perform a fine needle aspiration biopsy, shave biopsy or punch biopsy?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform a final needle aspiration biopsy, shave biopsy or punch biopsy under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse administer intralesional injections?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to administer intralesional injections under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. This procedure requires a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse remove skin growths using electrodesiccation and curettage?
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The Nursing Care Quality Assurance Commission determines that it is not within the scope of a licensed practical nurse to perform electrodessication and curettage due to the complexity of the procedure. A licensed practical nurse may assist an authorized health care practitioner or registered nurse in performing the procedure, including administering the local anesthetic. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if any activities are within the nurse's legal and individual scope of practice.
- Dispensing, Compounding, Legend Drugs, Controlled Substances
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- Are there any medications that the licensed practical nurse is not allowed to administer?
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The nursing law and rule does not prohibit the competent and appropriately trained licensed practical nurse from administering any medication – legend or controlled substance (Schedule II-IV) or over-the-counter medications. The licensed practical nurse may administer medications by any route. The licensed practical nurse must be competent and follow the standards for medication administration.
- Can the licensed practical nurse be delegated to enter medication prescriptions into an electronic health system or call in an order to a pharmacy?
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Receiving telephone and verbal prescription orders, transcribing, and transmitting prescription orders are activities often performed by nurses and appropriately included by many organizations in the responsibilities of the licensed practical nurse. The licensed practical nurse has the skill and knowledge to receive a prescription order and transcribe it accurately for other nurses to implement or transmit the order to a pharmacist to dispense. There is no law or rule that prohibits the licensed practical nurse from calling in medication orders except for those restrictions in the Controlled Substances Act. The licensed practical nurse may enter medication prescriptions into an electronic health system under the direction of an authorized health care practitioner. These directions may come through standing orders or verbal orders. The standing orders are often used to renew medication prescriptions. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations. It is within the scope of practice of the appropriately prepared licensed practical nurse to write or enter the information into an electronic health record system the patient demographic information, as well as the drug, dosage, frequency and number of refills on a medical prescription as pursuant to a medical order. The nurse may not sign the nurse's name or the name of the individual authorizing the prescription on the prescription. WAC 246-870 Electronic Transmission of Prescription Information allows electronic prescriptions for legend drugs and controlled substances (except for Schedule II controlled substances). The laws states, “The system shall provide an audit trail of all prescriptions electronically transmitted that documents for retrieval all actions and persons who have acted on a prescription, including authorized delegation of transmission.” The order must be authenticated. See the Washington State Department of Health Pharmacies website for more information.
- Can the licensed practical nurse renew a prescription?
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It is not within the scope of practice for the licensed practical nurse to renew an existing medication without a new prescription from an authorized health care practitioner. The licensed practical nurse may follow standing orders or verbal orders to renew an existing medication. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.
- Can the licensed practical nurse give out drug samples?
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Giving out drug samples is considered dispensing. Dispensing of medication is outside the scope of practice of the licensed practical nurse. It may be within the scope of practice of the licensed practical nurse to hand a patient a pre-packaged sample that is properly labeled by an authorized health care practitioner or pharmacist. The licensed practical nurse needs to be competent regarding the specific medication including the indications, contraindications, and side effects that is being delivered to the patient. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if handing out a pre-labeled, pre-packed sample is within the licensed practical nurse's regulatory and individual scope of practice.
- Can the licensed practical nurse compound medications?
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The competent and appropriately trained licensed practical nurse may compound medications under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. A prescription or order from an authorized health care practitioner is required. The licensed practical nurse must follow the WAC 246-878 Compounding Practices and the United States Pharmacopeia (USP) compounding guidelines. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if performing compounding medications is within the licensed practical nurse's regulatory and individual scope of practice. See the Compounding Medications by Licensed Practical Nurses, Registered Nurses, and Advanced Registered Nurse Practitioners Advisory Opinion for more information.
- Can the licensed practical nurse mix and administer allergy serums?
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It may be within the scope of practice of the competent and appropriately trained licensed practical nurse to prepare allergenic extracts as compounded sterile preparations under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. A prescription or order from an authorized health care practitioner is required. The licensed practical nurse must follow the WAC 246-878 Compounding Practices and the United States Pharmacopeia (USP) compounding guidelines. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if performing compounding medications and preparing and administering allergenic extracts is within the licensed practical nurse's regulatory and individual scope of practice. See the Compounding Medications by Licensed Practical Nurses, Registered Nurses, and Advanced Registered Nurse Practitioners Advisory Opinion for more information.
- Can the licensed practical nurse administer medications following standing orders?
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The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from administering medications following standing orders. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if administering medications following a specific standing order within the licensed practical nurse's regulatory and individual scope of practice.
- Can the licensed practical nurse perform medication reconciliation?
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The process for reconciliation of medication is the responsibility of the prescriber. It is important to remember that the licensed practical nurse is not authorized or approved to sign orders that must be reconciled with patient medication. Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient's current medications and comparing the list to those in the patient record or medication orders. The purpose of reconciliation is to avoid errors that include but are not limited to transcription, omissions, duplication, dosing errors, or drug interactions. Taking a medication history has always been part of the nursing assessment and this information should be conveyed to the prescriber. The NCQAC suggests the following:
- Follow the policies and procedures relative to the documentation (paper or electronic) system used by the organization.
- Collect and verify the patient's complete medication history.
- Clarify that the medications and dosages taken by the patient are correct and enter the information into the patient's record.
- Notify provider of updated list.
- Licensed prescriber reviews the medications list and reconciles.
- Can the licensed practical nurse administer and read a tuberculosis (TB) skin test?
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It may be within the scope of practice of the competent and appropriately trained licensed practical nurse to administer and “read” the TB skin test under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required as TB skin test formulations are legend drugs. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if this activity is within the nurse's regulatory and individual scope of practice. The order may be made using a standing order. The prescriber or the registered nurse does not need to be on onsite when the licensed practical nurse administers medications. The licensed practical nurse should communicate with the medical provider or registered nurse as appropriate or follow standing orders for additional follow-up and referral. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse follow the Washington State Tuberculosis Laws and Guidelines and the Centers for Disease Control Guidelines for TB Screening and Follow-Up. Refer to the Standing Order Advisory Opinion for more information on use of standing orders.
- Can the licensed practical nurse give prescribed off-label medications?
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The nursing law and rules do not prohibit the competent and appropriately trained licensed practical nurse from giving off-label medications under the direction of an authorized provider or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within his or her regulatory and individual scope of practice. The Food and Drug Administration Understanding Unapproved Use of Approved Drugs "Off-Label" website provides information about using unapproved off-label drugs. Off-label use should be done with careful insight and understanding of the risks and benefits to the patient considering high-quality evidence supporting efficacy, effectiveness, and safety. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.
- Can the licensed practical nurse give antineoplastic drugs, including administration by bladder installation?
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The nursing law and rules do not prohibit the competent and appropriately trained licensed practical nurse from giving drugs, including antineoplastic drugs, under the direction of an authorized provider or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within the nurse's regulatory and individual scope of practice. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.
- Does the licensed practical nurse require a specific certification to give chemotherapy in the home setting?
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The state and federal laws and regulations do not require the licensed practical nurse to have a special certification to give chemotherapy in the home setting. The facility or employer may require a specific certification or training program. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within the nurse's regulatory and individual scope of practice.
- Can the licensed practical nurse give experimental drugs?
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The nursing law and rules do not prohibit the competent and appropriately trained licensed practical nurse from giving experimental drugs by any route under the direction of an authorized provider or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required. The licensed practical nurse must be competent. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of experimental drugs is within his or her regulatory and individual scope of practice. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.
- Does the licensed practical nurse need a written order to administer medications from a properly labeled prescription bottle?
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The label will suffice if the label completed following state law, is legible, properly identified, has the name of the patient on it, and the medication prescription has not expired. The facility or employer may require a prescription or other authentication/documentation for verification. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.
- Can the licensed practical nurse administer medications or perform treatments or procedures without a registered nurse or physician onsite?
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The licensed practical nurse works under the direction of an authorized health care practitioner within the practitioner's. A licensed practical nurse may administer medications and perform treatments or procedures without the registered nurse or other authorized health care practitioner on the premises. A prescription or order from an authorized provider is required for legend drugs, controlled substances, over-the-counter drugs, or for medical treatments.
RCW 18.79.270 LPN - Activities Allowed - Can the licensed practical nurse administer immunizations under the direction of a pharmacist?
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A pharmacist is not identified as an authorized health care practitioner that the licensed practical nurse may take orders or direction from. This does not mean the licensed practical nurse may not work in a pharmacy setting administering immunizations. It is acceptable for orders for immunizations to be made by an authorized health care practitioner using standing orders. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.
- Can the licensed practical nurse crush or split medications without an order?
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The nursing law and rule does not prohibit the licensed practical nurse in making a decision to crush or split medications without an order. The licensed practical nurse can use nursing judgment. The employer may have policies or guidelines about crushing or splitting medications. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if crushing a medication is within the nurse's regulatory and individual scope of practice. The licensed practical nurse should make the decision whether or not to crush or split the medication based on patient needs, prescribing information by the provider, and safety of the medication being administered in this form. The licensed practical nurse administering the medication is responsible for ensuring the medication is safe to crush or split before giving it. Follow-up with the prescribing provider is warranted if a medication order states to crush or split the medication is necessary, but it is not recommended. Other alternatives may be necessary such as a liquid medication. The Institute for Safe Medication Practices (ISMP) is a good resource for determining whether a medication is safe to crush. Splitting medications may result in dosage errors. Not all medications may be split. The licensed practical nurse needs to determine whether the medication can be safety split to ensure proper dosage. The licensed practical nurse should consider consulting with a pharmacist and follow current guidance or standards and/or contact the prescriber or pharmacist to see if there is another alternative, such as liquid form or getting the medication in the appropriate dose.
- Can the licensed practical nurse hide medication in food for a patient who refuses to take the medication?
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The nursing laws and rules do not address this question. Some facility laws do address medication refusal. The WAC 388-76 Adult Family Home Minimum Licensing Requirements addresses medication refusal: WAC 388-76-10435 Medication Refusal. Hiding medications and not notifying the patient may be a violation of patient rights. See the Washington State Department of Health Patient Rights Guidelines for more information.
- Can the licensed practical nurse administer epinephrine for anaphylaxis without an order?
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The licensed practical nurse may carry and administer epinephrine under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. The licensed practical nurse may not administer epinephrine without an order from an authorized health care practitioner. The order or prescription may be for a specific patient or through the use of standing orders. Another option is for the facility or employer to become an authorized entity. SSB 6421 was passed in 2016 allowing authorized entities to obtain epinephrine autoinjectors. This allows an authorized health care practitioner to issue a prescription made out in the name of the authorized entity. Authorized entities that choose to acquire epinephrine autoinjectors must have people connected with the entity, such as employees, who have completed an anaphylaxis and epinephrine autoinjector training. These people will be responsible for the storage, maintenance, and general oversight of the epinephrine autoinjectors. They may administer or provide an epinephrine autoinjector to people who are experiencing anaphylaxis. An authorized entity is required to report to the Washington State Department of Health each incident of use of an obtained epinephrine autoinjector that was provided or administered to a person. Other laws may apply depending on the setting. RCW 28A.210.380 and 28A.210.383 regulations stipulate the requirements for epinephrine autoinjector use in public and private schools including the option of having a school stock supply of epinephrine autoinjectors for nurses to give following standing orders approved by an authorized health care practitioner. See the Washington State Department of Health's Epinephrine Autoinjectors and Anaphylaxis Training and Reporting for Authorized Entities Frequently Asked Questions and the SSB 6421 Status Update Document for more information.
- Can the licensed practical nurse administer naloxone for a suspected opioid overdose without an order?
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The licensed practical nurse may administer naloxone or other opioid antagonist to anyone at risk for having or witnessing an opioid overdose. See the NCQAC's Prevention and Treatment of Opioid-Related Overdoses Advisory Opinion and Frequently Asked Questions for Nursing Professionals of the Prevention and Treatment of Opioid-Related Overdoses for more information.
- Can the licensed practical nurse implement range orders?
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The laws and rules do not prohibit the competent and appropriately trained licensed nurse from implementing a drug order that has a dosage range. The medical provider makes the "medical judgment" as to the specific medication and dosage. The licensed practical nurse is given the latitude to use "nursing judgment" in determining the amount to be administered based on the patient's clinical status. The licensed practical nurse must apply adequate knowledge and skills in determining the dosage to be administered at any given time. Appropriate documentation of a focused patient assessment and evaluation must substantiate intervention. It is recommended that medication orders be patient/condition specific even if prescribed pro re nata (PRN), when needed. This would take away some of the notion of the nurse "prescribing" the medication. There should be some consultation with the physician to initiate a standing order particularly if the signs/symptoms are deviations from the patient's norm. Standing orders are certainly not to be used in lieu of medical consultation or intervention. Range orders should ideally consist of:
- The full name of the medication being ordered;
- The total amount of medication to be given in a specified time period;
- The order should state if the dose can be given in divided doses;
- The order should state if the dose can be repeated;
- If repeated, the order should indicate how frequently, and in what time frame; and
- The order should include what action should be taken if pain is unrelieved
- Can the licensed practical nurse assist in providing case management and preparing prescriptions for patients in a medication assisted treatment (MAT)?
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The state laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from assisting in providing case management and support for patients in MAT within the licensed practical nurse's scope of practice. The Drug Enforcement Administration (DEA) does state that, “an individual (secretary or nurse) may be designated by the practitioner to prepare prescription for the practitioner's signature.”
- Can the licensed practical nurse administer intra-articular injections?
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The nursing law and rules do not prohibit the competent and appropriately trained licensed practical nurse from administering intra-articular injections under the direction of an authorized provider, or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of intra-articular injections with within his or her regulatory and individual scope of practice. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.
- Can the licensed practical nurse destroy, witness, and/or cosign the destruction or wasting of controlled substances in a skilled nursing facility (SNF)?
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The licensed practical nurse may destroy, witness, and/or cosign the destruction of wasting of controlled substances in a SNF home. See the WAC 246-865-060 Pharmaceutical Services-Extended Care Facility for more information.
See the WAC 246-874-050 Accountability Requirements for an Automated Drug Dispensing Device (ADDD) if using an ADDD. - Can the licensed practical nurse administer or recommend over-the-counter (OTC) drugs without an order from a physician?
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It is not within the scope of practice of a licensed practical nurse to administer or recommend OTC drugs. The licensed practice nurse must work under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. Orders for OTC drugs or devices may be done using standing orders from an authorized health care practitioner or a registered nurse as identified in the nursing care plan. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.
- Can the licensed practical nurse fill medication organizers or repackage medications into an individual pill container with individual doses?
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WABON supports the use of medication organizers following standards of practice for medication administration. It is acceptable for the licensed practical nurse to prepare a medication organizer or individual pill containers under the following conditions:
- Medications being placed into an organizer or individual pill container must already be dispensed by a pharmacist or other authorized health care provider;
- The medication organizer or individual pill container must be properly labeled with the patient's name, name of the medication, dosage of each medication, frequency which the mediation is given;
- The licensed practical nurse must consult with the prescriber, pharmacist or other health care provider as appropriate; and
- The medication must be stored properly and safely in a secured system.
See the Advisory Opinion on Medisets, the Medication Organizer Device Letter from Secretary of Health (PDF), and the Medication Organizer Device (PDF) for more information.
- Gastroenterology Procedures
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- Can the licensed practical nurse insert a feeding tube in a neonate or infant?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to insert a feeding tube in a neonate, infant, child, or adult under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. An order from an authorized health care practitioner is required. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical's legal and individual scope of practice.
- Can the licensed practical nurse assist with inserting a percutaneous endoscopic gastrostomy (PEG) tube?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse assist with an authorized health care practitioner or registered nurse to insert a PEG tube, . The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Can the licensed practical nurse manipulate the endoscope when assisting during an endoscopic procedure?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to manipulate the endoscope when assisting in performing an endoscopic procedure. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Can the licensed practical nurse assist in performing an endoscopy, colonoscopy or sigmoidoscopy?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to assist in performing an endoscopy, sigmoidoscopy, or colonoscopy. The licensed practical nurse may assist an authorized provider or the registered nurse in performing these procedures following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform colostomy care?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform ostomy care under the direction of an authorized provider or under the direction and supervision of a registered nurse, following clinical practice standards. A prescription or order from an authorized provider may be necessary if complications occur or if medical treatment is required. Generally, a prescription from an authorized health care practitioner is required for reimbursement of medical supplies. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Can the licensed practical nurse re-insert a dislodged gastrostomy tube?
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It is within the scope of practice of an appropriately trained and competent licensed practical nurse to re-insert a gastrostomy tube in a mature stoma site under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. If there are signs of infection or other concerns, the licensed practical nurse should seek advice from an authorized provider or the registered nurse before attempting to re-insert. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse's legal and individual scope of practice.
- General Scope of Practice
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- How can the licensed practical nurse determine if a specific procedure or skill is the nurse's scope of practice?
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The RCW 18.79 Nursing Care and theWAC 246-840 Practical and Registered Nursing allow nurses to employ their full scope of practice in multiple settings. The Nursing Care Quality Assurance Commission also approves advisory opinions and interpretive statements that address specific nursing practice questions. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice.
- Can a licensed practical nurse practice independently?
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It is not within the scope of practice for a licensed practical nurse to practice independently. The licensed practical nurse must work under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse.
- What settings can a licensed practical nurse practice in?
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A licensed practical nurse may work in any setting where nursing care is provided. Scope of practice remains the same regardless of setting. Examples of settings include (but not limited to): Hospitals, nursing homes, assisted living facilities, adult family homes, schools, camps, clinics, public health clinics, homes, hospice, community health centers, homeless shelters, insurance companies and other businesses, law offices, travel clinics, occupational health centers, private clinics, outpatient clinics, ambulatory surgery centers, dialysis centers, mental health centers, infusion centers, medical spas, nursing informatics programs, correctional centers/jails, county health departments, government offices, cruise ships, churches, casinos, and retail clinics.
- Can a licensed practical nurse practice in a complex care setting such as intensive care unit (ICU), post-anesthesia care unit (PCU), or recovery room?
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The nursing laws and rules allow a licensed practical nurse to provide care in an ICU, PCU, or recovery room. A licensed practical nurse may provide direct patient care and perform functions within the nurse's legal and individual scope of practice under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse.
- Can a medical assistant or non-nurse supervise a licensed practical nurse or can a licensed practical nurse supervise a registered nurse?
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Most health care facilities or employers include an organizational structure that defines a person's manager or supervisor. A non-nurse may be a “supervisor” of a licensed practical nurse. A licensed practical nurse may be a “supervisor” of a registered nurse in an organizational structure related to human resource and administrative functions. This is different than the definition of “supervision” of a nursing activity. The nursing rules define “supervision” as, “The provision of guidance and evaluation for the accomplishment of a nursing task or activity with the initial direction of the task or activity; periodic inspection of the actual act of accomplishing the task or activity; and the authority to require corrective action.” A registered nurse practices independently and does not require supervision or evaluation of nursing care. Only a registered nurse or advanced registered nurse practitioner may supervise and evaluate the practice of nursing provided by a licensed practical nurse. It is beyond the scope of a licensed practical nurse to independently perform training, performance appraisals, or competency validation related to nursing practice of the registered nurse or advanced registered nurse practitioner. A licensed practical nurse may assist in providing training, performing appraisals, or competency validation related to nursing practice within the scope of the licensed practical nurse and under the direction of the registered nurse or advanced registered nurse practitioner.
- Is there any activity that require a licensed practical nurse to have a health care practitioner or registered nurse on the premises?
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The nursing laws and rules requires general supervision of a licensed practical nurse. The nursing law and rule does not require the registered nurse or an authorized health care practitioner to be on the premises when a licensed practical nurse provides care in any setting. A facility or supervisor may require direct or immediate supervision for specific activities or if there are concerns about the licensed practical nurse's competency. An exception exists in the physician rules that require a physician to be on the immediate premises during the patient's initial treatment when a nurse is performing laser therapy: WAC 246-919-605 Use of Laser, Light, Radiofrequency, and Plasma (LLRP) Devices as Applied to the Skin.
- Can the employer or registered nurse expand the scope of practice of a licensed practical nurse if a physician or advanced registered nurse practitioner signs off on the procedure?
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The employer may not expand licensed practical nurse scope of practice. The licensed practical nurse must provide nursing care within the nurse's statutes and regulations that govern nursing practice.
- Can the licensed practical nurse train unlicensed assistive personal (UAP)?
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It may be within a licensed practical nurse's scope of practice to provide routine or basic training to UAP if the licensed practical nurse is competent under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse based on the nursing care plan. In some settings (community-based and in-home care) only a registered nurse may delegate and is required to validate competency prior to nursing delegation.
- Can the licensed practical nurse provide or delegate nursing care in an assisted living facility (ALF)?
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The ALF may choose to provide, but is not required to provide, intermittent nursing services. Some nursing services may be done through registered nurse delegation to a nursing assistant or home care aide. A licensed practical nurse may provide nursing care in an ALF within the licensed practical nurse's scope of practice under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. Only a registered nurse may delegate nursing activities to a nursing assistant-certified (NA-C), nursing assistant-registered (NA-R), or home care aid-certified (HCA-C) in an ALF. See the RCW 18.20 Assisted Living Facilities and WAC 388-78A Assisted Living Facility Licensing Rules for more information.
- Can the licensed practical nurse give test results to a patient?
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It is not in the scope of practice for a licensed practical nurse to make a medical diagnosis based on interpretation of diagnostic test results. Medical test results must be interpreted by an authorized health care practitioner. The nursing laws and rules allow the licensed practical to relay test results or a medical diagnosis if already made by an authorized health care practitioner. It is important to consider what types of questions or discussion the patient might have when receiving test results or when a diagnosis is relayed to the patient by the nurse. Abnormal test results should be communicated by someone who can provide supporting information about the test, implications, and follow-up care. The complexity and seriousness of the test results may also determine who gives the results and by what method test results should be given. The person giving the test results or diagnosis must be competent to answer the patient's questions.
- Can the licensed practical nurse provide nursing care to a minor patient without parental consent?
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The general age of majority for health care is eighteen years old in Washington State as defined in . Other laws do allow exceptions for specific types of treatment: See the Providing Health Care to Minors under Washington Law Summary for more information.
- Can the licensed practical nurse admit a patient to a skilled nursing facility (SNF) with an order from an authorized health care practitioner without a registered nurse on the premises?
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WAC 388-97-1080 addresses the nursing services requirements in a SNF. A SNF may limit the admission of a patient if a registered nurse is not available to perform the admission assessment. The SNF may allow the licensed practical nurse to initiate the admission assessment within licensed practical nurse's scope of practice including collecting information and data without a registered nurse on the premises with the intent that the registered nurse will complete the comprehensive assessment and care planning.
- Infusion Therapy, Phlebotomy, and Laboratory Tests
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- Does a licensed practical nurse require a special certification to perform infusion therapy, phlebotomy, or laboratory tests?
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The nursing laws and rules do not require a licensed practical nurse to get a special certification to perform infusion therapy, phlebotomy, or laboratory tests. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are the nurse's legal and individual scope of practice.
- What activities can a licensed practical nurse perform related to a vascular access device (VAD) or other infusion devices?
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The nursing laws and rules allow the competent and appropriately trained licensed practical nurse to perform infusion therapy. Invasive procedures require an order from an authorized health care practitioner. It may be within the scope of practice of the competent and appropriately trained licensed practical nurse to perform the following tasks related to a VAD or other infusion devices under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse:
- Short peripheral catheter line intraosseous access device, and subcutaneous infusion device insertion and removal;
- Preparing, initiating, managing, and monitoring infusion pumps;
- Peripheral (including short peripheral or midline), CVAD, arterial, umbilical arterial catheter (UAC) or umbilical venous catheter (UVC), intraspinal, intraosseous access device, and subcutaneous infusion device site monitoring, care, and dressing changes;
- Administration of infusion fluids and medications via peripheral, CVAD, and arterial catheters including through an implanted vascular access port, hemodialysis VAD, and UAC) or UVC;
- Medication administration via a VAD using piggyback, push, or bolus methods;
- Transfusion of blood products;
- Infusion of biologic therapies;
- Blood sampling via a peripheral, VAD, and arterial device;
- Administration of total parenteral nutrition;
- Monitor patency of the peripheral, CVAD, and arterial catheters;
- Change infusion sets; and
- Assist an authorized health care practitioner or registered nurse in removing or reinserting a CVAD or arterial catheter.
It is not within the scope of a licensed practical nurse to perform the following tasks:
- Independently insert or remove a CVAD, arterial catheter, or intraspinal catheter;
- Insert a peripherally inserted midline catheter.
The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The nurse must follow clinical standards of care. Examples include the Infusion Nurses Society (INS) and the National Infusion Center Association (NICA) practice, training, and competency standards for the licensed practical nurse.
- Complete an infusion therapy educational program, including supervised clinical practice on infusion therapy to document competency assessment and validation;
- Practice analysis for the licensed practical nurse including venipuncture for blood sampling and insertion and removal of peripheral catheters, maintenance of central vascular access devices (CVADs), and administration of IV medications by piggyback method; and
Perform infusion-related tasks under the supervision of a registered nurse or other authorized health care practitioner with appropriate infusion therapy knowledge and skills.
- Can a licensed practical nurse start an intravenous line without an order from an authorized health care practitioner in certain situations, such as for an unstable/high acuity patient or if a practitioner ordered a blood transfusion but did not order in
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It is not within the scope of practice for a licensed practical nurse to start an intravenous line without an order from an authorized health care practitioner. The RCW 18.71.011 Definition of the Practice of Medicine stipulates the practice of medicine to include severing penetrating the tissues of human beings. Standing orders may be an option to allow the nurse to start an intravenous line based on specific criteria (such as a high acuity patient), admission to a specific unit (such as intensive care), or for a specific condition. Standing orders may also be used to allow a nurse to start more than one intravenous line based on specific criteria. The nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
- Does a licensed practical nurse need an additional order to restart an intravenous line that is no longer patent?
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The licensed practical nurse does not need an additional order from an authorized health care practitioner to restart an intravenous line that is no longer patent. The nurse may want to consult with an authorized health care practitioner or a registered nurse in situations when the nurse is unsure if the patient still requires an intravenous line or if the patient's intravenous line is insufficient to support the therapy needed.
- Can the licensed practical nurse administer stem cell transplants?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse from administering stem cell-based products via a peripheral intravenous line, intra-arterial catheter, intradermal technique, or intramuscular technique. An order is required from an authorized health care practitioner. The Nursing Care Quality Assurance Commission determines that it is not within the scope of the licensed practical nurse to administer stem cell transplants by intravitreal infusion, retrobulbar infusion, spinal infusion, or other complex administration techniques. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse perform venipuncture to obtain blood samples for laboratory tests in the home setting?
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The nursing laws and rules allow the competent and appropriately trained licensed practical nurse performing venipuncture to obtain blood samples for laboratory testing in any setting. The licensed practical nurse must work under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The nurse must follow Federal and State blood-borne pathogen and Clinical Laboratory Improvement Amendments (CLIA) regulations. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's regulatory and individual scope of practice.
- Does a licensed practical nurse require an order to perform Clinical Laboratory Improvement Amendments (CLIA) Food and Drug Administration tests such as a human chorionic gonadotropin (hCG), urine dipstick, occult blood screening, or blood glucose capill
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The licensed practical nurse does not practice nursing independently. A licensed practical nurse must have direction from an authorized health care practitioner or a registered nurse to perform tests such as a human chorionic gonadotropin (hCG), urine dipstick, occult blood screening, blood glucose capillary tests or other CLIA approved waiver under the CLIA criteria. Any CLIA waived test involving puncturing the skin requires an order from an authorized health care practitioner. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse obtain blood specimens and submit to a laboratory to do lead screening, hepatitis B screening, or other employee health laboratory tests?
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The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to obtain a blood specimen via a capillary or venous blood sample to perform lead screening, hepatitis B screening, or other employee health laboratory tests under the direction of an authorized health care provider or under the direction and supervision of a registered nurse. An order is required from an authorized health care practitioner for laboratory tests involving puncturing of the skin. Standing orders may also be followed to direct occupational health activities. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations. The nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse perform an arterial blood draw for an arterial blood gas (ABG)?
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The nursing laws and rules allow the competent and appropriately trained licensed practical nurse to obtain an arterial blood gas directly from an artery or through an arterial line under the direction of an authorized health care practitioner or under the direction and supervision of a RN. This procedure requires a prescription from an authorized health care practitioner. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can a licensed practical nurse perform iliac crest bone marrow aspirations and biopsies?
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The Nursing Care Quality Assurance Commission determines that it is not within the scope of a licensed practical nurse to perform iliac crest bone marrow aspirations and biopsies due to the complexity of the procedure. A licensed practical nurse may assist an authorized health care practitioner or registered nurse in performing the procedure.
- Can a licensed practical nurse perform therapeutic phlebotomy?
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The nursing laws and rules allow the competent and appropriately trained licensed practical nurse to perform therapeutic phlebotomy for conditions, such as polycythemia vera, under the direction of an authorized health care practitioner or under the direction and supervision of a RN. These procedures require a prescription from an authorized health care practitioner. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Neurological and Musculoskeletal Procedures
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- Can the licensed practical nurse operate a transcutaneous electrical nerve stimulation unit (TENS) for pain relief?
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It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to apply and operate a TENS for chronic and acute pain, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if performing these activities is within the licensed practical nurse's regulatory and individual scope of practice.
- Can the licensed practical nurse perform a lumbar puncture?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to lead this activity due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing a lumbar puncture, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform electroencephalography (EEG) or electromyography (EMG)?
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It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to perform an EEG or EMG under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform iliac crest bone marrow aspirations and biopsies?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to lead this activity due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing a lumbar puncture, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Nursing Assessment
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- What is the difference between a pre-admission/resident assessment and a comprehensive nursing care assessment?
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A pre-admission/resident assessment is a needs assessment screening tool used to obtain information about the personal care needs and requests of a potential resident. The pre-admission/resident assessment findings may identify needs for a comprehensive nursing care assessment.
A nursing care assessment gathers information about the person's health status through the collection of data and/or physical examination. This assessment includes the use of the nursing process (WAC 246-840-700). Although a nursing care assessment may include elements of a non-skilled personal care assessment, it is a comprehensive nursing care evaluation and must be performed by the registered nurse. The licensed practical nurse may assist in gathering information for the nursing care assessment under the direction and supervision of the registered nurse.
- Who can perform the pre-admission/resident assessment in adult family homes and assisted living facilities?
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The laws and rules found in Aging and Adult Service Section of WAC 388-78A (assisted living facilities) and 388-76 (adult family homes) define the qualifications required for an individual to perform the required pre-admission/resident assessment. An individual with a nursing license (licensed practical nurse or registered nurse) meets the qualifications to perform the pre-admission/resident assessment. Other professionals may also perform the pre-admission/resident assessment (WAC 388-76-10150 and WAC 388-78A-2080).
This pre-admission/resident assessment (screening tool) does not necessarily require the services of a professional licensed nurse or the use of the nursing process (WAC 246-840-700). The goal of the pre-admission/resident assessment is to determine the personal care services needs of a potential resident and at times, the nursing care needs of said resident. If a comprehensive nursing assessment is contemplated as part of the care plan, the registered nurse must undertake that portion of the pre-admission assessment.
- Who can provide training of staff in adult family homes and assisted living facilities related to personal care services?
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Staff must meet the credentialing, training and competency requirements established in the state and federal laws and rules specific to the setting. Training and competency assessment for personal care services (non-nursing care) does not require the services of a Washington state licensed professional nurse. Training and education of staff employed in these facilities that address personnel, performance and other administrative activities do not require the utilization of a registered nurse.
- Nursing Delegation
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- Is the licensed practical nurse (LPN) allowed to perform a Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 test without an order or standing order from an authorized health care practitioner?
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No. The LPN does not practice independently. The LPN may perform a CLIA-waived COVID-19 test based following directions/orders and supervision of the registered nurse or authorized health care practitioner in any setting. The LPN may follow standing orders. Employers/facilities may have policies requiring an order for these tests and other requirements (e.g., competency assessment completion and quality control testing). The employer/facility must have a CLIA-waiver certification:
Medical Test Sites (MTS) | Washington State Department of Health
Clinical Laboratory Improvement Amendments (CLIA) | FDA
The facility/employer should follow established guidelines specific to the facility type:
Point of Care Testing Guidelines (wa.gov)
The employer/facility must follow quality control measures as required with the CLIA-waived certification and as required by accreditation organizations (e.g., Joint Commission):
Other Resources:
- Is the licensed practical nurse (LPN) allowed to perform a polymerase chain reaction (PCR) COVID-19 test without an order or standing order from an authorized health care practitioner?
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No. The LPN does not practice independently. The LPN may perform a PCR COVID-19 test following directions/orders and supervision of the RN or authorized health care practitioner. The LPN may follow standing orders.
Medical Test Sites (MTS) | Washington State Department of Health
Clinical Laboratory Improvement Amendments (CLIA) | FDA
COVID-19 RT-PCR Test - Healthcare Provider Fact Sheet (fda.gov)
- Is the licensed practical nurse (LPN) allowed to delegate COVID-19 testing to the nursing assistant-registered/nursing assistant certified (NA-R/NA-C), home care aide-certified (HCA-C), medical assistant-registered/medical assistant/certified (cont.)
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Is the licensed practical nurse (LPN) allowed to delegate COVID-19 testing to the nursing assistant-registered/nursing assistant certified (NA-R/NA-C), home care aide-certified (HCA-C), medical assistant-registered/medical assistant/certified (MA-R/MA-C), or non-credentialed staff?
No. The LPN cannot delegate COVID-19 testing or other tasks to the NA-R/NA-C, HCA-C, MA-R/MA-C, or non-credentialed staff.
- What is the responsibility of the licensed practical nurse (LPN) for reporting positive COVID-19 tests to the Washington State Department of Health (WA DOH)?
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The LPN is responsible for following the employer/facility protocols/directions in reporting positive COVID-19 tests. If the LPN owns the business/facility, then the LPN must report positive COVID-19 test results to WADOH.
- Is the LPN required to have a Medical Test Site (MTS) certification to perform Clinical Laboratory Improvement (CLIA)-waived or polymerase chain reaction (PCR) COVID-19 tests?
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It depends. MTS Certification is required for the employer/facility to perform CLIA-waived tests regardless of setting. If the LPN owns the business/facility, then the business/facility must have the appropriate MTS certification.
Medical Test Sites (MTS) | Washington State Department of Health
- Is the licensed practical nurse (LPN) required to document COVID-19 testing activities?
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Yes. The LPN must document the care provided, including COVID-19 testing activities, regardless of the setting. Documentation can be done electronically or on paper using a patient’s medical record. The LPN should follow the employer/facility documentation policies and procedures. Standardized screening forms that include the results may be used for documentation. Documentation of positive tests must be reported to the Washington State Department of Health.
- Nursing Process
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- What is the licensed practical nurse's role in the nursing process?
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The licensed practical nurse's scope of practice in the nursing process is limited and focused. The licensed practical nurse practices in an interdependent role when carrying out nursing care and a dependent role when carrying out medical regimens. The licensed practical nurse may perform nursing care under the direction of an authorized health care practitioner or at the direction and under the supervision of the registered nurse. The licensed practical nurse implements health care plans developed by the registered nurse or other authorized health care practitioner.
- Can the licensed practical nurse use clinical judgment?
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Clinical judgment (critical thinking) is used throughout all components of the nursing process. It is within the scope of the licensed practical nurse to use critical thinking skills. It is also an expectation. Critical thinking is purposeful and reflective judgment in response to events, observations, experiences, and verbal or written expressions. It involves determining the meaning and significance of what is observed or expressed to determine need for action. The licensed practical nurse is required to use critical thinking in clinical problem-solving and decision-making processes relative to scope of practice, knowledge, competency, and experience.
- Can the licensed practical nurse perform a hospital, residential treatment facility, or skilled nursing facility (SNF) admission assessment?
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Different types of assessments, such as “initial”, “admission”, or “event-focused” assessment, are not defined in the nursing law and rules. These terms are often used by health care agencies to describe different types of assessment. Other examples include post-fall and pre-transfer assessments. The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from initiating the admission of a patient to a hospital or SNF. Agency policy based on statutes and regulations, standards of care, accreditation standards, and reimbursement requirements may stipulate who can perform a specific assessment in different practice settings. The licensed practical nurse may contribute to the patient assessment in a hospital, SNF, or other health care facility under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. Joint Commission Nursing Assessment standards require the registered nurse to perform the nursing assessment within twenty-four hours after admission to a hospital. The licensed practical nurse may collect the data and then have the registered nurse review the data and complete the assessment to determine the patient' needs and developing the nursing care plan. It is not within the scope of practice of the licensed practical nurse to perform an assessment by proxy.
- Can the licensed practical nurse perform a pre-anesthesia assessment?
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The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from collecting the information for a pre-anesthesia assessment. The Centers for Medicare and Medicaid Services (CMS) does not allow the licensed practical nurse to perform a pre-anesthesia assessment. It is expected that the registered nurse would complete an appropriate age-specific nursing assessment and nursing care plan. The licensed practical nurse may assist in carrying out the assessment process and carrying out these plans. Frequency of assessment may be determined by institutional policy, patient condition, CMS requirements, and accreditation standards. See the NCQAC's Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion for more information.
- Can the licensed practical nurse perform an Emergency Medical Treatment and Active Labor Act (EMTALA) Medical Screening Exam (MSE)?
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The EMTALA is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide MSE to each person presenting to the emergency department to determine if a medical emergency exists. MSE is beyond initial triage. EMTALA requires the assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. The EMTALA Interpretive Guidelines identify the licensed registered nurse to be considered qualified medical personnel who can perform the EMTALA MSE and circumstances where the registered nurse consult with a physician. The licensed practical nurse may assist the registered nurse in performing the MSE collecting the information and data and performing a focused assessment. The MSE requires a comprehensive assessment. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform a pulmonary function assessment?
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It may be within the scope of practice of a competent and appropriately trained licensed practical nurse to perform a focused assessment and monitor the patient collecting the information and data related to pulmonary function. It would be within the scope of practice for the licensed practical nurse to assess lung sounds before and after treatments. The licensed practical nurse must be competent to do these activities. WAC 246-840-700 allows the licensed practical nurse to make basic observations, gather data and assist in identification of needs and problems relevant to the patient, collect specific data as directed, and, communicate outcomes of the data collection process in a timely manner to the registered nurse or other authorized health care provider. The method of communication must be appropriate for the situation. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Can the licensed practical nurse make a nursing diagnosis using North American Nursing Diagnosis Association, International (NANDA-I) taxonomies in the medical record?
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A nursing diagnosis is used to determine the appropriate nursing care plan for the patient. The nursing diagnosis drives interventions and patient outcomes, enabling the registered nurse to develop the nursing care plan. WAC 246-840-700 Standards of Nursing Conduct or Practice clarifies that only the registered nurse is permitted to make a nursing diagnosis. The licensed practical nurse may provide data to assist in the development of a nursing diagnosis. The licensed practical nurse may document symptoms or other findings and may document using a nursing diagnosis already made by the registered nurse. The licensed practical nurse uses and applies nursing diagnosis (formulated by the registered nurse) as a foundation for implementing interventions.
- What is the licensed practical nurse's role in implementing the nursing care plan?
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The licensed practical nurse's role in implementing the care plan includes the following activities:
- Procuring resources needed;
- Implementing nursing interventions and medical orders consistent with nursing rules and within an environment conducive to patient safety;
- Prioritizing performance of nursing interventions within the assignment;
- Recognizing responses to nursing interventions;
- Modifying immediate nursing interventions based on changes in the patient's status; and
- Delegating specific nursing tasks as outlined in the plan of care and consistent with nursing delegation laws and rules.
- What is the licensed practical nurse's role in evaluating the nursing care plan?
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The licensed practical nurse's role, in collaboration with the registered nurse, assists in making adjustments in the care plan and reporting outcomes of care to the registered nurse or other authorized health care practitioner.
- What is the licensed practical nurse's role in performing nursing assessment and care plan development?
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Nursing assessment may include a comprehensive nursing assessment and/or a focused nursing assessment. A comprehensive nursing assessment means collection, analysis, and synthesis of data performed by the registered nurse used to establish a health status baseline, plan care and address changes in a patient's condition as defined in the National Council State Boards of Nursing (NCSBN) Model Act (2012). The licensed practical nurse may perform a focused nursing assessment. A focused nursing assessment means recognizing patient characteristics that may affect the patient's health status, gathering and recording nursing assessment data and demonstrating attentiveness by observing, monitoring and reporting signs, symptoms, and changes in patient conditions in an ongoing manner to the registered nurse or other authorized medical provider. The focused assessment may include obtaining health care history information and physical assessment. The competent and appropriately trained licensed practical nurse may also perform specific assessments or screening activities, such as mental health status screening, suicidal risk screening, substance use screening, behavioral health screening, oral health screening, growth and developmental screening, neonatal abstinence syndrome scoring system, or nutritional health screening. The licensed practical nurse not analyze, synthesize, or evaluate the data or develop the nursing care plan. The licensed practical nurse is a valuable member of the health care team and should contribute to the development of the nursing care plan.
- Can the licensed practical nurse assist in performing a sports physical examination?
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The nursing laws and rules do prohibit the competent and appropriately trained licensed practical nurse from assisting in performing a sports physical examination under the direction of an authorized provider or under the direction and supervision of the registered nurse. Organizational policies may dictate who can perform a sports physical examination. RCW 28A.600.200 Interscholastic Athletic and Other Extracurricular Activities for Students provides authority to the school district board of directors to control, supervise, and regulate the conduct of interschool athletic activities including delegating control, supervision and regulation to the Washington Interscholastic Activities Association (WIAA) or other voluntary nonprofit entity. The WAII Handbook identifies a Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Registered Nurse Practitioner (ARNP), Physician' Assistant (PA), and Naturopathic Physician as a medical authority to perform a sports physical examination.
- Obstetrical. Gynecological, and Reproductive Care
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- Can the licensed practical nurse apply or remove an external or internal electronic fetal monitor?
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It is within the scope of an appropriately prepared and competent licensed practical nurse to apply or remove an external electronic fetal monitor under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. It is beyond the scope of the licensed practical nurse to apply or remove an internal electronic fetal monitor. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse insert a fetal spiral electrode (FSE) or an intrauterine pressure catheter (IUPC)?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to insert a FSE or IUPC. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse, in inserting a FSE or IUPC, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse insert prostaglandin analogs (e.g. misoprostol or dinoprostone) into the vagina for cervical ripening or induction of labor with a viable fetus?
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It is within the scope of an appropriately prepared and competent licensed practical nurse to insert prostaglandin into the vagina for a cervical ripening or induction of labor with a viable fetus under the direction of an authorized health care practitioner, or under the direction and supervision, of the registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse insert prostaglandin into the vagina to induce abortion?
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It is within the scope of an appropriately prepared and competent licensed practical nurse to insert prostaglandin into the vagina for a chemical abortion under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform a fetal non-stress test (NST) and an amniotic fluid index level using ultrasound?
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It is within the scope of an appropriately prepared and competent licensed practical nurse to perform a fetal NST and amniotic fluid index level using ultrasound under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform a sterile speculum examination and obtain specimens for cytologic, such as a Papanicolaou (PAP) smear, in a pregnant patient?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of a licensed practical nurse to perform a sterile speculum examination. The licensed practical nurse may assist an authorized health care practitioner, or the registered nurse, in performing a sterile speculum examination, including obtaining cytology specimens, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform a vaginal examination?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of a licensed practical nurse to perform a vaginal examination. The licensed practical nurse may assist an authorized health care practitioner, or the registered nurse, in performing a vaginal examination, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform Assisted Reproductive Technology (ART) to treat infertility including Intrauterine Insemination (IUI)?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical to perform IUI. It is in the scope of an appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner or the registered nurse, in providing IUI or other ART procedures, following clinical practice standards. The licensed practical nurse may perform some activities related to ART within the nurse's scope of practice, such as medication administration, routine laboratory testing, and basic education, under the direction of an authorized health care practitioner, or under the direction and supervision, of the registered nurse. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform electronic fetal monitoring?
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It is within the scope of an appropriately prepared and competent licensed practical nurse to perform internal or external electronic fetal monitoring under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform sexual assault examinations, including using colposcopy to collect forensic evidence collection?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to perform sexual assault examinations and perform colposcopy to collect forensic evidence. The licensed practical nurse may assist an authorized health care practitioner, or the registered nurse in performing colposcopy and collecting forensic evidence, following clinical practice guidelines. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse provide epidural care during labor and delivery?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical to provide epidural care during labor and delivery. It is within the scope of an appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner or the registered nurse, in providing epidural care, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. See the Nursing Care Quality Assurance Commission's Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion for additional guidance and recommendations.
- Can the licensed practical nurse remove a Strut Assisted Volume Implant (SAVI) applicator device?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to remove a SAVI® applicator device. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse to remove the device, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice
- Can the licensed practical nurse to perform an amniotomy?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to perform an amniotomy. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse, in performing an amniotomy, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse use standing orders to provide birth control or to screen for and treat sexually transmitted diseases?
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It is within the scope of an appropriately prepared and competent licensed practical nurse to follow standing orders to provide routine birth control or to screen for and treat sexually transmitted diseases. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations in using standing orders. The Public Health Nurses: Dispensing Medications/Devices for Prophylactic and Therapeutic Treatment of Communicable Diseases and Reproductive Health Advisory Opinion provides guidelines and recommendations. While this is specific to public health nurses, the general concepts apply to any setting. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Patient Abandonment
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- What is the legal definition of patient abandonment?
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The Washington State nursing laws and rules don't define patient abandonment.
The Washington State Board of Nursing (WABON) has investigated and disciplined nurses for issues surrounding the concept of abandonment as it relates to the nurse’s duty to a patient.
The WABON’s position applies to the licensed practical nurse, registered nurse, and advanced registered nurse practitioner.
Some behavior may be considered an employer-employment issue and not patient abandonment.
The American Nurses Association (ANA) defines patient abandonment as “a unilateral severance of the established nurse-patient relationship without giving reasonable notice to the appropriate person so that arrangements can be made for the continuation of nursing care by others…”
- What does the Washington State Board of Nursing (WABON) consider as patient abandonment?
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The nurse’s duty is not defined by any single event, such as clocking in or taking a report.
From the WABON standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.
The primary concern is whether the nurse's actions compromised patient safety or caused patient abandonment. The nurse must:
- Have first accepted the patient assignment, thus establishing a nurse-patient relationship, and then,
- Severed that nurse-patient relationship without giving reasonable notice to the appropriate person (e.g., supervisor, patient, contractor) so that arrangements can be made for the continuation of nursing care by others.
Failure to fulfill a nursing responsibility may result in unsafe nursing care. Failure to practice with reasonable skill and safety is a ground for disciplinary action by the WABON.
The decision to take disciplinary action is based on the facts of the individual case, and the unique circumstances of each situation, and their application to grounds for disciplinary action in the nursing laws and rules.
The concept of the nurse’s duty to promote patient safety also serves as the basis for determining behavior that could be considered unprofessional conduct.
The Board believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.
Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse’s license.
- Is it considered patient abandonment if a nurse is the sole provider of care of the patient, and no other care provider is available to relieve the nurse?
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There are some unique circumstances about which at may be considered patient abandonment.
An example is a registered nurse with a private practice or a contract to provide care to a patient who does not arrange for another qualified care provider to continue the care, may be considered patient abandonment.
A complaint should be reported to the Washington State Board of Nursing (WABON) for possible disciplinary action.
Conduct that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.
- What is the nurse’s responsibility specific to patient abandonment?
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The Washington State Board of Nursing (WABON) holds nurses accountable to the minimum standard of care, which requires the nurse to fulfill a patient care assignment or transfer responsibility to another qualified person once a nurse has accepted an assignment.
- What are some examples of an employee-employment issue vs. patient abandonment?
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The Washington State Board of Nursing (WABON) has no jurisdiction over employers, employment-related issues or disputes.
Other laws regulating facility licensure may apply certain responsibilities to the employer for patient safety, such as developing effective patient care systems or providing adequate numbers of qualified staff.
Specific requirements for a given facility may be obtained by contacting the applicable licensing authority for the institution.
WABON believes that the following are examples of employment issues that would not typically involve violations of nursing laws and rules:
- Resignation without advance notice, assuming the nurse’s current patient care assignment and work shift have been completed.
- Refusal to work additional shifts, either “doubles” or extra shifts on days off.
- Other work-related issues, such as frequent absenteeism, tardiness, or conflicts between staff/employees.
- Not showing up for work or not calling in.
- Refusing to work all remaining scheduled shifts after resigning.
- Refusing an assignment for religious, cultural, legal, or ethical reasons.
- Not returning from a leave of absence.
- Refusing to work in an unsafe situation.
- Refusing to delegate to an unsafe caregiver.
- Refusing to give care that may harm the patient.
- Refusing to accept an assignment or a nurse-patient relationship.
- Refusing to work mandatory overtime beyond the regularly scheduled number of hours.
- Refusing to work in an unfamiliar, specialized, or “high-tech” practice area when there has been no orientation, educational preparation, or employment experience.
- Refusing to “float” to an unfamiliar unit to accept a patient assignment.
Examples of abandonment:
- Accepting the assignment and then leaving the unit without notifying a qualified person.
- Leaving without reporting to the on-coming shift.
- Leaving patients without licensed supervision (especially at a long-term care facility with no licensed person coming on duty).
- Sleeping on duty.
- Going off the unit without notifying a qualified person and arranging coverage of patients.
- Leaving in an emergency.
- Overlooking or failing to report abuse or neglect.
- Giving care while impaired.
- Giving incompetent care.
- Delegating care to an unqualified caregiver.
- Failure to perform assigned responsibilities.
- Closing a private practice without making reasonable arrangements for the patient to transfer care.
- If a nurse is assigned to see a home-bound patient daily, but did not show up for a week, notify anyone, and did not arrange for another nurse to see the patient, is this patient abandonment?
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It is important to consider what the nurse-patient assignment involves.
Acceptance of a patient assignment may vary from setting to setting and requires a clear understanding of the workload and the agreement to provide care.
In this situation, since the nurse failed to see the patient for a week and failed to request another nurse visit, this may be considered patient abandonment.
A complaint should be reported to the Washington State Board of Nursing (WABON).
Conduct, that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.
- If it is unsafe for the nurse to provide care during an emergency or disaster, is this patient abandonment?
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A nurse may have to choose between the duty to provide safe patient care and protecting the nurse's own life during an emergency, including but not limited to disasters, infectious disease outbreaks, acts of terrorism, active shooter incidents, and workplace violence.
All nurses must adhere to nursing laws and rules regardless of practice setting, position title, or role.
There is also no routine answer to the question, "When does the nurse's duty to a patient begin?"
The nurse's duty is not defined by any single event, such as clocking in or taking a report.
From a Washington State Board of Nursing (WABON) standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.
WABON believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.
The nurse should take steps to protect patients if there is time and use a method that does not jeopardize the nurse’s safety or interfere with law enforcement personnel.
An example is an active shooter incident. This scenario may include evacuating the area or preventing entry to a place where the active shooter is located. However, a nurse may find insufficient time to do anything but ensure their own safety during the situation, In this case, as soon as the situation has been resolved the nurse should promptly resume care of patients.
In accordance with FBI active shooter training provides, the safe and ethical response would be to maintain the safety of oneself instead of rushing to an injured party in a dangerous situation. When the immediate danger to self is over, a nurse would go to any injured person and assist in the most informed and efficient way possible.
Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse's license.The Washington State Board of Nursing (WABON) recommends that employers develop and periodically review policies and procedures to provide nurses with clear guidance and direction so patients can receive safe and effective care.
- What do I do if my employer requires me to work a double shift during a disaster, and I am already physically exhausted?
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A nurse must accept only assignments that consider patient safety and are commensurate with the nurse’s educational preparation, experience, knowledge, physical, and emotional ability.
This is an employer-employment issue that the Washington State Board of Nursing does not have authority over.
- How does the Washington State Board of Nursing (WABON) decide whether a complaint is patient abandonment or an employee-employment issue?
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Complaints of “patient abandonment” when it is evident from the allegation that it is an employment issue will not be investigated by WABON.
Some general factors that would be considered in investigating a complaint alleging a nurse left an assignment would include, but not be limited to:
- The extent of dependency or disability of the patient.
- Stability of the patient.
- The length of time the patient was deprived of care.
- Any harm to the patient/level of risk of harm to the patient.
- Steps taken by the nurse to notify a supervisor of the inability to provide care.
- Previous history of leaving a patient care assignment.
- Emergencies that require nurses to respond, including but not limited to disasters, disease outbreaks, and bioterrorism.
- Workplace violence, including but not limited to an active shooter situation.
- Other unprofessional conduct concerning the practice of nursing.
- The nurse's general competency regarding adherence to minimum nursing standards.
As with all allegations received by WABON, the alleged conduct by a nurse will be thoroughly investigated to determine what, if any, violations of the nursing laws and rules have occurred.
Depending upon the case analysis, actions may range from the case being closed with no findings or action, to suspension or revocation, or voluntary surrender of the nurse’s license.
If evidence of violations exists, WABON must determine what sanction is appropriate for the nurse’s license and what specific stipulation requirements will be applied.
- Can the nurse invoke “Safe Harbor” in Washington State if asked to accept an assignment that could cause the nurse to violate their duty to a patient?
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Washington State does not have a “Safe Harbor” law.
Safe Harbor is a means by which a nurse can request a peer review committee determination of a specific situation concerning the nurse’s duty to a patient, affording nurse immunity from the board action against the nurse’s license.
- Portable Orders for Life Sustaining Treatment
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- What is a Portable Order for Life Sustaining Treatment (POLST) form?
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POLST is a set of portable medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals.
POLST is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year. Advanced care planning is thoughtful conversations between health care professionals, the patient and/or surrogate.
It is within the scope of the appropriately prepared and competent LPN to discuss end-of-life care with the patient or surrogate under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse (RN).
For more information and resources on POLST, go to:
- Advisory Opinion: Portable Order for Life Sustaining Treatment (POLST) (PDF)
- DOH: Portable Orders for Life Sustaining Treatment (POLST)
- WSMA: Advance Care Planning
- WSMA: POLST Form & Brochure
- How should the decisions in a POLST be made?
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The patient (or surrogate decision-maker) and the health care provider should discuss information to assure the POLST reflects the patient's wishes, as expressed in an advance directive or through communications with family or others. The patient's most recent communications, made in the context of their current medical condition, are the most likely to reflect their current wishes. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. RCW 7.70.065(1)(c).
- Does the licensed practical nurse (LPN) have legal immunity when following Portable Orders for Life Sustaining Treatment (POLST)?
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Washington state law gives medical responders protection from legal liability when following POLST.
The LPN honoring those wishes would have legal protection under the Chapter 70.122 RCW: Natural Death Act if POLST reflects patient’s wishes stated in an advance directive.
POLST is a portable medical order, and the LPN should follow it within scope of practice and standard of care.
- What should the licensed practical nurse (LPN) do if a patient is admitted without Portable Orders for Life Sustaining Treatment (POLST) to a long-term care facility at the time of admission?
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The LPN should suggest a care planning conference to evaluate whether POLST is appropriate when the patient or resident is admitted to a long-term care facility without POLST.
The planning conference should include the patient’s or resident’s medical provider, the patient and/or surrogate decision-maker, and key family members.
Discussions should include a review of the patient's or resident’s medical history and recommendations from treating providers.
POLST should not be written as part of routine admission paperwork without medical professional involvement and extensive discussion.
- What if a family member tells the licensed practical nurse (LPN) to do cardiopulmonary resuscitation (CPR) when Portable Orders for Life Sustaining Treatment (POLST) indicating “Do Not Attempt Resuscitation (DNAR)?”
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A competent adult patient or the legal surrogate may always change their medical decisions and request alternative treatment. In an emergency it may be difficult to determine whether the family member is the legal surrogate. Facilities should develop policies to manage legal risk in these situations.
- What if emergency medical services (EMS) tells the licensed practical nurse (LPN) to do cardiopulmonary resuscitation (CPR) when Portable Orders for Life Sustaining Treatment (POLST) indicating “Do Not Attempt Resuscitation” (DNAR)?”
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A competent adult patient or the legal surrogate may always change their medical decisions and request alternative treatment.
In an emergency it may be difficult to determine whether the family member is the legal surrogate.
Facilities should develop policies to manage legal risk in these situations.
- Is it within the scope of practice of the licensed practical nurse (LPN) to sign Portable Orders for Life Sustaining Treatment (POLST)?
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No. It is not within the scope of practice of the LPN to sign POLST.
The POLST form must be signed by the advanced registered nurse practitioner (ARNP), physician, or physician assistant and the patient or surrogate decision-maker to be valid.
- Can the licensed practical nurse (LPN) follow Portable Orders for Life Sustaining Treatment (POLST)?
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Yes. The LPN may follow POLST in any setting based on regulatory and individual scope of practice.
- Can the licensed practical nurse (LPN) delegate Portable Orders for Life Sustaining Treatment (POLST) to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or other unlicensed assistive personnel (UAP)?
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Delegation is not required for the NA-R/NA-C or other UAP to follow the cardiopulmonary resuscitation (CPR)/DO NOT ATTEMPT RESUSCITATION (DNAR) POLST in Section A.
Section B may require nursing delegation for some tasks following the delegation process.
- Can the licensed practical nurse (LPN) determine, pronounce, or certify death?
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The LPN may determine and pronounce death. It is not within the LPN’s scope of practice to certify death.
See the Nursing Care Quality Assurance Commission (NCQAC)’s Determining, Pronouncing, and Certifying Death Advisory Opinion for more information.
- What should the licensed practical nurse (LPN) do if they find a patient who is non-responsive or has no heartbeat?
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The LPN should call the nursing supervisor, 911, or hospice for emergency help, and stay with the patient.
This plan should be made in advance as part of the patient plan of care.
- The LPN should not initiate CPR if valid POLST exists indicating “Do Not Attempt Resuscitation” (DNAR).” The LPN should give comfort care and wait for help to arrive.
- The LPN should begin CPR and continue until help arrives if a valid POLST indicating “CPR/Attempt Resuscitation”.
- The LPN should begin CPR if a valid POLST does not exist and continue until help arrives.
- The LPN should not initiate CPR if valid POLST exists indicating “Do Not Attempt Resuscitation” (DNAR).” The LPN should give comfort care and wait for help to arrive.
- Should a licensed practical nurse (LPN) follow Portable Orders for Life Sustaining Treatment (POLST) indicating “Do Not Attempt Resuscitation” (DNAR) if a patient is choking?”
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The patient's care plan should include details specifying actions in the POLST applies in all circumstances, including whether CPR should be initiated if a patient is choking.
This should be noted in the POLST, or a statement should be included in the POLST with any exceptions.
Bedside caregivers and supervisors should be familiar with this detail in the patient care plan and POLST. In most circumstances, if the patient’s heartbeat stops during a witnessed choking incident or other accident, the LPN should perform first aid measures.
If the person has no pulse or becomes nonresponsive, begin cardiopulmonary resuscitation (CPR) even if the POLST indicates DNAR. Continue CPR until licensed staff or emergency medical responders arrive.
The patient may want to refuse CPR under all circumstances including choking or accidents. This may be appropriate for patients with advanced dementia at risk for aspiration, patients with osteoporosis, or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient.
- What if the licensed practical nurse (LPN) starts cardiopulmonary resuscitation (CPR) on a patient with Portable Orders for Life Sustaining Treatment (POLST) indicating “Do Not Attempt Resuscitation” (DNAR)?
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CPR should be stopped in absence of a pulse if CPR is started for a patient with a POLST indicating DNAR.
This is an example of a situation where health care providers caring for the patient must be aware of the POLST.
Facilities should develop policies to manage legal risk in such a situation.
- May a RN or LPN delegate POLST orders to nursing assistants or other unlicensed assistive personnel (UAP)?
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Delegation is not required for a nursing assistant to follow the CPR/DNAR POLST orders in Section A. Sections B and D of the POLST may require delegation of some tasks using the delegation process.
- Prevention and Treatment of Opioid-Related Overdoses
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- What opioid antagonists are commonly prescribed to reverse the effects of opioid overdose?
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Opioid antagonists reverse the effects of an opioid overdose. Naloxone (Narcan®) is the current standard of treatment for opioid overdose. The Food and Drug Administration (FDA) approves administration by intravenous, intramuscular, or subcutaneous routes; a hand-held auto-injector (Evzio®) for intramuscular or subcutaneous injection; and, in 2018, approved the first generic Naloxone Hydrochloride nasal spray. These are legend drugs, and not categorized as a controlled substance. Naloxone has not been shown to produce tolerance or cause physical or psychological pain. It will produce withdrawal symptoms. Severity and duration of the withdrawal relate to the dose of naloxone and the degree and type of opioid dependency. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Is the Licensed Practical Nurse required to carry naloxone?
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RCW 69.41.095 does not require the Licensed Practical Nurse to carry an opioid antagonist, such as naloxone. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Licensed Practical Nurse administer naloxone follow a standing order for a suspected opioid overdose?
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The Licensed Practical Nurse may administer an opioid antagonist following a standing order from an authorized health care practitioner. This includes following the Washington State Department of Health Statewide Standing Order to Dispense Naloxone. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides guidance and recommendations. For more information, go to the Washington State Department of Overdose Education and Naloxone Distribution Website.
- Can the Licensed Practical Nurse carry naloxone for emergent administration for a suspected drug overdose to an unknown person?
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RCW 69.41.095 allows the Licensed Practical Nurse to carry and administer an opioid antagonist (such as naloxone) to a person suspected of experiencing an opioid overdose in any setting. The nurse must have a valid prescription, either in the nurse's name, in the name of an entity, in the name of a person or patient, or through a standing order. The nurse may get a prescription from a pharmacist with a Collaborative Drug Therapy Agreement (CDTA) or use the Washington State Department of Health Statewide Standing Order to Dispense Naloxone to get a prescription from a pharmacy. The nurse may also get a prescription in their own name from their health care practitioner. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Licensed Practical Nurse dispense or distribute naloxone?
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RCW 69.41.095 allows the Licensed Practical Nurse to dispense or distribute an opioid antagonist (such as naloxone) for a high-risk person, their family members, or friends following standing orders or a prescription from an authorized health care practitioner. Any person or entity may lawfully possess, store, deliver, distribute, or administer an opioid overdose reversal medication with a prescription or standing order. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Is the Licensed Practical Nurse required to have a special certification or specific training to prescribe, dispense, and administer naloxone for a suspected drug overdose?
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The Licensed Practical Nurse, just as in all care the nurse provides, must be appropriately prepared and competent to perform the activity safely. The Washington state laws and rules do not require a specific training course or certification. Stop Overdose.com offers education, resources, and technical assistance for individuals, professionals, and communities in Washington State who want to learn to prevent and respond to overdose and improve the health of people who use drugs. An employer or institution may have specific requirements for training or certification. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information and training resources, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Licensed Practical Nurse get a prescription to carry and administer naloxone in a non-work setting?
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RCW 69.41.095 allows the Licensed Practical Nurse to have a prescription for an opioid antagonist in the nurse's name to carry and administer in the non-work setting. Nurses may carry and administer an opioid antagonist (such as naloxone) in a suspected opioid overdose whether the person is a family member, friend, stranger, or a patient. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Licensed Practical Nurse delegate to the nursing assistant to administer naloxone for a suspected opioid overdose?
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It is not within the Licensed Practical Nurse's scope of practice to delegate administration of an opioid antagonist by any route in any setting. RCW 69.41.095 provides an exception to the nursing delegation laws and rules and does not require delegation for a nursing assistant to administer an opioid overdose medication by intranasal spray or by injection. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- School Nursing
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- Can the licensed practical nurse in a school setting delegate to assistive personnel for asthma management?
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It is not within the scope of practice for the licensed practical nurse to delegate to assistive personnel nursing tasks in the public and private, kindergarten through twelve grade school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements). Only the registered nurse may delegate to assistive personnel to perform asthma management tasks in this setting.
- Can the licensed practical nurse in the school setting delegate administration of nursing tasks for diabetes to non-credentialed assistive personnel?
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It is not within the scope of practice for the licensed practical nurse to delegate nursing tasks to non-credentialed assistive personnel in the public and private, kindergarten through twelve grade school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements). Only the registered nurse may delegate to assistive personnel to perform diabetes management tasks in this setting.
- Can Symjepi® be substituted for an epinephrine autoinjector (EAI) currently allowed to be delegated to unlicensed assistive personnel (UAP) in schools?
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The Nursing Care Quality Assurance Commission does not have authority to interpret the laws governing the provision of health care in K-12, public and private schools. Chapter 28A.210.383 RCW provides that the Office of the Superintendent of Public Instruction (OSPI) and school districts have the authority to develop anaphylactic policies for schools.
The law specifies that epinephrine autoinjectors may be prescribed to be maintained by schools for use when necessary. RCW 28A.210.383(2)(a). However, it may be feasible for OSPI and school districts to develop written policies to allow a substitution for the EAI for an individual student when the substitution is permitted by the prescriber according to the student's anaphylaxis care plan. RCW 28A.210.383(2)(b). RCW 28A.210.383(4)(b) provides: “In the event a school nurse or other school employee administers epinephrine in substantial compliance with a student's prescription that has been prescribed by an authorized health care practitioner with prescriptive authority and written policies of the school district or private school, then the school employee, the school district or school of employment, and the members of the governing board and chief administrator are not liable in any criminal action or for civil damages as a result of administering epinephrine.” (RCW 28A.210.383).
RCW 28A.210.380 and RCW 28A.210.383 specifically require the use of an “autoinjector” to administer epinephrine. Symjepi® (https://www.symjepi.com/) is not classified as an EAI. This may apply to prescriptions for individual students as well as for the school supply.
RCW 28A.210.370 allows self-administration of medications, including epinephrine, if the student meets the requirements under the treatment plan for anaphylaxis, and has a prescription from their health care practitioner. This may include self-administering epinephrine using an EAI or a prefilled medication device if authorized in the prescription.
- School Nursing During the COVID-19 Emergency
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- Can school nurses provide telehealth services to students during the coronavirus (COVID-19) emergency?
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School registered nurses or licensed practical nurse (LPN) may provide telehealth services to students during the COVID-19 emergency within their legal scope of practice. The same standards apply regardless of whether the services are provided face-to-face or through telecommunication technology.
- Can the school registered nurse delegate to unlicensed assistive personnel (UAP) using telehealth services?
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The nursing and nursing assistant laws and rules do not prohibit the registered nurse delegator from using telehealth services to initiate or provide ongoing evaluation, or supervision of delegated tasks to UAP. The nurse must use nursing judgment and consider what aspects of the initial and ongoing assessment, supervision, and evaluation need to be done face-to-face. Telehealth may not be appropriate in some circumstances. The most important consideration is whether it is safe for the patient to perform the initial and ongoing assessment, evaluation, or supervision using telehealth services following the nursing and delegation laws and rules (RCW 18.79, WAC 246-840, RCW 18.88A, WAC 246-841).
- Standing Orders, Verbal Orders, Electronic Orders, Triage, and Case Management
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- Can the licensed practical nurse follow standing orders or verbal orders?
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The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from following a standing order or obtaining and carrying out a verbal order that is non-complex and routine. Standing orders and verbal orders may include medical orders or nursing orders. The licensed practical nurse may assist an authorized provider or registered nurse in carrying out a complex standing order or verbal order. The licensed practical nurse must be competent to carry specific steps identified in the standing order or verbal order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
- Can the licensed practical nurse accept a verbal or written order from a physician relayed through an unlicensed person or an order that has been electronically transmitted?
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The laws and rules do not prohibit the licensed practical nurse from accepting an order from an authorized medical provider through another unlicensed or licensed person. The licensed practical nurse should use nursing judgment and determine whether additional verification or clarification is required. The laws and rules place accountability on the nurse who is implementing the order to implement or clarify that the order is accurate, valid, properly authorized, and is not harmful or potentially harmful to the patient, or is not contraindicated by documented information. The licensed practical nurse implementing the order is required to see clarification of the order when the licensed practical nurse has any reason to believe any contraindications exists, and to take any other action necessary to assure the safety of the patient. The licensed practical nurse must be competent to carry specific steps identified in the standing order or verbal order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
- Can the licensed practical nurse call in medication ordered by an authorized provider to a pharmacy?
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The laws and rules do not prohibit the licensed practical nurse from calling in a medication ordered by an authorized health care provider order, or under the direction and supervision of the registered nurse, to a pharmacist. The licensed practical nurse should use nursing judgment and determine whether additional verification or clarification is required. The licensed practical nurse implementing the order is required to see clarification of the order when the licensed practical nurse believes or has any reason to believe one of these contraindications exists, and to take any other action necessary to assure the safety of the patient.
- Can the licensed practical nurse work as a case manager or care coordinator?
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The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from working as a case manager or care coordinator. The licensed practical nurse must practice within his or her legal scope of practice. It is not within the scope of a licensed practical nurse to practice independently. The licensed practical nurse practices interdependently when providing nursing care and dependently when carrying out medical regimens. The licensed practical nurse may contribute and assist in collecting information and performing case management or care coordination activities identified in the nursing care plan within the licensed practical nurse's scope of practice. The nursing care plan may only be developed, implemented, and evaluated by a registered nurse.
- Can the licensed practical nurse perform triage or a Medical Screening Exam (MSE)?
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The competent and appropriately trained licensed practical nurse can perform triage under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. The licensed practical nurse does not work “under” authorized health care practitioner's license the registered nurse's license. For example, it would not be within the licensed practical nurse's scope of practice to modify the standing or verbal order without consulting with the registered nurse or other authorized health care practitioner. The licensed practical nurse must consult with an authorized health care practitioner or the registered nurse if the patient's situation is going outside the standing order. Any changes to the standing order must be documented and communicated to an authorized health care practitioner or the registered nurse. The licensed practical nurse cannot provide nursing care independently. The licensed practical nurse must have the training, knowledge, skills and abilities to perform triage competently (RCW) 18.79, (WAC) 245-840 and Advisory Opinion on Telenursing. The licensed practical nurse must be competent to carry specific steps identified in the standing order or verbal order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
- What is the licensed practical nurse's scope of practice when triaging calls dealing with an unstable situation or complex issue such as a caller disclosing he/she wants to harm themselves?
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Triaging occurs in various setting such as managed care organization, primary and specialty care, emergency departments, and crisis lines. The laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from triaging calls under the direction (direction can be following a standing order) of an authorized health care practitioner or under the direction and supervision of the registered nurse if the licensed practical nurse has the training, knowledge, skills and ability to carry out the activity safely and competently and is willing to accept any consequences of his/her actions.
Some settings may use the licensed practical nurse to manage calls after specialized training and under the supervision of the registered nurse or other authorized health care provider. The licensed practical nurse may collect demographic data from the caller and screen the patient who presents with suicide thoughts. If a patient is deemed potentially dangerous to others, the licensed practical nurse may need to consult with the registered nurse cases are considered more complex and are often deferred to the registered nurse or other professional team member who is trained to handle the needs and complexities of the patient.
It would be prudent to identify steps in the standing order as to what level a triage call becomes complex requiring the licensed practical nurse to refer to or consult with the registered nurse or other authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
All nurses in Washington State are required to complete a suicide prevention training course from an approved list. For more information, see the Washington State Department of Health's Suicide Prevention Training for Health Professionals Approved Courses.
- Can the licensed practical nurse take verbal or telephone orders?
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The nursing laws and rules do not prohibit the licensed practical nurse from taking a verbal or telephone order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
- Telehealth and Telemedicine Training Requirements
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- Does the training requirement apply to a nurse who provides Virtual Directed Observed Therapies (VDOT) for tuberculosis treatment?
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VDOT is the use of a videophone or other video/computer equipment to observe client’s taking their medications remotely.
Using synchronous and asynchronous VDOT for tuberculosis treatment adherence is occurring across the United States and in Washington State.
- The nurse providing synchronous (real-time audio and video) VDOT is required to take the telemedicine training.
- The nurse providing asynchronous (store-and-forward) VDOT is not required to take the training, but NCQAC recommends all nurses take the training.
For more information go to the Washington State Department of Health Tuberculosis Website (this site is accessible only to LHJs at this time).
- Telemedicine Training Requirements
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- Is a registered nurse (RN), licensed practical nurse (LPN), or Advanced Registered Nurse Practitioner (ARNP) required to take telemedicine training?
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Yes, licensed nurses (RN, LPN, or ARNP) in Washington state are required to take telemedicine training if the nurse provides telemedicine services. RCW 43.70.495 requires the nurse who provides clinical services through telemedicine independently or under the direction of an authorized health care practitioner to complete telemedicine training. “Telemedicine” as defined in RCW 70.41.020(13) means, “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment [but] does not include the use of audio-only telephone, facsimile, or email.”
The Washington State Telehealth Collaborative uses the following slightly different Medicaid definition of telemedicine in the training:
“Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.” WAC 182-531-1730(1). It does not include “the use of audio-only telephone, facsimile, or email.”
- Does the training requirement apply to a nurse who provides telephone triage?
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No, the telemedicine training requirement doesn't apply to audio-only telephone (telephone triage), facsimile, or email. However, the Nursing Care Quality Assurance Commission (NCQAC) recommends licensed nurses complete the telemedicine training if they provide services such as; telephone triage, remote patient monitoring (“RPM”, which enables recording and monitoring health data remotely), asynchronous telehealth (such as Store and Forward technology that allows patient data to be collected, stored, and later retrieved by another professional), Mobile Health (“mHealth,” using smart devices such as smartphones and smart wearables that allow continuous data collection about a person's behavior or condition) or other types of telehealth. The telemedicine training provides a valuable overview of the roles, responsibilities, liability, and legal requirements when providing telehealth services.
- Does the nurse need to send in the certification to the Nursing Care Quality Assurance Commission (NCQAC)?
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The law, RCW 43.70.495, requires the nurse to sign and retain an attestation of completion. The nurse does not need to send the attestation or documentation to the NCQAC unless requested.
- When is completion of telemedicine training required?
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The Nursing Care Quality Assurance Commission (NCQAC) recommends telemedicine training be completed as soon as possible as a demonstration of competency. The licensed nurse (RN, LPN, or ARNP) providing telemedicine clinical services licensed prior to January 1, 2021, will need to complete telemedicine training by December 31, 2021. The newly licensed RN, LPN, or ARNP or the RN, LPN, or ARNP licensed through the endorsement process who provides clinical services will need to meet the requirement one year after the initial license is issued. The Nursing Care Quality Assurance Commission (NCQAC) recommends all Washington nurses complete the telemedicine training as a demonstration of competence as soon as practical to provide an overview of the roles, responsibilities, liability, and legal requirements for providing telehealth services.
- Does telemedicine training taken prior to January 1, 2021 meet the telemedicine training requirement?
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Telemedicine training taken prior to January 1, 2021 meets the requirement if it includes the content defined in RCW 43.70.495(2). The RN must be appropriately trained and competent to provide nursing telehealth services. To learn more about the different training options available and access additional resources, see the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training website.
- What are the options to meet telemedicine training requirements?
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To learn more about the different training options available and access additional resources, please visit the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training webpage.
- Urological and Hemodialysis
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- Can the licensed practical nurse perform bladder instillation therapy?
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It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to perform bladder instillation therapy under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. Examples include instillation of dimethyl sulfoxide (DMSO), chemotherapy (e.g. Mitomycin C), and Bacillus Calmette-Guérin (immunotherapy) drugs. There must be an order from an authorized provider. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform hemodialysis in the home setting?
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It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The procedure may be performed in a home setting or an in-center setting. A prescription or order from an authorized provider is required. This includes preparing and monitoring the dialysis machine, accessing an arteriovenous (AV) fistula or graft or a central venous catheter, initiating or discontinuing hemodialysis, collecting specimens, catheter site care, and performing tubing or adaptor changes. The patient must be in a stable condition. If the patient is not in a stable condition, the licensed practical nurse may assist an authorized provider, or the registered nurse, in performing these procedures. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse perform peritoneal in the home setting?
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It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The procedure may be performed in a home setting or an in-center setting. A prescription or order from an authorized provider is required. This includes initiating or discontinuing therapy using pre-mixed medicated peritoneal dialysis bags, collecting specimens, catheter site care, and performing tubing or adaptor changes. The patient must be in a stable condition. If the patient is not in a stable condition, the licensed practical nurse may assist an authorized provider, or the registered nurse, in performing these procedures. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse remove a suprapubic catheter?
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It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to remove a suprapubic under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. There must be an order from an authorized provider. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Can the licensed practical nurse replace a suprapubic catheter?
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It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to replace a suprapubic in an established tract under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. There must be an order from an authorized provider. It is not within the scope of the licensed practical nurse to replace a suprapubic catheter in a non-established tract. The licensed practical nurse may assist an authorized provider in replacing a suprapubic catheter in a non-established tract. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.
- Is it acceptable practice for the licensed practical nurse to withhold medications prior to dialysis without an order from an authorized provider?
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Withholding medications, primarily anti-hypertensives, prior to dialysis is not uncommon. Due to the frequent tendency for patients to become hypotensive during treatment, and also the “pulling off” of medications during the dialysis procedure, nurses often withhold medications. It has often been considered a ‘community practice' and has been taken for granted that medications could be withheld whether written orders by an authorized provider are obtained or not. Then the withheld medications are given post dialysis, usually with communication to the provider on the patient's tolerance and outcomes for a successful dialysis and the provider's determination of the next dialysis. It is not acceptable for the licensed practical nurse to routinely withhold medications without any medication prior to dialysis without an order from an authorized provider. This order may be written for an individual patient or through a standing order. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion and Verbal Orders provides additional guidance and recommendations.
Registered Nurse (RN)
- Cardiology and Respiratory Procedures
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- Can the registered nurse change or reposition a tracheostomy tube?
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It is within the scope of practice of an appropriately trained and competent registered nurse to perform tracheostomy care under the direction of an authorized health care practitioner, following clinical practice standards, including:
- Changing, repositioning, or reinserting a tracheostomy tube in an established or non-established tract;
- Tracheostomy site care and dressing changes; and
- Inflation and deflation of cuff in a healed and fresh, established or non-established tracheostomy stoma.
The registered nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse’s legal and individual scope of practice. Standing orders may be used. See the Nursing Care Quality Assurance Commission’s Neonatal Intubation and Related Procedures Advisory Opinion for additional information.
- Can the registered nurse perform cardiac stress testing?
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It is within the scope of practice of an appropriately trained and competent registered nurse to perform a routine and non-complex cardiac stress test under the direction of an authorized provider, following clinical practice standards. A prescription or order from an authorized health care practitioner is required. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. There may be other regulations, such as Centers for Medicare and Medicaid Services (CMS) who defines the requirements for supervision (general or direct), and other parameters, for reimbursement of the procedure.
- Can the registered nurse perform endotracheal intubation or other resuscitative procedures?
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It is within the scope of practice of an appropriately trained and competent registered nurse too perform endotracheal intubation, laryngeal mask placement, or other resuscitative procedures under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. Standing orders may be used. See the Nursing Care Quality Assurance Commission’s Neonatal Intubation and Related Procedures Advisory Opinion and Standing Orders and Verbal Orders Advisory Opinion for additional information.
- Can the registered nurse perform pulmonary artery pressure monitoring procedures?
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It is within the scope of practice of an appropriately trained and competent registered nurse to perform a routine and non-complex cardiac stress test under the direction of an authorized provider, following clinical practice standards. A prescription or order from an authorized health care practitioner is required. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform respiratory therapy procedures?
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It is within the scope of practice of an appropriately trained and competent registered nurse too perform respiratory therapy procedures, It may be within the scope of practice for the registered nurse to perform respiratory therapy procedures and activities such as administering or adjusting oxygen settings, adjusting ventilator settings, nebulizer treatments, suctioning, chest physical therapy, nebulizer treatments, intermittent positive pressure breathing therapy, or pulmonary function testing. Medical regimens require a prescription or order from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree may not use the title of respiratory therapist unless the nurse is dually licensed.
- Can the registered nurse pull an intra-aortic balloon pump (IABP) and temporary pacer wires?
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It is within the scope of practice of the appropriately prepared and competent registered nurse from removing an IABP or temporary pacing wires under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Is it within the scope of practice of the registered nurse to administer the OSHA Respirator Medical Evaluation Questionnaire in accordance with the OSHA Respirator Protection Standard (29 CFR 1910.134) and perform a respiratory fit?
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It is within the scope of the appropriately prepared and competent registered nurse to perform the OSHA Respirator Medical Evaluation Questionnaire and perform a respiratory fit test, under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse’s legal and individual scope of practice. Please see the regulations for OSHA Respirator Medical Evaluations. The registered nurse may perform the evaluation and/or respiratory fit testing following standing orders. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
- Is it within the scope of the registered nurse to perform needle decompression for a tension pneumothorax?
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It is within the scope of practice of the appropriately prepared and competent registered nurse to perform needle decompression for a tension pneumothorax under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Is it within the scope of the registered nurse to remove trans-thoracic (epicardial) pacing wire following open-heart surgery?
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It is within the scope of practice of the appropriately prepared and competent registered nurse to remove trans-thoracic (epicardial) pacing wire following open-heart surgery under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Is the registered nurse required to have a current first aid certification and cardiopulmonary resuscitation certification (CPR), and if so, does it have to be the health care provider CPR?
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The nursing laws and rules do not require the registered nurse maintain first aid certification, CPR or stipulate whether the registered nurse needs to have Basic Cardiac Life Support (BLS) or have BLS for health care providers. The laws and rules require nurses to demonstrate competence and accountability in all areas of practice in which the nurse is engaged. The registered nurse should consider the area of practice in which the nurse is working. Competent practice may require the administration of first aid and/or CPR. Employers or facilities may require the registered nurse to maintain first aid and/or CPR certification. Some facility laws and rules require nurses to have a CPR certification. For example, WAC 246-320 Hospital Licensing Regulations require at least one nurse to have CPR and at least one nurse to have advanced cardiac life support (ACLS) in recovery areas and in critical care units. In neonatal and pediatric services in hospitals, at least one registered nurse and physician must be trained in infant/pediatric resuscitation; in obstetrics, at least one registered nurse must be trained in neonatal resuscitation when infants are present. WAC 246-330 Ambulatory Surgical Facilities require at least one registered nurse to have current ACLS certification. WAC 388-112-0260 Adult Family Homes and Assisted Living Facilities also have specific requirements for CPR and first aid training. The Centers for Medicaid and Medicare Services (CMS) and accreditation organizations (such as the Joint Commission) may have specific requirements. It is the employer’s decision as to the first aid and CPR requirements including and what type (BCLS or BLS for Health Care Providers) in the absence of accreditation or facility regulations. The employer may also decide whether they want to require an in-person course or on-line course and other parameters.
- What activities can the registered nurse perform when caring for a patient with a chest tube?
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It is within the scope of practice of the appropriately prepared and competent registered nurse to perform the following tasks related to chest tube care under the direction of an authorized health care practitioner, following clinical practice standards:
- Chest tube insertion site are and dressing change;
- Clamp the tube in an emergency;
- Administer medications via a chest tube;
- Monitor patency of the draining system;
- Removing a chest tube (including pleural and mediastinal);
- Change bottles and/or disposable collection system; or
- Manipulate, advance, irrigate, milk, or remove a chest tube.
- Dermatology and Cosmetic Procedures
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- Can a registered nurse administer Botox® or inject medications for sclerotherapy, asclerotherapy, or dermal fillers?
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The nursing laws and rules allow a competent and appropriately trained registered nurse to administer neuromodulators (such as Botox®, Dysport®, or Xeomin®). These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within nurse’s legal and individual scope of practice. The nursing laws and rules do not require an authorized health care practitioner to be on the premises when a nurse provides nursing care or performs medical regimens. However, the Medical Quality Assurance Commission WAC 246-919-606 Nonsurgical Medical Cosmetic Procedures applies to nonsurgical medical cosmetic procedures that involve the injection of a medication or substance for cosmetic purposes, or use of a prescriptive device for cosmetic purposes (except for laser, light, radiofrequency and plasma devices). These rules allow delegation of these procedures to a properly trained registered nurse. The delegating physician need not be on the premises during the procedure, but the physician must be reachable by telephone to be able to respond within thirty minutes to treat complications. The Nursing Care Quality Assurance Commission recommends following the WAC 246-919-606 for physicians when carrying out these procedures.
- Can a registered nurse administer Botox® or dermal fillers under the direction of a dentist?
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The nursing laws and rules allow a registered nurse to take direction for a medical regimen from a dentist or other authorized health care practitioners within their scope of practice. A dentist may prescribe neuromodulators (such as Botox®) or dermal fillers when it is used to treat functional esthetic dental conditions and their direct esthetic consequences. See the Dentist Scope of Practice - Use of Botulinum Toxin Injections/Dermal Fillers Interpretive Statement for more information.
- Can a registered nurse administer laser treatment for cosmetic purposes?
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The nursing laws and rules allow a competent and appropriately trained registered nurse to perform laser therapy for cosmetic purposes.
These procedures require a prescription from an authorized health care practitioner.
The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within nurse’s legal and individual scope of practice. The nursing laws and rules do not require an authorized health care practitioner to be on the premises when a nurse provides nursing care or performs medical regimens.
However, the Medical Quality Assurance Commission WAC 246-919-605 Use of Laser, Light, Radiofrequency, and Plasma (LLRP) Devices as Applied to the Skin includes language and requirements for physicians. The rules allow delegation to a properly trained and licensed professional and require a physician to be on the immediate premises during the patient’s initial treatment.
The authorized health care practitioner may provide treatment following an established treatment plan during temporary absences of the prescribing physician provided there is local back-up physician who will be available by telephone and see the patient within sixty minutes.
The Nursing Care Quality Assurance Commission recommends the nurse follow the WAC 246-919-605 for physicians when carrying out laser treatment procedures under the direction of an authorized health care practitioner.
- Does a registered nurse require dual licensure an esthetician's license to perform laser treatment for cosmetic purposes?
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A registered nurse does not require additional licensure as an esthetician to perform laser therapy for cosmetic purposes.
- Does a registered nurse require a special certificate to perform cosmetic procedures such as administering Botox® or performing laser treatments?
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The laws and rules do not require a special certificate to perform cosmetic procedures. The nurse must be competent and getting a certificate may be one method to demonstrate training, knowledge, skills, and abilities. A facility or employer may require a specific certification or training program.
- Can a registered nurse apply eyelash extensions?
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The nursing laws and rules allow a competent and appropriately trained registered nurse from applying eyelash extensions as an intervention based on nursing assessment, nursing diagnosis, or under the direction of an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. The Food and Drug Administration (FDA) approves cosmetics. No color additives are approved by the FDA for permanent dyeing or tinting of eyelashes or eyebrows. False eyelashes and extensions, as well as their adhesives, must meet the safety and labeling requirements for cosmetics. See the Food and Drug Administration’s website, Using Eye Cosmetics Safely, for more information.
- Can a registered nurse apply Latisse® for eyelash growth?
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The nursing laws and rules allow a competent and appropriately trained registered nurse from applying medications, such as Latisse® (a prescriptive medication), used for eyelash growth. This procedure requires a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse apply chemical peels and microdermabrasion?
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The nursing laws and rules allow a competent and appropriately trained registered nurse from applying superficial chemical peels or microdermabrasion. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse perform medical tattooing, body piercing, electrolysis, or application of permanent makeup?
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The nursing laws and rules allow a competent and appropriately trained registered nurse from performing medical tattooing, permanent makeup application, body piercing, and electrolysis. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse perform body sculpting using cold methods (such as CoolSculpting®) or heat methods (such as Vanquish™) for fat removal?
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The nursing laws and rules allow a competent and appropriately trained registered nurse from applying cold therapy (cryotherapy) heat therapy for fat removal. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse perform wart removal using liquid nitrogen (cryotherapy) or topical medications?
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The nursing laws and rules allow a competent and appropriately trained registered nurse to perform wart removal using liquid nitrogen or topical medications. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse administer phototherapy?
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The nursing laws and rules allow a competent and appropriately trained registered nurse from performing phototherapy such as Type B Ultraviolet (UVB), Grenz Ray, or Psoralen and Long-Wave Ultraviolet Radiation (PUVA). These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse perform a fine needle aspiration biopsy, shave biopsy or punch biopsy?
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The nursing laws and rules allow a competent and appropriately trained registered nurse from performing a fine needle aspiration biopsy, shave biopsy, or punch biopsy. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse administer intralesional injections?
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The nursing laws and rules allow a competent and appropriately trained registered nurse to administer intralesional injections. This procedures requires a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse remove skin growths using electrodesiccation and curettage?
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The nursing laws and rules allow a competent and appropriately trained registered nurse to perform electrodessication and curettage. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Dispensing, Compounding, Legend Drugs, Controlled Substances
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- Are there any medications that the registered nurse is not allowed to administer?
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The nursing law and rule does not prohibit a competent and appropriately trained registered nurse from administering any medication – legend or controlled substance (Schedule II-IV) or over-the-counter medications. The registered nurse may administer medications by any route. The registered nurse must be competent and follow the standards for medication administration.
- Can the registered nurse be delegated to enter medication prescriptions into an electronic health system or call in an order to a pharmacy?
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Receiving telephone and verbal prescription orders, transcribing, and transmitting prescription orders are activities often performed by nurses and appropriately included by many organizations in the responsibilities of the registered nurse. The registered nurse has the skill and knowledge to receive a prescription order and transcribe it accurately for other nurses to implement or transmit the order to a pharmacist to dispense. The laws and rules do not prohibit the registered nurse from calling in medication orders except for those restrictions in the Controlled Substances Act. The registered nurse may enter medication prescriptions into an electronic health system under the direction of an authorized health care practitioner. These directions may come through standing orders or verbal orders. Standing orders are often used to renew medication prescriptions. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations. It is within the scope of practice of the appropriately prepared registered nurse to write or enter the information into an electronic health record system the patient demographic information, as well as the drug, dosage, frequency and number of refills on a medical prescription as pursuant to a medical order. The nurse may not sign the nurse's name or the name of the individual authorizing the prescription on the prescription. WAC 246-870 Electronic Transmission of Prescription Information allows electronic prescriptions for legend drugs and controlled substances (except for Schedule II controlled substances). The laws states, “The system shall provide an audit trail of all prescriptions electronically transmitted that documents for retrieval all actions and persons who have acted on a prescription, including authorized delegation of transmission.” The order must be authenticated. See the Washington State Department of Health Pharmacies Website for more information.
- Can the registered nurse renew a prescription?
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It is not within the scope of practice for the registered nurse to renew an existing medication without a new prescription from an authorized health care practitioner. A competently and appropriately trained registered nurse may follow standing orders or verbal orders to renew an existing medication. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.
- Can the registered nurse give out drug samples?
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Giving out prescription drug samples is considered dispensing. It may be within the scope of practice of the competent and appropriately trained registered nurse to dispense pre-packaged a prescription sample that is properly labeled by an authorized health care practitioner or pharmacist. The registered nurse needs to be competent regarding the specific medication including the indications, contraindications, and side effects that is being delivered to the patient. The registered nurse should use the Scope of Practice Decision Tree to determine if handing out a pre-labeled, pre-packed sample is within the registered nurse’s regulatory and individual scope of practice. See the NCQAC's Public Health Nurses: Dispensing Medications/Devices for Prophylactic and Therapeutic Treatment of Communicable Diseases and Reproductive Health Advisory Opinion for more information
- Can the registered nurse compound medications?
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The competent and appropriately trained registered nurse may compound medications under the direction of an authorized health care practitioner. A prescription or order from an authorized health care practitioner is required. The registered nurse must follow the WAC 246-878 Compounding Practices and the United States Pharmacopeia (USP) compounding guidelines. The registered nurse should use the Scope of Practice Decision Tree to determine if performing compounding medications is within the registered nurse’s regulatory and individual scope of practice.
- Can the registered nurse mix and administer allergy serums?
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It may be within the scope of practice of the competent and appropriately trained registered nurse to prepare allergenic extracts as compounded sterile preparations under the direction of an authorized health care practitioner. A prescription or order from an authorized health care practitioner is required. The registered nurse must follow the WAC 246-878 Compounding Practices and the United States Pharmacopeia (USP) compounding guidelines. The registered nurse should use the Scope of Practice Decision Tree to determine if performing compounding medications and preparing allergenic extracts is within the registered nurse’s regulatory and individual scope of practice. See the Compounding Medications by Licensed Practical Nurses, Registered Nurses, and Advanced Registered Nurse Practitioners Advisory Opinion for more information.
- Can the registered nurse administer medications following standing orders?
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The nursing laws and rules do not prohibit the competent and appropriately trained registered nurse from administering medications following standing orders. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations. The registered nurse should use the Scope of Practice Decision Tree to determine if administering medications following a specific standing order within the registered nurse’s regulatory and individual scope of practice.
- Can the registered nurse perform medication reconciliation?
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The process for reconciliation of medication is the responsibility of the prescriber. It is important to remember that the registered nurse is not authorized or approved to sign orders that must be reconciled with patient medication. Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders. The purpose of reconciliation is to avoid errors that include but are not limited to transcription, omissions, duplication, dosing errors, or drug interactions. Taking a medication history has always been part of the nursing assessment and this information should be conveyed to the prescriber. The NCQAC suggests the following:
- Follow the policies and procedures relative to the documentation (paper or electronic) system used by the organization;
- Collect and verify the patient’s complete medication history;
- Clarify that the medications and dosages taken by the patient are correct and enter the information into the patient’s record;
- Notify provider of updated list; and
- Licensed prescriber reviews the medications list and reconciles.
- Can the registered nurse administer and read a tuberculosis skin test?
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It may be within the scope of practice of the competent and appropriately trained registered nurse to administer and “read” the tuberculosis (TB) skin test under the direction of an authorized health care practitioner. A prescription or order from an authorized provider is required as TB skin test formulations are a legend drug. Standing orders may be used. The registered nurse should use the Scope of Practice Decision Tree to determine if this activity is within the regulatory and individual scope of practice. The order may be made using a standing order. The prescriber or the registered nurse does not need to be on the premises when the registered nurse is administering medications. The registered nurse should communicate with the medical provider as appropriate or follow standing orders as appropriate for additional follow-up and referral. The Nursing Care Quality Assurance Commission recommends the registered nurse follow the Washington State Tuberculosis Laws and Guidelines and the Centers for Disease Control Guidelines for TB Screening and Follow-Up. Refer to the Standing Order Advisory Opinion for more information on use of standing orders.
- Can the registered nurse fill medication organizers or repackage medications into an individual pill container with individual doses?
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The NCQAC supports the use of medication organizers when using the standards of practice of medication administration. It is acceptable for the registered nurse to prepare a medication organizer or individual pill containers under the following conditions:
- Medications being placed into an organizer or individual pill container must already be dispensed by a pharmacist or other authorized health care provider;
- The medication organizer or individual pill container must be properly labeled with the patient’s name, name of the medication, dosage of each medication, frequency which the mediation is given;
- The RN must consult with the prescriber, pharmacist or other health care provider as appropriate.
- The medication must be stored properly and safely in a secured system.
See the Advisory Opinion on Medisets, the Medication Organizer Device Letter from Secretary of Health (PDF), and the Medication Organizer Device (PDF) for more information.
- Can the registered nurse give prescribed off-label medications?
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The nursing law and rules do not prohibit the competent and appropriately trained registered nurse from giving off-label medications under the direction of an authorized provider. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within his or her regulatory and individual scope of practice. The Food and Drug Administration Understanding Unapproved Use of Approved Drugs "Off-Label" website provides information about using unapproved off-label drugs. Off-label use should be done with careful insight and understanding of the risks and benefits to the patient considering high-quality evidence supporting efficacy, effectiveness, and safety. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides.
- Can the registered nurse give antineoplastic drugs, including administration by bladder installation?
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The nursing law and rules do not prohibit the competent and appropriately trained registered nurse from giving drugs, including antineoplastic drugs under the direction of an authorized provider. he facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within his or her regulatory and individual scope of practice. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides.
- Does the registered nurse require a specific certification to give chemotherapy in the home setting?
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The state and federal laws and regulations do not require the registered nurse to have a special certification to give chemotherapy in the home setting. he facility or employer may require a specific certification or training program. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of the chemotherapy is within his or her regulatory and individual scope of practice.
- Can the registered nurse give experimental drugs?
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The nursing law and rules do not prohibit the competent and appropriately trained registered nurse from giving experimental drugs by any route under the direction of an authorized provider. The registered nurse be competent. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of experimental drugs is within his or her regulatory and individual scope of practice. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides.
- Does the registered nurse need a written order to administer medications from a properly labeled prescription bottle?
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The label will suffice if the label completed following state law, is legible, properly identified, has the name of the patient on it, and the medication prescription has not expired. The facility or employer may require a prescription or other authentication/documentation for verification. The registered nurse is always responsible for verifying the order with the prescriber if there are concerns.
- Can the registered nurse administer medications or perform treatments or procedures without a physician onsite?
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The registered nurse works under the direction of an authorized health care practitioner within the practitioner’s scope of practice. The registered nurse may administer medications and perform treatments or procedures without an authorized health care practitioner on the premises. A prescription or order from an authorized provider is required for legend drugs, controlled substances or for medical treatments.
- Can the registered nurse administer immunizations under the direction of a pharmacist?
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A pharmacist is not identified as an authorized health care practitioner that the registered nurse may take orders or direction from. This does not mean the registered nurse may not work in a pharmacy setting administering immunizations. It is acceptable for orders for immunizations to be made by an authorized health care practitioner using standing orders. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.
- Can a registered nurse crush or split medications without an order?
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The nursing law and rule does not prohibit a registered nurse in making a decision to crush or split medications without an order. A registered nurse can use nursing judgment. The employer may have policies or guidelines about crushing or splitting medications. The registered nurse should use the Scope of Practice Decision Tree to determine if crushing a medication is within the registered nurse’s regulatory and individual scope of practice. The registered nurse should make the decision whether or not to crush or split the medication based on patient needs, prescribing information by the provider, and safety of the medication being administered in this form. The registered nurse administering the medication is responsible for ensuring the medication is safe to crush or split before giving it. Follow-up with the prescribing provider is warranted if a medication order states to crush or split the medication is necessary but it is not recommended. Other alternatives may be necessary such as a liquid medication. The Institute for Safe Medication Practices (ISMP) is a good resource for determining whether a medication is safe to crush. Splitting medications may result in dosage errors. Not all medications may be split. The registered nurse needs to determine whether the medication can be safety split to ensure proper dosage. The registered nurse should consider consulting with a pharmacist and follow current guidance or standards and/or contact the prescriber or pharmacist to see if there is another alternative, such as liquid form or getting the medication in the appropriate dose.
- Can the registered nurse hide medication in food for a patient who refuses to take the medication?
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The nursing laws and rules do not address this question. Some facility laws do address medication refusal. The WAC 388-76 Adult Family Home Minimum Licensing Requirements addresses medication refusal: WAC 388-76-10435 Medication Refusal. Hiding medications and not notifying the patient may be a violation of patient rights. See the Washington State Department of Health Patient Rights Guidelines for more information.
- Can the registered nurse administer epinephrine for anaphylaxis without an order?
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The registered nurse may carry and administer epinephrine under the direction of an authorized health care practitioner. The registered nurse may not administer epinephrine without an order from an authorized health care practitioner. The order or prescription may be for a specific patient or through the use of standing orders. Another option is for the facility or employer to become an authorized entity. SSB 6421 was passed in 2016 allowing authorized entities to obtain epinephrine autoinjectors. This allows an authorized health care practitioner to issue a prescription made out in the name of the authorized entity. Authorized entities that choose to acquire epinephrine autoinjectors must have people connected with the entity, such as employees, who have completed an anaphylaxis and epinephrine autoinjector training. These people will be responsible for the storage, maintenance, and general oversight of the epinephrine autoinjectors. They may administer or provide an epinephrine autoinjector to people who are experiencing anaphylaxis. An authorized entity is required to report to the Washington State Department of Health each incident of use of an obtained epinephrine autoinjector that was provided or administered to a person. Other laws may apply depending on the setting. RCW 28A.210.380 and 28A.210.383 regulations stipulate the requirements for epinephrine autoinjector use in public and private schools including the option of having a school stock supply of epinephrine autoinjectors for nurses to give following standing orders approved by an authorized health care practitioner. See the Washington State Department of Health’s Epinephrine Autoinjectors and Anaphylaxis Training and Reporting for Authorized Entities Frequently Asked Questions and the SSB 6421 Status Update Document for more information.
- Can the registered nurse administer naloxone for a suspected opioid overdose without an order?
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The registered nurse may administer naloxone or other opioid antagonist to anyone at risk for having or witnessing an opioid overdose. See the NCQAC's Prevention and Treatment of Opioid-Related Overdoses Advisory Opinion and Frequently Asked Questions for Nursing Professionals of the Prevention and Treatment of Opioid-Related Overdoses for more information.
- Can the registered nurse implement range orders?
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The laws and rules do not prohibit the competent and appropriately trained registered nurse from implementing a drug order that has a dosage range. The medical provider makes the "medical judgment" as to the specific medication and dosage. The registered nurse is given the latitude to use "nursing judgment" in determining the amount to be administered based on the patient’s clinical status. The registered nurse must apply adequate knowledge and skills in determining the dosage to be administered at any given time. Appropriate documentation of a focused patient assessment and evaluation must substantiate intervention. It is recommended that medication orders be patient/condition specific even if prescribed pro re nata (PRN), when needed. This would take away some of the notion of the nurse "prescribing" the medication. There should be some consultation with the physician to initiate a standing order particularly if the signs/symptoms are deviations from the patient's norm. Standing orders are certainly not to be used in lieu of medical consultation or intervention. Range orders should ideally consist of:
- The full name of the medication being ordered;
- The total amount of medication to be given in a specified time period;
- The order should state if the dose can be given in divided doses;
- The order should state if the dose can be repeated;
- If repeated, the order should indicate how frequently, and in what time frame; and
- The order should include what action should be taken if pain is unrelieved
- Can the registered nurse assist in providing case management and preparing prescriptions for patients in a medication assisted treatment (MAT)?
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The state laws and rules do not prohibit the competent and appropriately trained registered nurse from assisting in providing case management and support for patients in MAT within the registered nurse’s legal and individual scope of practice. The Drug Enforcement Administration (DEA) does state that, “an individual (secretary or nurse) may be designated by the practitioner to prepare prescription for the practitioner’s signature.”
- Can the registered nurse administer intra-articular injections?
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The nursing law and rules do not prohibit the competent and appropriately trained registered nurse from administering intra-articular injections under the direction of an authorized provider. he facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of intra-articular injections with within his or her regulatory and individual scope of practice. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides.
- Can the registered nurse destroy, witness, and/or cosign the destruction or wasting of controlled substances in a skilled nursing facility (SNF)?
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The registered nurse may destroy, witness, and/or cosign the destruction of wasting of controlled substances in a SNF home. See the WAC 246-865-060 Pharmaceutical Services-Extended Care Facility for more information. See the WAC 246-874-050 Accountability Requirements for an Automated Drug Dispensing Device (ADDD) if using an ADDD.
- Can the registered nurse administer or recommend over-the-counter (OTC) drugs without an order from a physician?
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The law and rules do not prohibit the registered nurse from administering or recommending OTC drugs as an intervention based on the nursing process, including nursing assessment, nursing diagnosis, and nursing evaluation. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if this activity is within the individual scope of practice. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides. Facilities or employers may be more restrictive.
- Gastroenterology Procedures
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- Can the registered nurse insert a feeding tube in a neonate or infant?
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It is within the scope of practice of an appropriately trained and competent registered nurse to insert a feeding tube in a neonate, infant, child, or adult under the direction of an authorized health care practitioner, following clinical practice standards. An order from an authorized health care practitioner is required. The registered nurse should use the Scope of Practice Decision Tree.
- Can the registered nurse insert a percutaneous endoscopic gastrostomy (PEG) tube?
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It is within the scope of practice of an appropriately trained and competent registered nurse to insert a PEG tube under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.
- Can the registered nurse manipulate the endoscope when assisting during an endoscopic procedure?
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It is within the scope of practice of an appropriately trained and competent registered nurse to manipulate the endoscope when assisting in performing an endoscopic procedure. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.
- Can the registered nurse perform an endoscopy, sigmoidoscopy, or colonoscopy?
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It is within the scope of practice of an appropriately trained and competent registered nurse to perform an endoscopy, sigmoidoscopy, or colonoscopy procedures, including obtaining biopsies, following clinical practice standards. Standing orders from an authorized health care practitioner may be used to order the procedure and for follow-up actions based on the results. The registered nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. Facility policies, accreditation organizations (such as the Joint Commission), and Federal regulations (such as the Centers for Medicare and Medicaid Services) may limit or restrict the scope of practice of registered nurse performing this procedure.
- Can the registered nurse perform ostomy care?
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It is within the scope of practice of an appropriately trained and competent registered nurse to perform ostomy care, following clinical practice standards. Routine care of a stoma should be addressed in the nursing care plan. A prescription or order from an authorized provider may be necessary if complications occur or if medical treatment is required. Generally, a prescription from an authorized health care practitioner is required for reimbursement of medical supplies. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.
- Can the registered nurse re-insert a dislodged gastrostomy tube?
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It is within the scope of practice of an appropriately trained and competent registered nurse to re-insert a gastrostomy tube in a mature stoma site under the direction of an authorized health care practitioner, following clinical practice standards. If there are signs of infection or other concerns, the registered nurse should seek advice from an authorized provider before attempting to re-insert. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.
- General Scope of Practice
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- How can the registered nurse determine if a specific procedure or skill is within the nurse's scope of practice?
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The RCW 18.79 Nursing Care and the WAC 246-840 Practical and Registered Nursing allow a nurse to employ their full scope of practice in multiple settings. NCQAC also approves advisory opinions and interpretive statements about specific nursing practice questions. The NCQAC recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse’s scope of practice.
- Can the registered nurse practice independently?
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The registered nurse practices nursing care independently. The registered nurse practices interdependently taking direction from an authorized health care practitioner when carrying out medical regimens.
- What settings can the registered nurse practice in?
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The registered nurse may work in any setting where nursing care is provided. Examples of settings include (but not limited to): Hospitals, nursing homes, assisted living facilities, adult family homes, schools, camps, clinics, public health clinics, homes, hospice, community health centers, homeless shelters, insurance companies, law offices, travel clinics, occupational health centers, private clinics, outpatient clinics, ambulatory surgery centers, dialysis centers, mental health centers, infusion centers, medical spas, nursing informatics programs, correctional centers/jails, county health departments, government offices, cruise ships, churches, casinos, retail clinics and other businesses.
- Can a licensed practical nurse, medical assistant, or non-nurse supervise the registered nurse?
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Most health care facilities or employers include an organizational structure that defines a person’s manager or supervisor. A non-nurse may be a “supervisor” of the registered nurse in an organizational structure related to human resource and administrative functions. This is different than the definition of “supervision” of a nursing activity. The nursing rules define “supervision” as the “provision of guidance and evaluation for the accomplishment of a nursing task or activity with the initial direction of the task or activity; periodic inspection of the actual act of accomplishing the task or activity; and the authority to require corrective action.” The registered nurse practices independently and does not require supervision or evaluation of nursing care. Only the registered nurse or advanced registered nurse practitioner may supervise and evaluate the practice of nursing.
- Do any nursing activities require the registered nurse to have a health care practitioner on the premises?
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The nursing law and rule does not require an authorized health care practitioner to be on the premises when the registered nurse provides care in any setting. A facility or supervisor may require direct or immediate supervision of specific activities or if there are concerns about competency for a specific nurse. An exception exists in the physician rules that require a physician to be on the immediate premises during the patient’s initial treatment when a nurse is performing laser therapy: WAC 246-919-605 Use of Laser, Light, Radiofrequency, and Plasma (LLRP) Devices as Applied to the Skin.
- Can the employer expand the scope of practice of the registered nurse if a physician or advanced registered nurse practitioner signs off on the procedure?
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The employer may not expand the registered nurse’s scope of practice. The registered nurse must provide nursing care within Washington statutes and regulations that govern nursing practice.
- Can the registered nurse provide or delegate care in an assisted living facility (ALF)?
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An ALF may choose to provide, but is not required to provide, intermittent nursing services. The registered nurse may provide nursing care and in an ALF within the registered nurse’s scope of practice and carryout medical regimens under the direction of an authorized health care practitioner. Only the registered nurse may delegate nursing activities to a nursing assistant-certified (NA-C), nursing assistant-registered (NA-R), or home care aid-certified (HCA-C) in an ALF. See the RCW 18.20 Assisted Living Facilities and WAC 388-78A Assisted Living Facility Licensing Rules for more information.
- Can the registered nurse provide nursing care to a minor patient without parental consent?
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The general age of majority for health care is eighteen years old in Washington State as defined in RCW 26.28. Other laws do allow exceptions for specific types of treatment: See the Providing Health Care to Minors under Washington Law Summary for more information.
- Can the registered nurse give test results to a patient?
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It is not in the scope of practice for a registered nurse to make a medical diagnosis based on interpretation of diagnostic test results. Medical test results must be interpreted by an authorized health care practitioner. The nursing laws and rules do not prohibit the registered nurse from relaying test results or a medical diagnosis if already made by an authorized health care practitioner. It is important to consider what types of questions or discussion the patient might have when receiving test results or when a diagnosis is relayed to the patient by the nurse. Abnormal test results should be communicated by someone who can provide supporting information about the test, implications, and follow-up care. The complexity and seriousness of the test results may also determine who gives the results and by what method test results should be given. The person giving the test results or diagnosis must be competent to answer the patient’s questions.
- Infusion Therapy, Phlebotomy, and Laboratory Tests
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- Does a registered nurse require a special certification to perform infusion therapy, phlebotomy, or laboratory tests?
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The nursing laws and rules do not require a registered nurse to get a special certification to perform infusion therapy, phlebotomy, or laboratory tests. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- What activities can a registered nurse perform related to a vascular access device (VAD) or other infusion devices?
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The nursing laws and rules allow the competent and appropriately trained registered nurse from performing infusion therapy. Invasive procedures require an order from an authorized health care practitioner. It may be within the scope of practice of a registered nurse to perform the following tasks related to a VAD or other infusion devices under the direction of an authorized health care practitioner:
Short peripheral catheter line intraosseous access device, and subcutaneous infusion device insertion and removal; Preparing, initiating, managing, and monitoring infusion pumps;
- Peripheral (including short peripheral or midline), CVAD, arterial, umbilical arterial catheter (UAC) or umbilical venous catheter (UVC), intraspinal, intraosseous access device, and subcutaneous infusion device insertion or removal, site monitoring, care, and dressing changes;
- Insertion or removal, administration of infusion fluids and medications via peripheral, CVAD, and arterial catheters including through an implanted vascular access port, hemodialysis VAD, and UAC) or UVC;
- Medication administration via a VAD using piggyback, push, or bolus methods;
- Transfusion of blood products;
- Infusion of biologic therapies, including stem cell therapies;
- Blood sampling via a peripheral, VAD, and arterial device;
- Administration of total parenteral nutrition;
- Monitor patency of the peripheral, CVAD, and arterial catheters; and
- Change infusion sets.
The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. The nurse must follow clinical standards of care. Examples include the Infusion Nurses Society (INS) and the National Infusion Center Association (NICA) practice, training, and competency standards for the registered nurse.
- Can a registered nurse start an intravenous line without an order from an authorized health care practitioner in certain situations, such as for an unstable/high acuity patient?
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It is not within the scope of practice for a registered nurse to start an intravenous line without an order from an authorized health care practitioner. The RCW 18.71.011 Definition of the Practice of Medicine stipulates the practice of medicine to include severing or penetrating the tissues of human beings. Standing orders may be an option to allow the nurse to start an intravenous line based on specific criteria (such as a high acuity patient), admission to a specific unit (such as intensive care), or for a specific condition. Standing orders may also be used to allow a nurse to start more than one intravenous line based on specific criteria. The nurse must be competent to carry specific steps identified in the standing order. The registered nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the nurse’s legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion and Verbal Orders provides additional guidance and recommendations.
- Does a registered nurse need an additional order to restart an intravenous line that is no longer patent?
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A registered nurse does not need an additional order from an authorized health care practitioner to restart an intravenous line that is no longer patent. The nurse may want to consult with the authorized health care practitioner in situations when the nurse is unsure if the patient still requires an intravenous line or if the patient’s intravenous line is insufficient to support the therapy needed.
- Can a registered nurse administer stem cell transplants?
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The nursing laws and rules allow the competent and appropriately trained registered nurse to administer stem cell-based products via a peripheral intravenous line, intra-arterial catheter, intradermal technique, or intramuscular technique, intravitreal infusion, retrobulbar infusion, spinal infusion, or other complex administration techniques. This procedure requires a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse perform venipuncture to obtain blood samples for laboratory tests in the home setting?
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The nursing laws and rules allow the competent and appropriately trained registered nurse to perform venipuncture to obtain blood samples for laboratory testing in any setting. These procedures require a prescription from an authorized health care practitioner. The nurse must follow Federal and State blood-borne pathogen and Scope of Practice Decision Tree to determine if these activities are within the nurse’s regulatory and individual scope of practice.
- Does a registered nurse require an order to perform Clinical Laboratory Improvement Amendments (CLIA) FDA tests such as a human chorionic gonadotropin (hCG), urine dipstick, strep throat screening, occult blood screening, or blood glucose capillary test?
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It is not within the scope of the registered nurse to make a medical diagnosis – CLIA waived tests are considered screening (not diagnostic tests). The nursing laws and rules allow the competent and appropriately trained registered nurse to perform tests such as a human chorionic gonadotropin (hCG), urine dipstick, strep throat screening, occult blood screening, blood glucose capillary tests or other CLIA approved waiver under the CLIA criteria. An order is required from an authorized health care practitioner to perform any activity that involves puncturing the skin as this is considered part of the definition of the practice of medicine. The CLIA waived tests that do not involve puncturing the skin may be initiated by a registered nurse without an order from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse obtain blood specimens and submit to a laboratory to perform lead screening, hepatitis B screening, or other employee health laboratory tests?
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The nursing laws and rules allow the of the competent and appropriately trained registered nurse from obtaining and submitting capillary or venous blood specimens for lead screening, hepatitis B screening or other employee health tests. An order is required from an authorized health care practitioner for laboratory tests involving puncturing of the skin. Standing orders may also be followed to direct occupational health activities. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations. The registered nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse perform an arterial blood draw for an arterial blood gas (ABG)?
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The nursing laws and rules allow the competent and appropriately trained registered nurse from obtaining an arterial blood gas directly from an artery or through an arterial line. This procedure requires a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can a registered nurse perform iliac crest bone marrow aspirations and biopsies?
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The nursing laws and rules allow the competent and appropriately trained registered nurse from obtaining an iliac crest bone marrow aspiration and biopsies. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform therapeutic phlebotomy?
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The nursing laws and rules allow the competent and appropriately trained registered nurse from performing therapeutic phlebotomy for conditions (such as polycythemia vera). These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Neurological and Musculoskeletal Procedures
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- Is the registered nurse (RN) allowed to operate a transcutaneous electrical nerve stimulation (TENS) unit for pain relief?
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It is within the scope of practice of the appropriately prepared and competent RN to apply and operate a TENS unit for chronic and acute pain, following clinical practice standards. TENS units are available over the counter or prescriptive. The RN may use an over the counter device without an order from an authorized health care practitioner as an intervention following the nursing process. The RN is required to have an order from an authorized health care practitioner to apply a prescriptive TENS unit. The RN should use the Scope of Practice Decision Tree to determine if specific activities are within the RN’s scope of practice based on competencies, legal parameters, and other factors.
- Is the registered nurse (RN) allowed to perform a lumbar puncture?
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It is within the scope of practice of the appropriately prepared and competent RN to perform a lumbar puncture, including obtaining laboratory specimens, under the direction of an authorized health care practitioner, following clinical practice standards. The RN should use the Scope of Practice Decision Tree to determine if specific activities are within the RN’s scope of practice based on competencies, legal parameters, and other factors.
- Is the registered nurse (RN) allowed to perform electroencephalography (EEG) or electromyography (EMG)?
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It is within the scope of practice of the appropriately prepared and competent RN to perform an EEG or EMG under the direction of an authorized health care practitioner, following clinical practice standards. The RN should use the Scope of Practice Decision Tree to determine if specific activities are within the RN’s scope of practice based on competencies, legal parameters, and other factors.
- Can the registered nurse (RN) perform iliac crest bone marrow aspirations and biopsies?
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The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to lead this activity due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing a lumbar puncture, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.
- Nursing Assessment
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- What is the difference between a pre-admission/resident assessment and a comprehensive nursing care assessment?
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A pre-admission/resident assessment is a needs assessment screening tool used to obtain information about the personal care needs and requests of a potential resident. The pre-admission/resident assessment findings may identify needs for a comprehensive nursing care assessment.
A nursing care assessment gathers information about the person’s health status through the collection of data and/or physical examination. This assessment includes the use of the nursing process (WAC 246-840-700). Although a nursing care assessment may include elements of a non-skilled personal care assessment, it is a comprehensive nursing care evaluation and must be performed by the registered nurse. The licensed practical nurse may assist in gathering information for the nursing care assessment under the direction and supervision of the registered nurse.
- Who can perform the pre-admission/resident assessment in adult family homes and assisted living facilities?
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The laws and rules found in Aging and Adult Service Section of WAC 388-78A (assisted living facilities) and 388-76 (adult family homes) define the qualifications required for an individual to perform the required pre-admission/resident assessment. An individual with a nursing license (licensed practical nurse or registered nurse) meets the qualifications to perform the pre-admission/resident assessment. Other professionals may also perform the pre-admission/resident assessment (WAC 388-76-10150 and WAC 388-78A-2080).
This pre-admission/resident assessment (screening tool) does not necessarily require the services of a professional licensed nurse or the use of the nursing process (WAC 246-840-700). The goal of the pre-admission/resident assessment is to determine the personal care services needs of a potential resident and at times, the nursing care needs of said resident. If a comprehensive nursing assessment is contemplated as part of the care plan, the registered nurse must undertake that portion of the pre-admission assessment.
- Who can provide training of staff in adult family homes and assisted living facilities related to personal care services?
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Staff must meet the credentialing, training and competency requirements established in the state and federal laws and rules specific to the setting. Training and competency assessment for personal care services (non-nursing care) does not require the services of a Washington state licensed professional nurse. Training and education of staff employed in these facilities that address personnel, performance and other administrative activities do not require the utilization of a registered nurse.
- Nursing Delegation
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- Is the registered nurse (RN) allowed to perform a Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 test without an order or standing order from an authorized health care practitioner?
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Yes. The RN may perform a CLIA-waived COVID-19 test based on the nursing process without an order or standing order from an authorized health care practitioner if the CLIA-waived test is done for screening purposes and not diagnostic purposes. For screening tests, the RN must document whether a test result is positive or negative but may not diagnose the patient with COVID-19 or any other condition. Employers/facilities may have policies requiring an order for these tests and other requirements, such as completion of competency assessment, and quality control testing. The employer/facility must have a CLIA-waived certification:
Medical Test Sites (MTS) | Washington State Department of Health
Clinical Laboratory Improvement Amendments (CLIA) | FDA
The employer/facility should follow established guidelines specific to the facility type:
Point of Care Testing Guidelines (wa.gov)
The employer/facility must follow quality control measures as required with the CLIA-waived certification and/or as required by accreditation organizations (e.g., Joint Commission):
Other Resources:
Waived Testing- Screening or Definitive | Laboratory | Waived Testing WT | The Joint Commission
Screening Versus Diagnostic Tests for COVID-19, What’s the Difference? (asm.org)
RN Authority with COVID-19 CLIA-Waived Tests in School Settings | WABON
Testing in Schools Frequently Asked Questions | Washington State Department of Health
Guidance for SARS-CoV-2 Rapid Testing Performed in Point-of-Care Settings | CDC
- Is the registered nurse RN allowed to perform a point of care polymerase chain reaction (PCR) COVID-19 test without an order or standing order from an authorized health care practitioner?
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No. An order or standing order from an authorized health care practitioner is required for the RN to perform a PCR COVID-19 test. A PCR test is considered the “gold standard” for COVID-19 tests as they are more likely to detect the virus than antigen tests. A PCR is regarded as a diagnostic test instead of a screening test.
Medical Test Sites (MTS) | Washington State Department of Health
Clinical Laboratory Improvement Amendments (CLIA) | FDA
COVID-19 RT-PCR Test - Healthcare Provider Fact Sheet (fda.gov)
- Is registered nurse RN delegation required if a patient self-tests for a COVID-19-waived test using a Clinical Laboratory Improvement Amendments (CLIA)-waived test?
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No. RN delegation is not required if a patient does a self-test using a COVID-19 CLIA-waived test. The RN can provide instructions to the patient for self-testing, observe the patient do the test, report (or assist) in reporting the results, and guidance for further testing, follow-up, self-care, quarantine, and other recommendations as appropriate.
COVID-19 Self-Testing Guidance for Establishments (wa.gov)
Medical Test Sites (MTS) | Washington State Department of Health
Point of Care Testing Guidelines (wa.gov)
RCW 74.39.050: Individuals with functional disabilities—Self-directed care. (wa.gov)
- What is the responsibility of the registered nurse (RN) for reporting positive COVID-19 tests to the Washington State Department of Health (WA DOH)?
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The RN is responsible for following the employer/facility processes in reporting positive COVID-19 tests to the WA DOH. If the RN owns the business/facility, then the RN must report positive COVID-19 test results to WADOH.
- Is the registered nurse (RN) required to have a Medical Test Site (MTS) certification to perform a point of care CLIA-waived or polymerase chain reaction (PCR) COVID-19 tests?
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It depends. MTS Certification is required by the employer/facility to perform a CLIA-waived or PCR COVID-19 tests regardless of setting. If the RN owns the business/facility, then the business/facility must have the appropriate MTS certification.
Medical Test Sites (MTS) | Washington State Department of Health
- Is the registered nurse RN required to document COVID-19 testing activities?
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Yes. The RN must document the care provided, including COVID-19 testing activities, regardless of the setting. Documentation can be done electronically or on paper using a patient’s medical record. The RN should follow the employer/facility documentation policies and procedures. Standardized screening forms that include the results may be used for documentation. Documentation of positive tests must be reported to the Washington State Department of Health.
- Is the registered nurse (RN) allowed to delegate to non-credentialed staff in a juvenile detention center performance of CLIA-waived COVID-19 tests or polymerase chain reaction (PCR) COVID-19 tests?
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No. The laws and rules only allow the RN to delegate to non-credentialed staff in public and private schools, kindergarten-twelve grades. In juvenile detention centers, the RN can delegate COVID-19 testing to a nursing assistant-registered/nursing-assistant-certified (NA-R/NA-C) or a medical assistant-registered/medical assistant-certified. An option may be to have specific staff obtain the NA-R/NA-C or MA-R/MA-C credential.
- What are the recommendations if a business or facility does not have a registered nurse (RN) to delegate COVID-19 testing to staff?
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Some businesses or facilities will not have an RN available to delegate testing to staff. For businesses or facilities without an RN, options may be to offer take-home COVID-19 rapid tests or have the patient self-test on site. Organizations should consider identifying an alternative mechanism and source of authority to conduct COVID-19 testing. The Washington State Board of Nursing (WABON) recommends that businesses/facilities consult with their legal counsel. This issue is outside the WABON’s authority.
- Is the registered nurse (RN) allowed to delegate to non-credentialed staff in a daycare, Head Start program, or preschool to perform Clinical Laboratory Improvement Amendments (CLIA) waived COVID-19 testing?
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No. The RN is not allowed to delegate COVID-19 testing to non-credentialed staff in a daycare, Head Start program, or preschool. The laws and rules regarding daycares, Head Start programs, and preschools permit the parent or legal guardian to consent for these entities to provide health care. This permission is known as loco parentis (in place of the parent) and allows these settings to designate staff to act in place of a parent or legal guardian. This also allows the staff to test without an order or standing order from an authorized health care practitioner. The RN may be involved in training staff and providing consultation and guidance regarding the testing. The daycare, Head Start program, or preschool must have the Medical Test Site (MTS) Certification. If a parent or legal guardian does the testing, the site would not be required to have the MTS Certification. The Washington State Board of Nursing (WABON) recommends that early childhood programs consult with the Department of Children, Youth, and Families (DCYF) and their legal counsel.
- Is the registered nurse (RN) allowed to delegate orogastric/nasogastric (OG/NG) tube enteral tube feedings, irrigation/flushing, or related medication administration to the nursing assistant-registered/nursing assisted-certified (NA-R/NA-C) or home(Cont.)
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Is the registered nurse (RN) allowed to delegate orogastric/nasogastric (OG/NG) tube enteral tube feedings, irrigation/flushing, or related medication administration to the nursing assistant-registered/nursing assisted-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
It depends on the setting. The RN is allowed to delegate OG/NG enteral tube feedings and related tasks (e.g., irrigation/flushing of the tube) to the NA-R/NA-C and HCA-C in any setting. The RN is allowed to delegate medication administration to the NA-R/NA-C or HCA-C only in community-based* and in-home care settings. Verification of OG/NG tube placement is required prior to each tube feeding following clinical practice standards. One method is by performing a pH test of gastric aspirates. The RN is allowed to delegate pH testing to the NA-R/NA-C or HCA-C with instructions specific to the results with what actions to take if the results are not within defined parameters. The RN must consider the risk of complications for the specific patient based on nursing assessment such as aspiration, tube malpositioning, dislodgement, refeeding syndrome, medication-related complications, insertion-site infection, agitation, and other factors to determine whether if it is safe to delegate.
Chapter 17 Enteral Tube Management - Nursing Skills - NCBI Bookshelf (nih.gov)
In all settings, the RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to make that determination.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate enteral tube feedings, related medication administration, stoma care, venting, and irrigation/flushing of a Gastrostomy tube (G-tube), such as Percutaneous Endoscopic Gastrostomy (PEG) tube, and (Cont.)
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Is the registered nurse (RN) allowed to delegate enteral tube feedings, related medication administration, stoma care, venting, and irrigation/flushing of a Gastrostomy tube (G-tube), such as Percutaneous Endoscopic Gastrostomy (PEG) tube, and Jejunostomy tube (J-tube), and Jejunostomy/Gastronomy (J-G) tube to the nursing assistant-registered/nursing assisted-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
It depends on the setting. The RN is allowed to delegate G-tube feedings, irrigation/flushing, stoma care, and venting with a syringe or venting with a gastric venting system to the NA-R/NA-C or HCA-C in any setting. The RN may delegate medication administration through G-tubes to the NA-R/NA-C and HCA-C only in community-based* and in-home care settings. The RN must consider the condition of the G-tube (such as maturity of stoma site, patency, and sustained skin integrity) to determine whether it’s safe to delegate. Further, delegation may only occur for patients with a mature stoma site.
Chapter 17 Enteral Tube Management - Nursing Skills - NCBI Bookshelf (nih.gov)
In all settings, the RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to make that determination.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate reinsertion of a displaced gastrostomy tube (G-tube) for a patient with a mature stoma site to the nursing assistant-registered/nursing assisted-certified (NA-R/NA-C) or HCA-C?
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Yes. The RN is allowed to delegate reinsertion of a displaced G-tube for patients with a mature stoma site to the NA-R/NA-C or HCA-C. An alternative is for the RN to delegate reinsertion of a Foley catheter as a temporary measure to keep the stoma site open until the G-tube can be replaced.
Chapter 17 Enteral Tube Management - Nursing Skills - NCBI Bookshelf (nih.gov)
In all settings, the RN must follow the delegation process outlined in RCW 18.79.260 (3)(a) to make that determination.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- What is registered nurse (RN) delegation and the process as it applies to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
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RN delegation is given by a specific nurse, for a specific nursing task, for a specific patient, and to a specific NA-R/NA-C or HCA-C. The RN delegating the task retains the responsibility and accountability for the nursing care of the patient. RN delegation is used when the task is not within the NA-R/NA-C’s standards of practice and core competencies defined in Chapter 246-841A WAC or the HCA-C’s standards of practice (WAC 246-980-150) The RN may delegate a nursing task after determining that it is in the best interest of the patient. The following nursing care tasks may not be delegated by the registered nurse (RN) to the NA-R/NA-C (Chapter 246-841A WAC) or HCA-C WAC 246-980-150:, WAC 246-980-130:
- Medication administration
- Except in community-based* and in-home care settings
- Sterile procedures
- Central line maintenance
- Acts that require piercing or puncturing of the skin
- Except for performing capillary blood glucose tests (RCW 18.79.260, RCW 18.88A.210, Chapter 246-841A WAC)
- Except for administering insulin used to treat Diabetes Mellitus in community-based* and in-home care settings (RCW 18.79.260, RCW 18.88A.210, Chapter 246-841A WAC)
- Acts that require nursing judgment.
Tasks that may be delegated vary in specific settings as defined in the laws and rules. See below.
For RN delegation in all settings, please see RCW 18.79.260 (3)(a).
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
It is within the scope of practice of the HCA-C to perform activities of daily living without direction and supervision of the RN. Other tasks that fall outside of the standards of practice of the HCA-C do require RN delegation. The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to delegation to the HCA-C:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Medication administration
- Do all nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) activities or tasks need to be delegated by the registered nurse (RN) following the delegation process?
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No. The NA-R/NA-C performs routine nursing care activities, identified in the core competencies (Chapter 246-841A WAC) under the direction and supervision of the registered nurse or licensed practical nurse (LPN). Tasks that fall outside of the core competencies do require RN delegation.
It is within the scope of practice of the HCA-C to perform activities of daily living without direction and supervision of the RN. RN delegation is only required for nursing tasks that fall outside of the standards of practice of the HCA-C. The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- How does registered nurse (RN) delegation differ from nursing direction, patient assignment, and supervision as it applies to the nursing assistant-registered/nursing assistant-certified and home care aide-certified (NA-R-NA-C, HCA-C)?
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The term “delegation” is often used synonymously with “direction” and patient “assignment” when working with the NA-R/NA-C. This is an inaccurate use of these terms. The RN or licensed practical nurse (LPN) gives directions or makes a patient assignment to the NA-R/NA-C to perform activities that are already within the NA-R/NA-C’s core competencies defined in Chapter 246-841A WAC.
The term “supervision” is sometimes used incorrectly in correlation with “supervisor” in an organizational structure. The RN or LPN is responsible for supervision and direction of assigned care. WAC 246-840-010 defines supervision as “… the provision of guidance and evaluation for the accomplishment of a nursing task or activity with the initial direction of the nursing task or activity; periodic inspection of the actual act of accomplishing the task, and the authority to require corrective action.”
RN delegation is when the RN transfers the performance of selected nursing tasks to the competent NA-R/NA-C in selected situations. It is a critical component that the RN has assessed the patient prior to delegation of tasks. The RN delegator must determine the level of supervision depending on the patient’s status, conditions, NA-R/NA-C or HCA-C competencies, or other factors. The RN delegator nurse must determine the level of supervision based on nursing judgment, considering the following levels of supervision (WAC 246-840-010):
- Direct Supervision means the licensed RN who provides guidance to nursing personnel and evaluation of nursing tasks is on the premises, is quickly and easily available, and has assessed the patient prior to the delegation of duties.
- Immediate supervision means the licensed RN who provides guidance to nursing personnel and evaluation of tasks is on the premises, is within audible and visible range of the patient, and has assessed the patient prior to the delegation of duties.
- Indirect supervision means the licensed RN who provides guidance to the nursing personnel and evaluation of nursing tasks is not on the premises but has given either written or oral instructions for the care and treatment of the patient and the patient has been assessed by the RN prior to the delegation of duties.
The RN delegating the task retains the responsibility and accountability for the nursing care of the patient. RN delegation is used when the task is not within the NA-R/NA-C’s core competencies. The RN may delegate a nursing task after determining that it is in the best interest of the patient. RN delegation is only given by a specific nurse, for a specific nursing task, and for a specific patient. Tasks that may be delegated may vary in specific settings as defined in the laws and rules. For RN delegation in all settings, please see RCW 18.79.260 (3)(a).
It is within the scope of practice of the HCA-C to perform activities of daily living without direction and supervision of the RN. RN delegation is only required for nursing tasks that fall outside of the standards of practice of the HCA-C.
In addition, for RN delegation in community-based* and in-home care settings, see the following statute and rules:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Does the delegating registered nurse (RN) need to be on the premises when the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) provides care or carries out delegated nursing tasks?
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No. The law and rules do not require the delegating RN to be on the premises when the NA-R/NA-C or HCA-C provides care, including when carrying out a delegated nursing task. The decision as to the level of supervision is based on nursing judgment following the nursing process.
WAC 246-840-010 defines supervision as “… the provision of guidance and evaluation for the accomplishment of a nursing task or activity with the initial direction of the nursing task or activity; periodic inspection of the actual act of accomplishing the task, and the authority to require corrective action.”
It is a critical component that the RN has assessed the patient prior to delegation of tasks. The RN delegator must determine the level of supervision depending on the patient’s status, conditions, NA-R/NA-C or HCA-C competencies, or other factors. The RN delegator nurse must determine the level of supervision based on nursing judgment, considering the following levels of supervision (WAC 246-840-010):
- Direct Supervision means the licensed RN who provides guidance to nursing personnel and evaluation of nursing tasks is on the premises, is quickly and easily available, and has assessed the patient prior to the delegation of duties.
- Immediate supervision means the licensed RN who provides guidance to nursing personnel and evaluation of tasks is on the premises, is within audible and visible range of the patient, and has assessed the patient prior to the delegation of duties.
- Indirect supervision means the licensed RN who provides guidance to the nursing personnel and evaluation of nursing tasks is not on the premises but has given either written or oral instructions for the care and treatment of the patient and the patient has been assessed by the RN prior to the delegation of duties.
For delegation and the levels of supervision in community-based* and in-home care settings please see WAC 246-840-920.
For RN delegation in all settings, please see RCW 18.79.260 (3)(a).
In addition, for RN delegation in community-based* and in-home care settings, see the following statute and rules:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- What are the requirements for supervision when the registered nurse (RN) delegates administration of insulin injectable medications to treat Diabetes Mellitus to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home-care (Cont.)
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What are the requirements for supervision when the registered nurse (RN) delegates administration of insulin injectable medications to treat Diabetes Mellitus to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home-care aide-certified (HCA-C) in community-based* and in-home care settings?
The RN delegator must supervise this task at least every two weeks for one month, or more often if needed. It is a critical component that the RN has assessed the patient prior to delegation of tasks. The RN delegator must determine the level of supervision depending on the patient’s status, conditions, NA-R/NA-C or HCA-C competencies, or other factors. The RN delegator nurse must determine the level of supervision based on nursing judgment, considering the following levels of supervision (WAC 246-840-010):
- Direct Supervision means the licensed RN who provides guidance to nursing personnel and evaluation of nursing tasks is on the premises, is quickly and easily available, and has assessed the patient prior to the delegation of duties.
- Immediate supervision means the licensed RN who provides guidance to nursing personnel and evaluation of tasks is on the premises, is within audible and visible range of the patient, and has assessed the patient prior to the delegation of duties.
- Indirect supervision means the licensed RN who provides guidance to the nursing personnel and evaluation of nursing tasks is not on the premises but has given either written or oral instructions for the care and treatment of the patient and the patient has been assessed by the RN prior to the delegation of duties.
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Can the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) refuse to consent to perform a delegated nursing task?
-
The NA-R/NA-C or HCA-C may refuse to consent to perform a delegated nursing task. The laws and rules protect the NA-R/NA-C or HCA-C from any employer reprisal or disciplinary action by the Department of Health for refusing to accept delegation of a nursing task based on patient safety issues. The NA-R/NA-C or HCA-C is accountable for their own actions in the delegation process.
RCW 18.88A.230: Delegation—Liability—Reprisal or disciplinary action. (wa.gov)
WAC 246-840-970: Accountability, Liability, and Coercion for community-based and in-home nurse delegation
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
- Are there tasks that cannot be delegated to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
Yes. The following nursing care tasks may not be delegated by the registered nurse to a NA-R/NA-C (Chapter 246-841A WAC) or HCA-C:
- Medication administration
- Except in community-based* and in-home care settings
- Sterile procedures
- Central line maintenance
- Acts that require piercing or puncturing of the skin
- Except for performing capillary blood glucose tests (RCW 18.79.260, RCW 18.88A.210, Chapter 246-841A WAC)
- Except for administering insulin injections used to treat Diabetes Mellitus in community-based* and in-home care settings (RCW 18.79.260, RCW 18.88A.210, Chapter 246-841A WAC)
- Acts that require nursing judgment.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Medication administration
- When the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) accepts a delegated task, is the NA-R/NA-C or HCA-C working under the delegating registered nurse’s (RNs) license?
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No. The NA-R/NA-C or HCA-C is working under their credential when accepting delegated tasks. The NA-R/NA-C or HCA-C is responsible for their own actions with their decision to consent (or refuse to consent) to nurse delegation and the performance of the delegated nursing task. The delegating RN is accountable and responsible for delegating the task correctly.
- Is the registered nurse (RN) allowed to delegate insertion or removal of a urinary catheter to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The RN is allowed to delegate insertion or removal of a urinary catheter using clean technique to the NA-R/NA-C or HCA-C. The RN delegator is not allowed to delegate the task of inserting or removing a urinary catheter using sterile technique. When nurse delegation is allowed, the RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate administration of medications via urinary catheters to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The RN is allowed to delegate administration of medications via clean technique to the NA-R/NA-C or HCA-C only in community-based* and in-home care settings. The RN cannot delegate any task that requires sterile technique in any setting.
When nurse delegation is allowed, the RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACS are applicable to nurse delegation to the HCA-C in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate performing a noninvasive bladder scan using an ultrasound device to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
Yes. The RN may delegate the task of performing a noninvasive bladder scan using an ultrasound device to the NA-R/NA-C or HCA-C. The RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate performance of wound care, dressing changes, or ostomy site care to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The RN may delegate the task of performing non-complex wound care, dressing changes, or ostomy site care that does not require sterile procedure, or nursing judgment to the NA-R/NA-C or HCA-C in any setting. RN delegation of medications or irrigation is allowed only in community-based* and in-home care settings. When nurse delegation is allowed, the RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate routine foot and nail care to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The NA-R/NA-C (WAC 246-980-140) or HCA-C (WAC 246-980-140) may perform personal care and assist patients with bathing, oral care, and skin care. However, the rules do not specifically address nail care. The Washington State Board of Nursing (WABON) determines that because it is not specifically addressed in the core competencies/scope of practice, that RN delegation is required for the NA-R/NA-C or HCA-C to perform routine foot and nail care.
However, WABON determines that RN delegation to the NA-R/NA-C or HCA-C to perform foot and nail care is not allowed for a patient with diabetes or a patient with other conditions resulting in poor circulation in any setting because of the risk for injury.
Further, WAC 388-106 Long-Term Care Services stipulates that it is not within the scope of practice of a NA-R, NA-C, or HCA-C to perform foot care on a patient with diabetes or a patient with poor circulation even through the nurse delegation process. This rule applies to long-term care services administered directly or through contract by the Washington State Department of Social and Health Services (DSHS) and identified in WAC 388-106-0015.
When nurse delegation is allowed, the RN must follow the delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate routine foot and nail care to a patient with diabetes or other circulatory problems to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
No. The Washington State Board of Nursing determines that RN delegation to the NA-R/NA-C or HCA-C to perform foot and nail care is not allowed for a patient with diabetes or a patient with other conditions resulting in poor circulation in any setting because of the risk for injury.
Further, WAC 388-106 Long-Term Care Services stipulates that it is not within the scope of practice of a NA-R, NA-C, or HCA-C to perform foot care on a patient with diabetes or a patient with poor circulation even through the nurse delegation process. This rule applies to long-term care services administered directly or through contract by the Washington State Department of Social and Health Services (DSHS) and identified in WAC 388-106-0015.
- Is the registered nurse (RN) allowed to delegate suprapubic catheter care and suprapubic ostomy care to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The RN may delegate to the NA-R/NA-C or HCA-C suprapubic catheter care and suprapubic ostomy care to the NA-R/NA-C or HCA-C using clean technique of an established (well-healed) urostomy. Examples include cleaning the urostomy site and changing the pouch. The statute and WACs prohibit RN delegation of tasks that use sterile technique in all settings. When nurse delegation is allowed, the RN must follow the delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate..
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate performance of hemodialysis or peritoneal dialysis to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home-care aide-certified (HCA-C)?
-
No. The dialysis process involves processes that are not within the scope of the RN to delegate to the NA-R/NA-C or HCA-C.
- Is the registered nurse (RN) allowed to delegate application of a transcutaneous electrical nerve stimulation (TENS) unit to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
Yes. The most common type of electrotherapy is TENS. The RN may delegate the task of applying a TENS unit to the NA-R/NA-C or HCA-C. The RN must follow the delegation process outlined in RCW 18.79.260 (3)(a) to make that determination.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to those listed above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate application of a percutaneous electrical nerve stimulation (PENS) device to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
No. PENS involves the application of electrical stimulation through small needles that penetrate the skin. The RN is not allowed to delegate this task in any setting as it involves piercing the skin.
- Is the registered nurse (RN) allowed to delegate performance of laboratory tests to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The RN is allowed to delegate some laboratory tests to the NA-R/NA-C or HCA-C, with some limitations. The RN delegation laws prohibit the NA-R/NA-C or HCA-C from performing activities that involve piercing or puncturing of the skin EXCEPT for capillary blood glucose (CBG) tests. The law allows RN delegation of CBG tests to the NA-R/NA-C in any setting where health care is provided. HCA-s are only allowed to work in community-based settings*, in-home care settings, and enhanced service facilities.
There are many laboratory tests regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), called waived tests. Waived tests include those cleared by the Food and Drug Administration (FDA) for home use and tests approved for waiver under the CLIA criteria. CLIA requires that waived tests be simple and a low risk for errors. They are often called over-the-counter tests. The RN may delegate CLIA-waived laboratory tests that do not involve piercing or puncturing of the skin without an order from an authorized health care practitioner for screening purposes based on nursing assessment. CBG tests are CLIA-waived.
Examples of other CLIA-waived laboratory tests that the NA-R/NA-C or HCA-C may perform under RN delegation (that do not involve piercing or puncturing the skin) include:
- Urine dipstick tests
- Urine drug tests
- Fecal occult blood tests
- Urine pregnancy test
- Rapid strep tests
- COVID-19 rapid tests
CLIA-waived laboratory tests require the employer/facility to have a Medical Test Site Waiver (MTSW) issued by the Washington State Department of Health. This is not required if a patient is self-testing. Medical Test Site Licensing Applications | Washington State Department of Health
The RN may also delegate diagnostic laboratory tests to the NA-R/NA-C or HCA-C if they do not involve using nursing judgment or piercing/puncturing of the skin (except for CBG tests). An example is the COVID-19 polymerase chain reaction (RT-PCR). Diagnostic lab tests, such as this, require the RN to have an order from an authorized health care practitioner for screening purposes.
Examples of CLIA-waived laboratory tests that cannot be delegated to the NA-R/NA-C or HCA-C in any setting (as they involve piercing of the skin) to perform include:
- Prothrombin/international normalized ratio (PT/INR)
- Hemoglobin/Hematocrit
The RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) who delegates Clinical Laboratory Improvement Amendments of 1988 (CLIA)-waived laboratory tests to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) required (Cont.)
-
Is the registered nurse (RN) who delegates Clinical Laboratory Improvement Amendments of 1988 (CLIA)-waived laboratory tests to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) required to get a Point-of-Care Testing (POCT) certification?
It depends. CLIA-waived laboratory tests require the employer/facility to have a Medical Test Site Waiver (MTSW) issued by the Washington State Department of Health. This is not required if a patient is self-testing. In some instances, it may be required for the RN to get a CLIA-waiver if the RN owns their own business and is not working for an employer/facility.
- Is the registered nurse (RN) allowed to delegate performance of a blood glucose fingerstick to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
Yes. The RN is allowed to delegate to the NA-R/NA-C or HCA-C to obtain a capillary blood glucose (CBG) specimen, also known as a blood glucose fingerstick, and perform a Clinical Laboratory Improvements Amendments (CLIA) waived test. RN delegation of this task to the NA-R/NA-C can be done in any setting where health care services are provided. RN delegation of this task to the HCA-C can only be done in community-based settings*, in-home care settings, or enhanced service facilities.
The RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate..
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate screening/diagnostic testing to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The RN is allowed to delegate simple, non-complex, and non-invasive screening and diagnostic testing to the NA-R/NA-C or HCA-C following the nurse delegation process. Examples include:
- Electrocardiograms
- Vision screening
- Hearing screening
- Spirometry
The RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to determine if delegation is appropriate.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) the task of performing routine, non-complex screening tests, such as growth (Cont.)
-
Is the registered nurse (RN) allowed to delegate to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) the task of performing routine, non-complex screening tests, such as growth and developmental screening, vision screening, and hearing screening?
It depends. The RN may delegate to the NA-R/NA-C or HCA-C the performance of routine, non-complex screening tests, such as growth and developmental screening, vision screening, and hearing screening, if the screening does not require nursing judgment, puncturing of the skin, or sterile procedure. In all settings, the RN must follow the delegation process outlined in RCW 18.79.260 (3)(a) to make that determination.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C, in addition to those noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- In what settings Is the registered nurse (RN) allowed to delegate administration of medications to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) and home care aide-certified (HCA-C)?
-
The RN is allowed to delegate medication administration to the NA-R/NA-C or HCA-C only in community-based settings* and in-home care settings. The RN must follow the nurse delegation process. The following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate administration of injectable epinephrine to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home care settings?
-
No. The laws and rules do not allow the RN to delegate administration of injectable epinephrine to the NA-R/NA-C or HCA-C in community-based* and in-home care settings.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate administration of intranasal glucagon to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home care settings?
-
Yes. The laws and rules allow the RN to delegate administration of intranasal glucagon to the NA-R/NA-C or HCA-C in community-based* and in-home care settings. The RN must follow the delegation process. The following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate administration of injectable glucagon to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home-care aide-certified (HCA-C) in community-based* and in-home care settings?
-
No. The laws and rules do not allow the RN to delegate administration of injectable glucagon to the NA-R/NA-C or HCA-C in community-based* and in-home care settings.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate preparing or filling a medication organizer device to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home (Cont.)
-
Is the registered nurse (RN) allowed to delegate preparing or filling a medication organizer device to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home care settings?
No. The laws and rules do not allow the RN to delegate the preparing or filling of a medication organizer device in community-based* and in-home care settings.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- When administering medications, by what routes of administration is the registered nurse (RN) allowed to delegate to the NA-R/NA-C or home care aide-certified (HCA-C) in community-based* and in-home care settings?
-
The RN may delegate administration of medications to the NA-R-/NA-C or HCA-C only in community-based* and in-home care settings by the following routes:
- Topical
- Eye drops
- Ocular
- Intranasal, inhalation, aerosol
- Oral, buccal, sublingual
- Vaginal
- Rectal
- Via an enteral feeding tube
- Via a urinary catheter
- Via a tracheal cannula
- Injectable – Limited to insulin injectable medications prescribed for treatment of Diabetes Mellitus*
The RN must follow the nurse delegation process. The following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
- RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
- WAC 246-840-910: Purpose
- WAC 246-840-920: Definitions
- WAC 246-840-930: Criteria
- WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
- WAC 246-840-950: How to Make Changes to Delegated Tasks
- WAC 246-840-960: Rescinding Delegation
- WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate preparation of an intravenous (IV) solution bag and priming the IV tube to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) (Cont.)
-
Is the registered nurse (RN) allowed to delegate preparation of an intravenous (IV) solution bag and priming the IV tube to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home care settings?
No. The laws and rules do not allow the RN to delegate preparing an IV solution bag or priming the IV tube to the NA-R/NA-C or HCA-C in community-based* and in-home care settings. The Washington State Board of Nursing (WABON) interprets that these tasks may not be delegated because it involves solutions (prescription) that will be given intravenously via a device that punctures/penetrates the skin. The process requires nursing judgment and may also involve reconstituting or compounding medications.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate administration of a tuberculosis (TB) skin test to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home care settings?
-
No. The laws and rules do not allow the RN to delegate administration of a TB skin test to the NA-R/NA-C or HCA-C in community-based* and in-home care settings because the test involves puncturing the skin.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate the task of “reading” (measuring the induration) of a tuberculosis (TB) skin test to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in (Cont.)
-
Is the registered nurse (RN) allowed to delegate the task of “reading” (measuring the induration) of a tuberculosis (TB) skin test to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home care settings?
Yes. The RN may delegate the “reading” of a TB skin test to the NA-R/NA-C or HCA-C to allow for measuring the induration of the TB screening site in community-based*or in-home care settings. The RN is not allowed to delegate interpretation of the TB skin test.
Fact Sheets | Testing & Diagnosis | Fact Sheet - Tuberculin Skin Testing | TB | CDC
The RN must follow the nurse delegation process. The following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is registered nurse (RN) delegation required for the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) to apply over the counter (OTC) skin creams, body lotions, or sunscreens in a (Cont.)
-
Is registered nurse (RN) delegation required for the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) to apply over the counter (OTC) skin creams, body lotions, or sunscreens in a community-based* or in-home care setting?
It depends. The laws and rules allow the RN to delegate administration of OTC skin creams, body lotions, or sunscreens without a prescription when used for personal hygiene based on nursing assessment only in community-based* and in-home care settings to the NA-R/NA-C or HCA-C. An prescription is required from authorized health care practitioner for the RN to delegate prescription skin creams, body lotions, or sunscreens in community-based* and in-home care settings to the NA-R/NA-C or HCA-C.
It is important to understand that some products, such as lotions, soaps, cleaners, and other products used daily may be classified by the Food and Drug Administration (FDA) as a cosmetic, an OTC/non-prescription drug, or a prescription drug depending on how they are made and how they are intended to be used. For example, soaps and cleansers marked as “antibacterial” are classified as OTC/non-prescription drugs (such as dandruff shampoos, acne medications, and antibacterial soaps). Lotions, moisturizers, ointments, and creams intended to affect the structure of the body, or for therapeutic purposes, may also be identified as an OTC/non-prescription drug. Examples include sunscreens and lip balms. Products used for oral care may also be classified as an OTC/non-prescription drug (such as toothpaste with fluoride and mouthwash). See the FDA Products website for more information.
The Washington State Board of Nursing (WABON) determines that RN delegation is not required for OTC/non-prescription drugs if they are used for personal hygiene purposes. The WABON determines that RN delegation is required for the RN to delegate OTC/non-prescription drugs if used for treatment of a condition rather than for personal hygiene.
Is It a Cosmetic, a Drug, or Both? (Or Is It Soap?) | FDA
The RN must follow the nurse delegation process. The following statute and WACs are applicable to delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is registered nurse (RN) delegation required for the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) to administer dietary or herbal supplements in a community-based* or in-home care setting?
-
Recommended. It is important to know that over the counter dietary supplements are classified as food by the Food and Drug Administration (FDA). There are also prescription dietary supplements. A prescription is required by an authorized health care practitioner is required if the supplement is classified as a prescription drug.
While RN delegation is not required to give dietary or herbal supplements classified as food by the FDA, the Washington State Board of Nursing recommends the RN delegate administration of dietary or herbal supplements to the NA-R/NA-C) or HCA-C in community-based* and in-home care settings.
Questions and Answers on Dietary Supplements | FDA
The RN must follow the nurse delegation process. The following statutes and WACs are applicable to community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate helping the patient get medication refills to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in a community-based* or in-home care setting?
-
Yes. While RN delegation is allowed, RN delegation is not required for the NA-R/NA-C or HCA-C to assist the patient in calling a pharmacy to request medication refills in community-based* and in-home care settings. While delegation is not required, the Washington State Board of Nursing recommends this activity be included in the nursing care plan.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) required to delegate tasks that involve delivering medications to a patient acting as a courier to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) (Cont.)
-
Is the registered nurse (RN) required to delegate tasks that involve delivering medications to a patient acting as a courier to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in a community-based* or in-home care setting?
No. RN delegation is not required for the NA-R/NA-C or HCA-C to deliver medications acting as a courier for a patient that are properly dispensed by a pharmacist, or an authorized health care practitioner with prescriptive authority, to a patient in a community-based* or in-home care setting. A system for safe handling, storage and tracking should be in place. While RN delegation is not required, the Washington State Board of Nursing recommends this activity be included in the nursing care plan.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate administration of marijuana products that contain more than 0.3% tetrahydrocannabinol (THC) to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (Cont.)
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Is the registered nurse (RN) allowed to delegate administration of marijuana products that contain more than 0.3% tetrahydrocannabinol (THC) to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) if the patient has a medical marijuana (cannabis) authorization in community-based* and in-home care settings?
No. RN delegation is not permitted. RN delegation to administer marijuana products that contain more than 0.3% THC is not permitted in community-based* and in-home care settings. In addition, it is not within the scope of practice for health care practitioners to prescribe or use any product, including topical oils or lotions, that contain more than 0.3% of THC regardless of being medical or recreational or whether the patient provides the product. RN delegation or applying cannabis oils or lotions that contain more than 0.3% THC would constitute illegally administering a Schedule I drug.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is registered nurse (RN) delegation required for the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) to administer marijuana products that contain less than 0.3% tetrahydrocannabinol (THC) in(Cont.)
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Is registered nurse (RN) delegation required for the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) to administer marijuana products that contain less than 0.3% tetrahydrocannabinol (THC) in community-based* and in-home care settings?
No. RN delegation is not required for the NA-R/NA-C or HCA-C to administer cannabis products in community-based* and in-home care settings as long as the tetrahydrocannabinol (THC) concentration is less than 0.3% as these are considered Cannabis Health and Beauty Aids (CHABA) products (RCW 69.50.575). While RN delegation is not required, the Washington State Board of Nursing recommends use of CHABA products be included in the nursing care plan. While these products are legal for all practitioners to use in their practice, an employer or facility may impose their own restrictions relating to the administration of CHABA products.
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate administration of synthetic forms of tetrahydrocannabinol (THC) drugs approved by the Food and Drug Administration (FDA) to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) (Cont.)
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Is the registered nurse (RN) allowed to delegate administration of synthetic forms of tetrahydrocannabinol (THC) drugs approved by the Food and Drug Administration (FDA) to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home care settings?
It depends. The RN may delegate administration of FDA approved drugs, including controlled substances (Schedule II-V), to the NA-R/NA-C or HCA-C in community-based* and in-home care settings if the medication is not given by injection. Examples of synthetic forms of THC drugs approved by the FDA for use as a prescription medication include:
- Syndros® (dronabinol) – Schedule II
- Marinol® (dronabinol) – Schedule III
- Epidiolex® (cannibidiol) – Not a controlled substance
Drug Fact Sheet: Marijuana/Cannabis (dea.gov)
The RN must follow the nurse delegation process. The following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the registered nurse (RN) allowed to delegate administration of insulin injectable medications for treatment of Diabetes Mellitus to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in (Cont.)
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Is the registered nurse (RN) allowed to delegate administration of insulin injectable medications for treatment of Diabetes Mellitus to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) in community-based* and in-home care settings?
Yes. The RN is allowed to delegate administration of insulin injectable medication for the treatment of Diabetes Mellitus to the NA-R/NA-C or HCA-C only in community-based* and in-home care settings. The RN delegator must supervise the task at least every two weeks for one month, or more often as needed. The RN must follow the nurse delegation process. The following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statutes and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
- Is the school RN allowed to delegate performance of a Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 test in public and private schools, Kindergarten-Twelve (K-12) grades, to non-credentialed staff?
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Yes. The school RN is allowed to delegate POC COVID-19 CLIA-waived in public and private schools, K-12 grades to non-credentialed staff. Based on nursing assessment, the RN may delegate a COVID-19 test without an order or standing order from an authorized health care practitioner, if the test is done for screening purposes and not diagnostic purposes. For screening tests, the RN documents whether a test result is positive or negative but may not diagnose the patient with COVID-19 or any other condition. See the Registered Nurse Delegation in School Settings Advisory Opinion for more information.
Schools may have policies that require an order for these tests and other requirements (e.g., competency assessment completion and quality control testing). The school or school district must have a CLIA-waived certification:
Medical Test Sites (MTS) | Washington State Department of Health
RN Authority with COVID-19 CLIA-Waived Tests in School Settings | WABON
Testing in Schools Frequently Asked Questions | Washington State Department of Health
- Is the school registered nurse (RN) allowed to delegate performance of a polymerase chain reaction (PCR) COVID-19 test in public and private schools, Kindergarten-Twelve (K-12) grades, to non-credentialed staff?
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Yes. The school RN is allowed to delegate performance of a PCR if there is an order or standing order from an authorized health care practitioner in public and private schools, Kindergarten-Twelve (K-12) grades to non-credentialed staff. A PCR test is considered the “gold standard” for COVID-19 tests as they are more likely to detect the virus than antigen tests. A PCR is regarded as a diagnostic test instead of a screening test.
Medical Test Sites (MTS) | Washington State Department of Health
Clinical Laboratory Improvement Amendments (CLIA) | FDA
COVID-19 RT-PCR Test - Healthcare Provider Fact Sheet (fda.gov)
- Is registered nurse (RN) delegation required if a student self-tests for COVID-19 using a Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 test in public and private schools, Kindergarten-Twelve (K-12) grades?
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No. RN delegation is not required if a student self-test using a CLIA-waived COVID-19 test in public and private schools, K-12 grades. The RN can direct school staff to instruct the student to do the self-test following the COVID-19 test kit instructions, including observing the student doing a self-test, and reporting the results to the school RN. The school or school district should have policies and procedures for students to perform self-testing.
COVID-19 Self-Testing Guidance for Establishments (wa.gov)
Medical Test Sites (MTS) | Washington State Department of Health
RN Authority with COVID-19 CLIA-Waived Tests in School Settings | WABON
Testing in Schools Frequently Asked Questions | Washington State Department of Health
Point of Care Testing Guidelines (wa.gov)
RCW 74.39.050: Individuals with functional disabilities—Self-directed care. (wa.gov)
- Is the registered nurse (RN) who volunteers at the school allowed to perform Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 or polymerase chain reaction (PCR) COVID-19 tests in public and private schools, Kindergarten-Twelve (Cont.)
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Is the registered nurse (RN) who volunteers at the school allowed to perform Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 or polymerase chain reaction (PCR) COVID-19 tests in public and private schools, Kindergarten-Twelve (K-12) grades?
It depends. The RN performing a CLIA-waived or PCR COVID-19 test for students in public and private schools, K-12 grades, must have a formal written agreement or contract with the school or school district.
- Is the registered nurse (RN) who works for a private company that has the Medical Test Site (MTS) Waiver allowed to perform Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 or polymerase chain reaction (PCR) COVID-19 tests in (Cont.)
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Is the registered nurse (RN) who works for a private company that has the Medical Test Site (MTS) Waiver allowed to perform Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 or polymerase chain reaction (PCR) COVID-19 tests in public and private schools, Kindergarten-Twelve (K-12) grades?
It depends. The RN working for a private company that has an MTS waiver may perform CLIA-waived or PCR COVID-19 testing for students, in public and private schools, K-12, if there is a formal agreement or contract with the school or school district.
Medical Test Sites (MTS) | Washington State Department of Health
- What should schools do if they don’t have a registered nurse (RN) employed or contracted with the school to perform COVID-19 tests?
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For schools without an RN available to perform COVID-19 tests, an option may be to offer or provide take-home COVID-19 rapid tests or have parents/legal guardians test the student. Staff members can hand a rapid COVID-19 test to students/parents and staff for individual or self-administered use.
Testing in Schools Frequently Asked Questions | Washington State Department of Health
- Is the registered nurse (RN) who works for a county health department, or the Washington State Department of Health (WA DOH) allowed to perform Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 or polymerase chain reaction (PCR) (Cont.)
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Is the registered nurse (RN) who works for a county health department, or the Washington State Department of Health (WA DOH) allowed to perform Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 or polymerase chain reaction (PCR) COVID-19 tests in public and private schools, Kindergarten-Twelve (K-12) grades?
It depends. The RN working for a county health department or the WA DOH may perform CLIA-waived COVID-19 or PCR tests to students in public and private schools, K-12 grades, if there is a formal written agreement or contract with the school or school district.
- Is the parent or legal guardian allowed to sign a form to let non-credentialed school staff perform a Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 test or a polymerase chain reaction (PCR) COVID-19 test without registered (Cont.)
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Is the parent or legal guardian allowed to sign a form to let non-credentialed school staff perform a Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 test or a polymerase chain reaction (PCR) COVID-19 test without registered nurse (RN) delegation through the process of in loco parentis (in place of the parent) in public and private schools, Kindergarten-Twelve (K-12 grades)?
No. The school laws do not allow a parent or legal guardian to sign a form to allow a non-credentialed school staff person to perform a CLIA-waived COVID-19 test or PCR COVID-19 test to non-credentialed school staff.
- Is a student’s parent or legal guardian allowed to perform a Clinical Laboratory Improvement Amendments (CLIA)-waived test COVID-19 test in public and private schools, Kindergarten-Twelve (K-12) grades?
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Yes. The laws and rules do not prohibit a parent or legal guardian from performing a CLIA-waived COVID-19 test in public and private schools, K-12 grades. This activity would be like testing at home.
Testing in Schools Frequently Asked Questions | Washington State Department of Health
- Is the school registered nurse (RN) allowed to delegate to non-credentialed staff whom the school or facility does not employ or contract with, performance of a Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 test, (Cont)
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Is the school registered nurse (RN) allowed to delegate to non-credentialed staff whom the school or facility does not employ or contract with, performance of a Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 test, or a polymerase chain reaction (PCR) COVID-19 test in public and private schools, Kindergarten-Twelve (K-12) grades?
No. The school RN is not allowed to delegate any CLIA waived COVID-19 testing to non-credentialed individuals who are not employed as a staff member or contracted with the school or school district.
- Is the school registered nurse (RN) allowed to delegate to non-credentialed staff to perform population-based (pooled) Clinical Laboratory Improvement Amendments (CLIA)-waived or polymerase chain reaction (PCR) COVID-19 tests without the RN (Cont.)
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Is the school registered nurse (RN) allowed to delegate to non-credentialed staff to perform population-based (pooled) Clinical Laboratory Improvement Amendments (CLIA)-waived or polymerase chain reaction (PCR) COVID-19 tests without the RN assessing each person?
No. The nurse delegation process requires the RN to assess the patient before delegating tasks to non-credentialed staff and provide instructions to perform the task. This process may be done using a routine screening form specific to COVID-19 testing that does not require nursing judgment with instructions of when to notify the RN based on specific responses, questions, or clarifications.
- Does the school registered nurse (RN) need to be on the premises when non-credential staff perform Clinical Laboratory Improvement Amendments (CLIA)-waived tests or polymerase chain reaction (PCR) COVID-19 tests?
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No. The school RN does not need to be on the premises when non-credential staff perform CLIA-waived or PCR COVID-19 tests. The RN must be available to answer questions or provide additional instructions as needed.
- Is the RN allowed to delegate to non-credentialed staff in a juvenile detention center, that provides Kindergarten-Twelve (K-12) education services to juveniles, to perform Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 tests or (Cont.)
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Is the RN allowed to delegate to non-credentialed staff in a juvenile detention center, that provides Kindergarten-Twelve (K-12) education services to juveniles, to perform Clinical Laboratory Improvement Amendments (CLIA)-waived COVID-19 tests or polymerase chain reaction (PCR) COVID-19 tests?
Yes. The RN is allowed to delegate CLIA-waived COVID-19 tests or PCR COVID-19 tests to non-credentialed staff in public and private schools (K-12) provided through the Institutional Education Program/Office of Superintendents of Public Instruction (OSPI), such as in a juvenile detention center. See the Registered Nurse Delegation in School Settings for more information. Institutional Education (ospi.k12.wa.us)
- Is the nursing assistant-registered/nursing-assistant-certified (NA-R/NA-C) protected under the “Good Samaritan” law if they choose to administer injectable emergency medications such as glucagon or injectable epinephrine to a patient during hours (Cont.)
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Is the nursing assistant-registered/nursing-assistant-certified (NA-R/NA-C) protected under the “Good Samaritan” law if they choose to administer injectable emergency medications such as glucagon or injectable epinephrine to a patient during hours of employment?
RCW 4.24.300: Immunity from Liability for Certain Types of Medical Care, commonly referred to as the “Good Samaritan” law provides protection for individuals who are not compensated to provide emergency care. The NA-R/NA-C is not covered under the “Good Samaritan” law if giving care during regular employment and receiving compensation for giving this care. In addition, with limited exceptions, nurse delegation is never allowed for tasks that require piercing of the skin.
- Is an order from an authorized health care practitioner needed for the registered nurse (RN) to delegate to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) the task of performing a (Cont.)
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Is an order from an authorized health care practitioner needed for the registered nurse (RN) to delegate to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C) the task of performing a capillary blood glucose (CGB) test?
Yes. An order is required from an authorized health care practitioner to perform any activity that involves puncturing the skin as this is considered part of the definition of the practice of medicine (RCW 18.71.011). This would include a CBG such as a fingerstick test. This can be done using a standing order approved by an authorized health care practitioner.
- Is the Registered Nurse (RN) required to have a Clinical Laboratory Improvement Amendments (CLIA)-waiver to delegate performing a capillary blood glucose (CBG) test to a nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home (Cont.)
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Is the Registered Nurse (RN) required to have a Clinical Laboratory Improvement Amendments (CLIA)-waiver to delegate performing a capillary blood glucose (CBG) test to a nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
It depends. A CBG test is a CLIA-waived test. CLIA-waived tests are simple and have a low risk of error and are used for screening. The Clinical Laboratory Improvement Amendments (CLIA) of 1988 (CLIA) regulates laboratory testing for health assessment, diagnosis, prevention, or treatment of disease. CLIA-waived tests include tests cleared by the Food and Drug Administration (FDA) for home use and tests approved for waiver under the CLIA criteria. See the Medical Test Site (MTS) Licensing Applications | Washington State Department of Health website for information and requirements about obtaining a CLIA-waiver. The legal owner of the business, entity, or facility (e.g., a hospital, nursing home, school/school district, private clinic, or a home health agency) is required to obtain the CLIA waiver. The RN may be required to have the CLIA waiver if they are the owner of the business. A facility/entity CLIA-waiver can be verified on the Facility Search Website. The Washington State Board of Nursing recommends contacting the Washington State Department of Health MTS Program for additional questions about the requirements. A CLIA-waiver is not required if the patient or family members perform the test.
- Is the registered nurse (RN) allowed to delegate insulin injections subcutaneously for the treatment of Diabetes Mellitus to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
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It depends. The RN is allowed to delegate insulin injections subcutaneously for the treatment of diabetes to the NA-R/NA-C or HCA-C only in community-based settings* and in-home care settings. The RN delegator must supervise the task at least every two weeks for one month, or more often as needed. The RN must follow the nurse delegation process.
The following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate the task of performing a Clinical Laboratory Improvements Amendments (CLIA)-waived capillary blood glucose (CBG) test to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or (Cont.)
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Is the registered nurse (RN) allowed to delegate the task of performing a Clinical Laboratory Improvements Amendments (CLIA)-waived capillary blood glucose (CBG) test to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
Yes. The RN is allowed to delegate the task of performing a CLIA-waived CBG test to the NA-R/NA-C in any setting where health care services are provided. The RN is allowed to delegate the task of obtaining a CBG to the HCA-C only in community-based* and in-home care settings. An order is required from an authorized health care practitioner to perform any activity that involves puncturing the skin as this is considered part of the definition of the practice of medicine (RCW 18.71.011). The RN must follow the nurse delegation process outlined in RCW 18.79.260 (3)(a) to make that determination.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate application of a continuous glucose monitor (CGM) sensor to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
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Yes. The RN is allowed to delegate application of a CGM sensor to the NA-R/NA-C in any setting. A CGM monitors blood glucose levels using a sensor, a small wire catheter inserted under the skin. CGMs have senor applicators for insertion under the skin.
Choosing a CGM| Glucose Monitor | American Diabetes Association
The RN must follow the delegation process outlined in RCW 18.79.260 (3)(a).
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate application of an insulin pump infusion set or pod to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
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It depends. The RN is allowed to delegate application of an insulin pump infusion set or pod to the NA-R/NA-C only in only in community-based settings* and in-home care setting. The RN must follow the delegation process outlined in RCW 18.79.260 (3)(a).
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate filling of an insulin pump reservoir to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
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It depends. The RN is allowed to delegate filling of an insulin pump reservoir to the NA-R/NA-C or HCA-C only in community-based settings* and in-home care settings. The RN must follow the nurse delegation process for community-based* and in-home care settings. The following statute and WACs are applicable to delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
Is the registered nurse (RN) allowed to delegate intermittent scanning of a continuous glucose monitor (CGM) sensor using a scanning device to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide (HCA-C)?
Yes. The RN is allowed to delegate the task of performing intermitting scanning of a CGM sensor in any setting to the NA-R/NA-C or HCA-C. The RN must follow the delegation process outlined in RCW 18.79.260 (3)(a) to make the determination if nurse delegation is appropriate.
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate administration of bolus doses of insulin for food/carbohydrate coverage via an insulin pump to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The decision by the RN to delegate administration of a bolus dose of insulin for food/carbohydrate coverage must be determined by the stability and condition of the patient and whether nursing judgment and/or frequent assessments are needed. RN delegation of this task can only be done in community-based settings* and in-home care settings if it’s determined that nursing judgment and/or frequent assessments are not needed. The RN must follow the nurse delegation requirements for community-based and in-home care settings.
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-Cin addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks Close Spacing Gap
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate administration of bolus doses of insulin for food/carbohydrate coverage via an insulin pump to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The decision by the RN to delegate administration of a bolus dose of insulin for food/carbohydrate coverage must be determined by the stability and condition of the patient and whether nursing judgment and/or frequent assessments are needed. RN delegation of this task can only be done in community-based settings* and in-home care settings if it’s determined that nursing judgment and/or frequent assessments are not needed. The RN must follow the nurse delegation requirements for community-based and in-home care settings.
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-Cin addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks Close Spacing Gap
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate administration of bolus doses of insulin via an insulin pump to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The decision by the RN to delegate administration of a bolus dose of insulin for blood sugar correction must be determined by the stability and condition of the patient and whether nursing judgment and/or frequent assessments are needed. RN delegation of this task can only be done in community-based settings* and in-home care settings if it’s determined that nursing judgment and/or frequent assessments are not needed. The RN must follow the nurse delegation requirements for community-based and in-home care settings.
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-Cin addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks Close Spacing Gap
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate administration of bolus doses of insulin via an insulin pump to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The decision by the RN to delegate administration of a bolus dose of insulin for blood sugar correction must be determined by the stability and condition of the patient and whether nursing judgment and/or frequent assessments are needed. RN delegation of this task can only be done in community-based settings* and in-home care settings if it’s determined that nursing judgment and/or frequent assessments are not needed. The RN must follow the nurse delegation requirements for community-based and in-home care settings.
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-Cin addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks Close Spacing Gap
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate calibration of a continuous glucose monitoring (CGM) system to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
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It depends. The RN is allowed to delegate to the NA-R/NA-C or HCA-C routine calibration of a CGM system. The RN must follow the delegation process outlined in RCW 18.79.260 (3)(a).
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the registered nurse (RN) allowed to delegate calibration of a continuous glucose monitoring (CGM) system to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) or home care aide-certified (HCA-C)?
-
It depends. The RN is allowed to delegate to the NA-R/NA-C or HCA-C routine calibration of a CGM system. The RN must follow the delegation process outlined in RCW 18.79.260 (3)(a).
In addition, the following statute and WACs are applicable to nurse delegation in community-based* and in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
WAC 246-840-960: Rescinding Delegation
WAC 246-840-970: Accountability, Liability, and Coercion
The HCA-C is allowed to work only in community-based*, in-home care settings, and enhanced service facilities. The following statute and WACs are applicable to nurse delegation to the HCA-C in addition to the statute and WACs noted above:
RCW 18.88B.070: Nurse Delegated Tasks
WAC 246-980-130 Provision of Delegation of Certain Tasks to the HCA-C
WAC 246-980-140: Scope of Practice for Long-Term Care Workers
WAC 246-980-150: Standards of Practice
*Community-based settings include adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities (RCW 18.79.260).
- Is the school registered nurse (RN) allowed to delegate performance of a capillary blood glucose (CBG) test to non-credentialed staff in public and private schools, kindergarten-twelfth (K-12) grades?
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No. The school laws and rules do not allow the school RN to delegate performance of a CGB test to non-credentialed staff in public and private schools, K-12 grades or any other task that involves piercing the skin.
- Is the school registered nurse (RN) allowed to delegate performance of a capillary blood glucose (CBG) test to non-credentialed staff in public and private schools, kindergarten-twelfth (K-12) grades?
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No. The school laws and rules do not allow the school RN to delegate performance of a CGB test to non-credentialed staff in public and private schools, K-12 grades or any other task that involves piercing the skin.
- Is the school registered nurse (RN) allowed to delegate application of an insulin pump continuous glucose monitor (CGM) set or pod to non-credentialed staff in public and private schools, kindergarten-twelfth (K-12) grades?
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No. The school laws and rules do not allow the school RN to delegate application of an insulin pump CGM set or pod to non-credentialed staff in public and private schools, K-12 grades.
- Is the school registered nurse (RN) allowed to delegate filling of an insulin pump reservoir to non-credentialed staff in public and private schools, kindergarten-twelfth (K-12) grades?
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No. The school laws and rules do not allow the school RN to delegate filling of an insulin pump reservoir to non-credentialed staff in public or private schools, K-12 grades.
- Is the school registered nurse (RN) allowed to delegate filling of an insulin pump reservoir to non-credentialed staff in public and private schools, kindergarten-twelfth (K-12) grades?
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No. The school laws and rules do not allow the school RN to delegate filling of an insulin pump reservoir to non-credentialed staff in public or private schools, K-12 grades.
- Is the school registered nurse (RN) allowed to delegate intermittent scanning of a continuous glucose monitor (CGM) sensor using a scanning device to non-credentialed staff in public and private schools, kindergarten-twelfth (K-12) grades?
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Yes. The school RN is allowed to delegate the task of performing intermittent scanning of a CGM sensor using a scanning device to non-credentialed staff in public and private schools, K-12 grades.
- Is the school registered nurse (RN) allowed to delegate administration of bonus doses of insulin for food/carbohydrate coverage via an insulin pump to non-credentialed staff in public and private schools, kindergarten-twelfth (K-12) grades?
-
No. The school RN is not allowed to delegate administration of bolus doses of insulin for food/carbohydrate coverage via an insulin pump to non-credentialed staff in public and private schools, K-12 grades.
- Nursing Process
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- What is the registered nurse’s role in performing nursing assessment and care plan development?
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Nursing assessment may include a comprehensive nursing assessment. A comprehensive nursing assessment means the collection, analysis, and synthesis of data performed by the registered nurse used to establish a health status baseline, plan care, and address changes in a patient’s condition as defined in the National Council State Boards of Nursing (NCSBN) Model Act (2012) (PDF).
- Can the registered nurse perform a hospital, residential treatment facility, or skilled nursing facility (SNF) admission assessment?
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The nursing laws and rules do not prohibit the competent and appropriately trained registered nurse from initiating the admission of a patient to a hospital or SNF. Joint Commission Nursing Assessment standards require the registered nurse to perform the nursing assessment within twenty-four hours after admission to a hospital. The nurse should be aware that other laws and rules may apply such as facility laws and rules or the Centers for Medicare and Medicaid regulations.
- Can the registered nurse perform a pre-anesthesia assessment?
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The nursing laws and rules do not prohibit the competent and appropriately trained registered nurse from performing a pre-anesthesia assessment. It is expected that the registered nurse would complete an appropriate age-specific nursing assessment and nursing plan of care. Frequency of assessment may be determined by institutional policy, patient condition, CMS requirements, and accreditation standards. See the NCQAC's Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion for more information. The nurse should be aware that other laws and rules may apply such as facility laws and rules or the Centers for Medicare and Medicaid regulations.
- Can the registered nurse perform an Emergency Medical Treatment and Active Labor Act (EMTALA) Medical Screening Exam (MSE)?
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The EMTALA is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide MSE to each person presenting to the emergency department to determine if a medical emergency exists. MSE is beyond initial triage. EMTALA requires the assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. The EMTALA Interpretive Guidelines identify the licensed registered nurse to be considered qualified medical personnel who can perform the EMTALA MSE and circumstances where the registered nurse must consult with a physician. MSE requires a comprehensive assessment. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse's legal and individual scope of practice.
- Can the registered nurse perform a pulmonary function assessment and tests?
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It may be within the scope of practice of the competent and appropriately trained registered nurse to perform a comprehensive on on-going assessment including pulmonary function tests (PFTs). The registered nurse must be competent to do these activities. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse legal and individual scope of practice.
- Can the registered nurse perform a sports physical examination?
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The nursing laws and rules do prohibit the competent and appropriately trained registered nurse from performing a sports physical examination, making a nursing diagnosis and nursing interventions using the nursing process. Organizational policies may dictate who can perform a sports physical examination. Washington Interscholastic Activities Association (WIAA) or other voluntary nonprofit entity. The WAII Handbook identifies a Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Registered Nurse Practitioner, Physician's Assistant (PA), and Naturopathic Physician as a medical authority to perform a sports physical examination.
- Obstetrical. Gynecological, and Reproductive Care
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- Can the registered nurse apply or remove an external or internal electronic fetal monitor?
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It is within the scope of an appropriately prepared and competent registered nurse to apply or remove an external or internal electronic fetal monitor under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse may apply the internal components if necessary. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse insert a fetal spiral electrode (FSE) or an intrauterine pressure catheter (IUPC)?
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It is within the scope of an appropriately prepared and competent registered nurse to insert a FSE or IUPC under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse insert prostaglandin analogs (e.g. misoprostol or dinoprostone) into the vagina for cervical ripening or induction of labor with a viable fetus?
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It is within the scope of an appropriately prepared and competent registered nurse to insert prostaglandin into the vagina for a cervical ripening or induction of labor with a viable fetus under the direction of an authorized provider, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse insert prostaglandin into the vagina to induce abortion?
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It is within the scope of an appropriately prepared and competent registered nurse to insert prostaglandin into the vagina for a chemical abortion under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform a fetal non-stress test (NST) and an amniotic fluid index level using ultrasound?
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It is within the scope of an appropriately prepared and competent registered nurse to perform a fetal NST and amniotic fluid index level using ultrasound, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform a sterile speculum examination and obtain specimens for cytologic, such as a Papanicolaou (PAP) smear, in a pregnant patient?
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It is within the scope of an appropriately prepared and competent registered nurse to perform a vaginal examination for pregnant or non-pregnant patients, following clinical practice standards. Obtaining cytologic specimens (e.g. a PAP smear or tests for sexually transmitted diseases) may require an order from an authorized provider in order for these test to be reimbursed. The registered nurse may perform cytologic tests following standing orders. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform a vaginal examination?
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It is within the scope of an appropriately prepared and competent registered nurse to perform a vaginal examination following, clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform Assisted Reproductive Technology (ART) to treat infertility including Intrauterine Insemination (IUI)?
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It is within the scope of an appropriately prepared and competent registered nurse to perform ART procedures under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform sexual assault examinations, including using colposcopy to collect forensic evidence collection?
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It is within the scope of an appropriately prepared and competent registered nurse to perform sexual assault examinations and perform colposcopy to collect forensic evidence under the direction of an authorized provider, following clinical practice guidelines. Standing orders may be used. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. The Nursing Care Quality Assurance Commission recommends the registered nurse receive training as a Sexual Assault Nurse Examiner (SANE).
- Can the registered nurse provide epidural care during labor and delivery?
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It is within the scope of an appropriately prepared and competent registered nurse to provide epidural care under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. See the Nursing Care Quality Assurance Commission’s Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion for additional guidance and recommendations.
- Can the registered nurse read a fetal monitor strip?
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It is within the scope of an appropriately prepared and competent registered nurse to read a fetal monitor strip, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse remove a Strut Assisted Volume Implant (SAVI) applicator device?
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It is within the scope of an appropriately prepared and competent registered nurse to remove a SAVI® applicator device under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse to perform an amniotomy?
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In most clinical situations, amniotomy should be primarily performed by authorized health care practitioners since complications may necessitate emergency medical intervention. While it is not routinely recommended that the registered nurse perform an amniotomy, it is within the scope of an appropriately prepared and competent registered nurse to perform this procedure under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse use standing orders to provide birth control or to screen for, and treat, sexually transmitted diseases?
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It is within the scope of an appropriately prepared and competent registered nurse to follow standing orders to provide birth control or to screen for and treat sexually transmitted diseases. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations in using standing orders. The Public Health Nurses: Dispensing Medications/Devices for Prophylactic and Therapeutic Treatment of Communicable Diseases and Reproductive Health Advisory Opinion provides guidelines and recommendations. While this is specific to public health nurses, the general concepts apply to any setting. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Patient Abandonment
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- What is the legal definition of patient abandonment?
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The Washington State nursing laws and rules don't define patient abandonment.
The Washington State Board of Nursing (WABON) has investigated and disciplined nurses for issues surrounding the concept of abandonment as it relates to the nurse’s duty to a patient.
The WABON’s position applies to the licensed practical nurse, registered nurse, and advanced registered nurse practitioner.
Some behavior may be considered an employer-employment issue and not patient abandonment.
The American Nurses Association (ANA) defines patient abandonment as “a unilateral severance of the established nurse-patient relationship without giving reasonable notice to the appropriate person so that arrangements can be made for the continuation of nursing care by others…”
- What does the Washington State Board of Nursing (WABON) consider as patient abandonment?
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The nurse’s duty is not defined by any single event, such as clocking in or taking a report.
From the WABON standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.
The primary concern is whether the nurse's actions compromised patient safety or caused patient abandonment. The nurse must:
- Have first accepted the patient assignment, thus establishing a nurse-patient relationship, and then,
- Severed that nurse-patient relationship without giving reasonable notice to the appropriate person (e.g., supervisor, patient, contractor) so that arrangements can be made for the continuation of nursing care by others.
Failure to fulfill a nursing responsibility may result in unsafe nursing care. Failure to practice with reasonable skill and safety is a ground for disciplinary action by the WABON.
The decision to take disciplinary action is based on the facts of the individual case, and the unique circumstances of each situation, and their application to grounds for disciplinary action in the nursing laws and rules.
The concept of the nurse’s duty to promote patient safety also serves as the basis for determining behavior that could be considered unprofessional conduct.
The Board believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.
Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse’s license.
- Is it considered patient abandonment if a nurse is the sole provider of care of the patient, and no other care provider is available to relieve the nurse?
-
There are some unique circumstances about which at may be considered patient abandonment.
An example is a registered nurse with a private practice or a contract to provide care to a patient who does not arrange for another qualified care provider to continue the care, may be considered patient abandonment.
A complaint should be reported to the Washington State Board of Nursing (WABON) for possible disciplinary action.
Conduct that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.
- What is the nurse’s responsibility specific to patient abandonment?
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The Washington State Board of Nursing (WABON) holds nurses accountable to the minimum standard of care, which requires the nurse to fulfill a patient care assignment or transfer responsibility to another qualified person once a nurse has accepted an assignment.
- What are some examples of an employee-employment issue vs. patient abandonment?
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The Washington State Board of Nursing (WABON) has no jurisdiction over employers, employment-related issues or disputes.
Other laws regulating facility licensure may apply certain responsibilities to the employer for patient safety, such as developing effective patient care systems or providing adequate numbers of qualified staff.
Specific requirements for a given facility may be obtained by contacting the applicable licensing authority for the institution.
WABON believes that the following are examples of employment issues that would not typically involve violations of nursing laws and rules:
- Resignation without advance notice, assuming the nurse’s current patient care assignment and work shift have been completed.
- Refusal to work additional shifts, either “doubles” or extra shifts on days off.
- Other work-related issues, such as frequent absenteeism, tardiness, or conflicts between staff/employees.
- Not showing up for work or not calling in.
- Refusing to work all remaining scheduled shifts after resigning.
- Refusing an assignment for religious, cultural, legal, or ethical reasons.
- Not returning from a leave of absence.
- Refusing to work in an unsafe situation.
- Refusing to delegate to an unsafe caregiver.
- Refusing to give care that may harm the patient.
- Refusing to accept an assignment or a nurse-patient relationship.
- Refusing to work mandatory overtime beyond the regularly scheduled number of hours.
- Refusing to work in an unfamiliar, specialized, or “high-tech” practice area when there has been no orientation, educational preparation, or employment experience.
- Refusing to “float” to an unfamiliar unit to accept a patient assignment.
Examples of abandonment:
- Accepting the assignment and then leaving the unit without notifying a qualified person.
- Leaving without reporting to the on-coming shift.
- Leaving patients without licensed supervision (especially at a long-term care facility with no licensed person coming on duty).
- Sleeping on duty.
- Going off the unit without notifying a qualified person and arranging coverage of patients.
- Leaving in an emergency.
- Overlooking or failing to report abuse or neglect.
- Giving care while impaired.
- Giving incompetent care.
- Delegating care to an unqualified caregiver.
- Failure to perform assigned responsibilities.
- Closing a private practice without making reasonable arrangements for the patient to transfer care.
- If a nurse is assigned to see a home-bound patient daily, but did not show up for a week, notify anyone, and did not arrange for another nurse to see the patient, is this patient abandonment?
-
It is important to consider what the nurse-patient assignment involves.
Acceptance of a patient assignment may vary from setting to setting and requires a clear understanding of the workload and the agreement to provide care.
In this situation, since the nurse failed to see the patient for a week and failed to request another nurse visit, this may be considered patient abandonment.
A complaint should be reported to the Washington State Board of Nursing (WABON).
Conduct, that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.
- If it is unsafe for the nurse to provide care during an emergency or disaster, is this patient abandonment?
-
A nurse may have to choose between the duty to provide safe patient care and protecting the nurse's own life during an emergency, including but not limited to disasters, infectious disease outbreaks, acts of terrorism, active shooter incidents, and workplace violence.
All nurses must adhere to nursing laws and rules regardless of practice setting, position title, or role.
There is also no routine answer to the question, "When does the nurse's duty to a patient begin?"
The nurse's duty is not defined by any single event, such as clocking in or taking a report.
From a Washington State Board of Nursing (WABON) standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.
WABON believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.
The nurse should take steps to protect patients if there is time and use a method that does not jeopardize the nurse’s safety or interfere with law enforcement personnel.
An example is an active shooter incident. This scenario may include evacuating the area or preventing entry to a place where the active shooter is located. However, a nurse may find insufficient time to do anything but ensure their own safety during the situation, In this case, as soon as the situation has been resolved the nurse should promptly resume care of patients.
In accordance with FBI active shooter training provides, the safe and ethical response would be to maintain the safety of oneself instead of rushing to an injured party in a dangerous situation. When the immediate danger to self is over, a nurse would go to any injured person and assist in the most informed and efficient way possible.
Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse's license.The Washington State Board of Nursing (WABON) recommends that employers develop and periodically review policies and procedures to provide nurses with clear guidance and direction so patients can receive safe and effective care.
- What do I do if my employer requires me to work a double shift during a disaster, and I am already physically exhausted?
-
A nurse must accept only assignments that consider patient safety and are commensurate with the nurse’s educational preparation, experience, knowledge, physical, and emotional ability.
This is an employer-employment issue that the Washington State Board of Nursing does not have authority over.
- How does the Washington State Board of Nursing (WABON) decide whether a complaint is patient abandonment or an employee-employment issue?
-
Complaints of “patient abandonment” when it is evident from the allegation that it is an employment issue will not be investigated by WABON.
Some general factors that would be considered in investigating a complaint alleging a nurse left an assignment would include, but not be limited to:
- The extent of dependency or disability of the patient.
- Stability of the patient.
- The length of time the patient was deprived of care.
- Any harm to the patient/level of risk of harm to the patient.
- Steps taken by the nurse to notify a supervisor of the inability to provide care.
- Previous history of leaving a patient care assignment.
- Emergencies that require nurses to respond, including but not limited to disasters, disease outbreaks, and bioterrorism.
- Workplace violence, including but not limited to an active shooter situation.
- Other unprofessional conduct concerning the practice of nursing.
- The nurse's general competency regarding adherence to minimum nursing standards.
As with all allegations received by WABON, the alleged conduct by a nurse will be thoroughly investigated to determine what, if any, violations of the nursing laws and rules have occurred.
Depending upon the case analysis, actions may range from the case being closed with no findings or action, to suspension or revocation, or voluntary surrender of the nurse’s license.
If evidence of violations exists, WABON must determine what sanction is appropriate for the nurse’s license and what specific stipulation requirements will be applied.
- Can the nurse invoke “Safe Harbor” in Washington State if asked to accept an assignment that could cause the nurse to violate their duty to a patient?
-
Washington State does not have a “Safe Harbor” law.
Safe Harbor is a means by which a nurse can request a peer review committee determination of a specific situation concerning the nurse’s duty to a patient, affording nurse immunity from the board action against the nurse’s license.
- Perioperative/Surgical Nursing
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- Is certification required for the Registered Nurse (RN) to perform in the role of a Registered Nurse First Assistant (RNFA) or surgical first assistant?
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The nursing laws and rules do not require the perioperative RN to obtain certification to function in the role as a RNFA/surgical first assistant. The Washington State Board of Nursing (WABON) recommends the RN obtain the CRNFA or other equivalent certification to demonstrate training and competency. The institution may require certification and/or specific training. The WABON recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse’s scope of practice.
- Is the hospital or institution required to perform the credentialing and privileging process for the Registered Nurse (RN) to function in the role of the Registered Nurse First Assistant (RNFA)/surgical first assistant?
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The institution may require the perioperative RN to complete the credentialing and privileging process to function in the role of the RNFA. Credentialing is the process of assessing and confirming the license or certification, education, training, and other qualifications or a licensed or certified healthcare practitioner. Privileging is the process of authorizing a health care practitioner’s specific scope and content of patient care services. The nursing laws and rules do not require credentialing and privileging. Other state facility laws/rules, federal requirements/regulations (such as the Centers for Medicare & Medicaid Services), and accreditation standards (such as Joint Commission) may require certification, credentialing, and privileging of the RN performing in the RNFA role. The Washington State Board of Nursing (WABON) recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse’s scope of practice.
- Can the RN function in the role of a RNFA to perform the functions of the MUM during robotic surgery without the RNFA Certification (CRNFA) or without going through the credentialing or privileging process performed by the institution?
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Can the Registered Nurse (RN) function in the role of a Registered Nurse First Assistant (RNFA) to perform the functions of the Master Uterine Manipulator (MUM) during robotic surgery (such as hysterectomy procedures) without the RNFA Certification (CRNFA) or without going through the credentialing or privileging process performed by the institution?
Within the role of the RNFA there are specialty surgical areas that may require additional training. It is within the scope of practice of the appropriately prepared and competent RN to perform the functions in the role of a RNFA to perform the functions of the MUM. The Washington State Board of Nursing (WABON) recommends the RN the CRNFA or other equivalent certification to demonstrate training and competency. The institution may require certification and/or specific training.
The institution may require the RN to complete the credentialing and privileging process to function in the role of the RNFA. Credentialing is the process of assessing and confirming the license or certification, education, training, and other qualifications or a licensed or certified healthcare practitioner. Privileging is the process of authorizing a health care practitioner’s specific scope and content of patient care services. Other state or federal requirements/regulations and accreditation standards (such as the Centers for Medicare & Medicaid Services or Joint Commission) may require certification, credentialing, and privileging of the RN performing in the RNFA role.
The WABON recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse’s scope of practice.
- Portable Orders for Life Sustaining Treatment
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- What is a Portable Order for Life Sustaining Treatment (POLST) form?
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POLST is a set of medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals. The POLST form is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year.
The POLST concept was originally created to guide emergency medical services (EMS) personnel in emergency situations. EMS staff was not able to honor advance directives or family member instructions for no cardiopulmonary resuscitation (CPR), because EMS must follow medical orders. POLST was developed to allow EMS to honor patients' no-CPR decisions by turning them into medical orders.
POLST is intended to prevent unwanted or futile treatment, reduce patient and family suffering, and help ensure that individual's wishes regarding end-of-life care are honored. A POLST is valid in all care settings and is portable from one care setting to another. It does not replace advance directives or a durable power of attorney. It is valid with or without advance directives or durable power of attorney. In Washington, it is a bright green form (photocopies and faxes of signed POLST forms are also legal and valid) and should be located in a prominent, easily noticeable location in the home or bedside and in the medical record.
- What medical orders are included in a POLST?
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The POLST order allows patients to specify whether they desire CPR or whether they prefer to allow a natural death to occur if they are in cardiopulmonary arrest. It contains additional instructions as well, indicating if they have a pulse and/or are breathing, whether they want comfort measures only, specific limited additional interventions, or full treatment.
The POLST form is separated into four sections:
- Section A identifies what action to take if the person is not breathing and does not have a pulse (CPR/Attempt Resuscitation or DNAR (Do Not Attempt Resuscitation) (Allow Natural Death).
- Section B identifies what action to take if the person has a pulse and/or is breathing, such use of oxygen, suction, intravenous fluids, airway support, and advanced interventions such as intubation, mechanical ventilation, and other intensive care-related procedures.
- Section C includes validation and signatures.
- Section D identifies non-emergency medical treatment preferences including whether the patient should receive antibiotics, medically assisted nutrition and hydration, and dialysis.
- How should the decisions in a POLST be made?
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The patient (or surrogate decision-maker) and the health care provider should discuss information to assure the POLST reflects the patient's wishes, as expressed in an advance directive or through communications with family or others. The patient's most recent communications, made in the context of their current medical condition, are the most likely to reflect their current wishes. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. RCW 7.70.065(1)(c).
- Is POLST mandated by law?
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No. Preparing and signing a POLST is always voluntary for patients. Care providers should follow a POLST as they would follow any other medical order. Chapter 43.70.480 RCW Emergency Medical Personnel - Futile Treatment and Natural Death Directives - Guidelines requires the Washington State Department of Health to adopt guidelines and protocols for how emergency medical personnel respond for the treatment of a person with a POLST.
- Does the law provide legal immunity for health care workers who follow POLST orders?
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Currently, only emergency medical responders are protected from legal liability when following the POLST orders. However, if a POLST order reflects a patient's wishes stated in an advance directive, the caregiver honoring those wishes would have legal protection under the Natural Death Act RCW 70.122. POLST is a medical order, and caregivers should follow it according to the standard of care. According to the Washington State POLST Task Force, no healthcare provider has reported being sued for following a POLST order since POLST was established in Washington State in 2000.
- May facilities require POLST as a part of the admission process?
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No. Preparing and signing a POLST is always voluntary. The Federal Patient Self-Determination Act (PSDA) and the Joint Commission require that health care facilities take steps to educate all adult patients on their right to accept or refuse medical care. Facilities must ask on admission whether a patient has made an advance directive, maintain policies and procedures on advance directives, and provide information to patients. The PDSA prohibits providers from conditioning care on whether or not an individual has an advance directive. The PDSA definition of advance directive has been interpreted to include a variety of advance planning documents, including POLST.
- Should facilities write a new POLST for each patient or resident when they are admitted?
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Not necessarily. The patient or resident's POLST is portable, and facilities should incorporate the patient's existing POLST into their records. Facilities may adopt policies requiring a provider with privileges to counter-sign the POLST.
A POLST should be reviewed upon admission. If a POLST has a recent date (within a year generally) and no major changes to the patient's condition have happen since the signing, it is acceptable to consider a confirmation of the POLST as meeting the requirement for inquiry of advance directives on admission.
There is a section on the POLST providers may initial to indicate that a review has been conducted and no changes are required.
- What should facility policies do if a patient or resident has no POLST at the time of admission?
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If a patient or resident has no POLST at the time of admission, suggest a care planning conference to evaluate whether POLST would be appropriate. These planning conferences should include the patient's medical provider, the patient and surrogate decision-maker, and key family members. These discussions should include a review of the patient's medical history and recommendations from treating providers. A POLST should generally not be written as part of routine admission paperwork without medical professional involvement and extensive discussion.
- May facilities refuse to honor a POLST?
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Yes. The Natural Death Act RCW 70.122 allows health care facilities or personnel to refuse to participate in withholding or withdrawing life-sustaining treatment due to moral or ethical objections. Residents or patients must be informed of this policy or practice when the provider or facility becomes aware of the existence of a directive or POLST order they do not intend to honor. If an individual provider objects, the facility should try to make a willing staff member available to provide care according to the patient's POLST order. If the facility objects, it should cooperate with the patient or resident and family in finding and transferring the patient to another facility willing to honor the POLST order.
- When should a POLST be changed?
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The POLST should be reviewed if the patient is transferred from one care setting or care level to another; if there is substantial change in the patient's health status; or if the patient's or decision-maker's treatment preferences change. There is a section on the POLST providers may initial to indicate that a review has been conducted and no changes are required. RNs and LPNs may explain or review the POLST form or existing POLST with the patient or surrogate.
Discussions about the appropriateness of the POLST or making significant changes to a POLST should include the patient's medical provider, the patient and surrogate decision-maker, and key family members. These discussions should include a review of the patient's medical history and recommendations from treating providers.
Discussions should consider whether the patient has advanced dementia, osteoporosis, bleeding disorder or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient. If the patient or surrogate and provider conclude this patient should not receive CPR even in case of choking or other accident, note “DNAR-No Exceptions” in Section A of the POLST. This note should be initialed by the provider authorized to sign the POLST.
- What if a family member tells the caregiver to do CPR when the POLST says DNAR?
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A competent adult patient or the legal surrogate may always change their medical decisions and request alternative treatment. However, in an emergency situation, it may be difficult to determine whether or not the family member is the legal surrogate. Facilities should establish policies to manage legal risk in these situations.
- What is the purpose of the NCQAC POLST advisory opinion?
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The purpose of this advisory opinion is to provide guidance about POLST for advanced registered nurse practitioners (ARNPs), registered nurses (RNs), licensed practical nurses, LPNs), and nursing assistants (NAs). Advisory opinions do not have the force of law.
- May an ARNP, LPN or registered nurse (RN) follow POLST orders?
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Yes. ARNPs, LPNs and RNs may follow valid POLST orders as they would follow any other medical orders, in any setting, based on their regulatory and individual scope of practice.
- May a RN or LPN delegate POLST orders to nursing assistants or other unlicensed assistive personnel (UAP)?
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Delegation is not required for a nursing assistant to follow the CPR/DNAR POLST orders in Section A. Sections B and D of the POLST may require delegation of some tasks using the delegation process.
- May a RN, LPN or NA pronounce death?
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An ARNP, RN or LPN may pronounce death. ARNPs may file a death certification. It is not within the nursing assistant's scope of practice to pronounce death.
- What if a person stops breathing because of an accident, such as choking? Do I follow a POLST order to not give CPR?
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In most circumstances, if a person's heartbeat stops during a witnessed choking incident or other accident, perform basic first aid measures per standard training. If the person has no pulse or becomes nonresponsive, begin CPR even if the POLST says “No CPR/allow natural death.” Continue CPR until licensed staff or emergency medical responders arrive.
However, some patients may want to refuse CPR under all circumstances including choking or accidents. This may be the medically appropriate decision for patients with advanced dementia at risk for aspiration, patients with osteoporosis, or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient.
Each patient's care plan should include details specifying if the POLST DNAR order applies in all circumstances. The POLST should include a note in Section A stating “DNAR-No Exceptions” initialed by an authorized provider. Bedside caregivers and supervisors should be familiar with this detail in the patient care plan and POLST.
- What if someone starts CPR on a patient with a POLST indicating "Do Not Attempt Resuscitation"?
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If a patient's POLST order indicates no CPR, CPR should not be initiated. In the event that CPR is initiated for a person in violation of a POLST with a DNAR order, CPR should be discontinued if no pulse is detectable. This is an example of a situation where all health care providers caring for the patient must be aware of the medical orders for the patient. Facilities should establish policies to manage legal risk in such a situation.
- Prevention and Treatment of Opioid-Related Overdoses
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- What opioid antagonists are commonly prescribed to reverse the effects of opioid overdose?
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Opioid antagonists reverse the effects of an opioid overdose. Naloxone (Narcan®) is the current standard of treatment for opioid overdose. The Food and Drug Administration (FDA) approves administration by intravenous, intramuscular, or subcutaneous routes; a hand-held auto-injector (Evzio®) for intramuscular or subcutaneous injection; and, in 2018, approved the first generic naloxone hydrochloride nasal spray. These are legend drugs, and not categorized as controlled substances. Naloxone has not been shown to produce tolerance or cause physical or psychological pain. It will produce withdrawal symptoms. Severity and duration of the withdrawal relate to the dose of naloxone and the degree and type of opioid dependency. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Is the Registered Nurse required to carry naloxone?
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RCW 69.41.095 does not require the Licensed Practical Nurse to carry an opioid antagonist, such as naloxone. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Registered Nurse administer naloxone follow a standing order for a suspected opioid overdose?
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The Registered Nurse may administer an opioid antagonist following a standing order from an authorized health care practitioner. This includes following the Washington State Department of Health Statewide Standing Order to Dispense Naloxone. The Registered Nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse’s legal and individual scope of practice. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides guidance and recommendations. For more information, go to the Washington State Department of Overdose Education and Naloxone Distribution Website.
- Can the Registered Nurse carry naloxone for emergent administration for a suspected drug overdose to an unknown person?
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RCW 69.41.095 allows the Registered Nurse, or any person, to carry and administer an opioid antagonist (such as naloxone) to a person suspected of experiencing an opioid overdose in any setting. The nurse must have a valid prescription, either in the nurse’s name, in the name of an entity, in the name of a person/patient, or through a standing order. The nurse may also get a prescription from a pharmacist with a Collaborative Drug Therapy Agreement (CDTA) or use the Washington State Department of Health Statewide Standing Order to Dispense Naloxone to get as a prescription. Anyone can take this standing order to a pharmacy to get a prescription. The nurse may also get a prescription in their own name from their health care practitioner. The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Registered Nurse dispense or distribute naloxone?
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The Registered Nurse may dispense or distribute an opioid antagonist (such as naloxone) for a high-risk person, their family members, or friends following standing orders from an authorized health care practitioner. Any person or entity may lawfully possess, store, deliver, distribute, or administer an opioid overdose reversal medication with a prescription or standing order (RCW 69.41.095). The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Is the Licensed Registered Nurse required to have a special certification or specific training to prescribe, dispense, and administer naloxone for a suspected drug overdose?
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The Registered Nurse must be appropriately prepared and competent to perform the activity safely; just as in all care the nurse provides. The Washington state laws and rules do not require a specific training course or certification for naloxone. Stop Overdose.com offers education, resources, and technical assistance for individuals, professionals, and communities in Washington State who want to learn to prevent and respond to overdose and improve the health of people who use drugs. An employer or institution may have specific requirements for training or certification. The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information and training resources, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Registered Nurse get a prescription to carry and administer naloxone in a non-work setting?
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RCW 69.41.095 allows the Registered Nurse to have a prescription for an opioid antagonist (such as naloxone) in the nurse’s name to carry and administer an opioid antagonist in the non-work setting. Nurses may carry and administer an opioid antagonist in a suspected opioid overdose whether the person is a family member, friend, stranger, or a patient. The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Registered Nurse Delegation delegate to the nursing assistant to administer naloxone for a suspected opioid overdose?
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The Registered Nurse may delegate administration of an intranasal opioid antagonist (such as naloxone) only in community-based (adult family homes, assisted living facilities, and community residential programs for people with developmental disabilities), in-home care settings, and K-12 public and private schools. It is not within the Registered Nurse’s scope of practice to delegate administration of an opioid antagonist by injection in any setting. RCW 69.41.095 provides an exception to the nursing delegation laws and rules and does not require nursing delegation for a nursing assistant-registered or nursing assistant-certified to administer naloxone. The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- School Nursing
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- Can the registered nurse in the school setting delegate to non-credentialed assistive personnel to assist a student using a peak flow meter to determine the need for inhaled medications for asthma?
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It is within the scope of an appropriately trained and competent registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate the use of a peak flow meter following the student’s health care plan and the prescribed medication based on peak flow meter readings. The health care plan must include actions to take in case of an emergency situation. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.
- Can the registered nurse in a school setting delegate to non-credentialed assistive personnel to mix medications in a nebulizer chamber for administration for inhalation via mask or mouthpiece?
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It is within the scope of an appropriately trained and competent registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate preparing a medication in a nebulizer chamber for inhalation via a mask or mouthpiece following the student’s health care plan and the prescribed medication. The order falls within the category of an oral medication whether or not the mask or spacer covers the mouth or the mouth and nose. Medications ordered intranasally are not included in this category. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within his or her scope of practice.
- Can the registered nurse in a school setting delegate to non-credentialed assistive personnel to administer a range order of medications for asthma, such as one to two puffs, using an oral inhaler?
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It is within the scope of an appropriately trained and competent registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate following a range order of medications, such as administering one to two puffs, using an oral inhaler based on the prescription and specific criteria and identified in the health care plan. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within his or her scope of practice.
- Can non-credentialed assistive personnel in the school setting provide urgent or emergent care for urgent asthma episodes?
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Non-credentialed assistive personnel may assist the student in identifying emergent or urgent asthma episodes in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements). This may include using the use of a peak flow meter and administration of quick-relief medications (such as inhaled bronchodilators). The nurse must include these activities in the emergency health care plan and medication prescription/orders, including the frequency that the medication can be given, from an authorized health care practitioner. The emergency health care plan must include actions to contact emergency services as appropriate.
- Can a student have a parent-designated adult (PDA) to provide asthma-related tasks?
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RCW 28A.210 Common School Provisions: Health-Screening and Requirements does not allow an exception for a student to have a PDA to provide asthma-related tasks.
- Can the school registered nurse delegate administration of injectable glucagon to non-credentialed assistive personnel?
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The school law does not provide an exception for the registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate administration of injectable glucagon to non-credentialed assistive personnel. RCW 28A.210.330 does allow a parent to authorize a parent-designated adult (PDA) to perform this task in this setting. The law allows a school staff person to volunteer to be a PDA or the parents can select a person not employed by the school to be the PDA. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.
- Can the school registered nurse delegate the administration of intranasal glucagon powder to non-credentialed assistive personnel?
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The Food and Drug Administration (FDA) approved the first treatment for severe hypoglycemia that can be administered without an injection July 24, 2019. Baqsimi™ nasal powder. It is within the scope of the appropriately trained and competent registered nurse in the in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate this medication to non-credentialed assistive personnel. RCW 28A.210.260(5) requires a school nurse to administer intranasal medications when a licensed practical nurse or registered nurse is on the premises. RCW 28A.210.260(1)(5) allows delegation of an intranasal medication only if a licensed practical nurse or registered nurse is not on the premises to administer the medication. RCW 28A.210.330 allows a parent-designated adult (PDA) to administer an intranasal medication for diabetes. A school employee may volunteer to act as a PDA. After an intranasal spray (legend drug or controlled substance) is administered by non-credentialed assistive personnel, the employee must summon emergency medical assistance as soon as possible. The law does not stipulate which types of legend drugs or controlled substances administered intranasally, or specific conditions in which emergency medical assistance must be summoned. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.
- Can the school registered nurse delegate non-credentialed assistive personnel to perform blood glucose fingersticks?
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The school law does not provide an exception for the registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate the task of performing a blood glucose capillary stick. RCW 28A.210.330 allows a parent to authorize a parent-designated adult (PDA) to perform this task. The law allows a school staff person to volunteer to be a PDA or the parents can select a person not employed by the school to be the PDA. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.
- Can the school registered nurse delegate non-credentialed assistive personnel to obtain blood glucose readings from an implanted continuous blood glucose monitoring device?
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It is within the scope of an appropriately trained and competent registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate non-credentialed assistive personnel to obtain blood glucose readings from an implanted continuous monitoring device. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.
- Can Symjepi®, an epinephrine injection, single-dose, pre-filled syringe recently approved by the FDA, be substituted for an epinephrine autoinjector (EAI) currently allowed to be delegated to unlicensed assistive personnel (UAP) in schools?
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The Nursing Care Quality Assurance Commission does not have authority to interpret the laws governing the provision of health care in K-12, public and private schools. Chapter 28A.210.383 RCW provides that the Office of the Superintendent of Public Instruction (OSPI) and school districts have the authority to develop anaphylactic policies for schools.
The law specifies that epinephrine autoinjectors may be prescribed to be maintained by schools for use when necessary. RCW 28A.210.383(2)(a). However, it may be feasible for OSPI and school districts to develop written policies to allow a substitution for the EAI for an individual student when the substitution is permitted by the prescriber according to the student’s anaphylaxis care plan. RCW 28A.210.383(2)(b). RCW 28A.210.383(4)(b) provides: “In the event a school nurse or other school employee administers epinephrine in substantial compliance with a student's prescription that has been prescribed by an authorized health care practitioner with prescriptive authority and written policies of the school district or private school, then the school employee, the school district or school of employment, and the members of the governing board and chief administrator are not liable in any criminal action or for civil damages as a result of administering epinephrine.” (RCW 28A.210.383).
RCW 28A.210.380 and RCW 28A.210.383 specifically require the use of an “autoinjector” to administer epinephrine. Symjepi® (https://www.symjepi.com/) is not classified as an EAI. This may apply to prescriptions for individual students as well as for the school supply.
RCW 28A.210.370 allows self-administration of medications, including epinephrine, if the student meets the requirements under the treatment plan for anaphylaxis, and has a prescription from their health care practitioner. This may include self-administering epinephrine using an EAI or a prefilled medication device if authorized in the prescription.
- Can school nurses provide telehealth services to students during the coronavirus (COVID-19) emergency?
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School registered nurses or licensed practical nurse (LPN) may provide telehealth services to students during the COVID-19 emergency within their legal scope of practice. The same standards apply regardless of whether the services are provided face-to-face or through telecommunication technology.
- Can the school registered nurse delegate to unlicensed assistive personnel (UAP) using telehealth services?
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The nursing and nursing assistant laws and rules do not prohibit the registered nurse delegator from using telehealth services to initiate or provide ongoing evaluation, or supervision of delegated tasks to UAP. The nurse must use nursing judgment and consider what aspects of the initial and ongoing assessment, supervision, and evaluation need to be done face-to-face. Telehealth may not be appropriate in some circumstances. The most important consideration is whether it is safe for the patient to perform the initial and ongoing assessment, evaluation, or supervision using telehealth services following the nursing and delegation laws and rules (RCW 18.79, WAC 246-840, RCW 18.88A, WAC 246-841).
- Is the school registered nurse (RN) allowed to delegate orogastric/nasogastric (OG/NG) enteral tube feedings, irrigation/flushing, and related medication administration to a non-credentialed staff in school settings?
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Yes. The school RN is allowed to delegate OG/NG enteral tube feedings and related tasks (e.g., medication administration, irrigation/flushing of the tube) to a non-credentialed employee following the nurse delegation process in public and private schools, kindergarten-twelve (K-12) grade. The school RN must follow the nurse delegation process. Verification of OG/NG tube placement is required prior to each feeding following clinical practice standards. One method is by performing a pH test of gastric aspirates. The RN is allowed to delegate pH testing to the NA-R/NA-C or HCA-C with instructions specific to the results with what actions to take if the results are not within defined parameters. The school RN must consider the risk of complications for the specific student based on nursing assessment such as aspiration, tube malpositioning, dislodgement, refeeding syndrome, medication-related complications, insertion-site infection, agitation, and other factors to determine whether if it is safe to delegate this task to a specific non-credentialed employee.
Registered Nurse Delegation in School Settings Advisory Opinion
The school RN must verify tube placement following clinical practice standards.
Chapter 17 Enteral Tube Management - Nursing Skills - NCBI Bookshelf (nih.gov)
RCW 28A.210.255: Provision of Health Services in Public and Private schools—Employee Job Description
RCW 28A.210.260: Public and Private schools—Administration of Medication—Conditions
- Is the school registered nurse (RN) allowed to delegate reinsertion of a displaced gastrostomy tube (G-tube) in a mature stoma to non-credentialed staff in school settings?
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Yes. The RN is allowed to delegate reinsertion of a displaced G-tube for patients with a mature stoma site to non-credentialed staff in school settings. An alternative is for the RN to delegate reinsertion of a Foley catheter as a temporary measure to keep the stoma site open until the G-tube can be replaced.
Registered Nurse Delegation in School Settings Advisory Opinion
Chapter 17 Enteral Tube Management - Nursing Skills - NCBI Bookshelf (nih.gov)
Registered Nurse Delegation in School Settings Advisory Opinion
RCW 28A.210.255: Provision of Health Services in Public and Private schools—Employee Job Description
RCW 28A.210.260: Public and Private schools—Administration of Medication—Conditions
- Is the school registered nurse (RN) allowed to delegate enteral tube feeding and related tasks to non-credentialed staff in daycares, preschools, or head start programs?
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No. Other than public and private schools, kindergarten through twelve (K-12) grade, the RN is not allowed to delegate tasks to non-credentialed employees even if the daycare, preschool, or head start program is housed in the school or school district. The school RN may still provide nursing consultation and training to non-credentialed staff. The Washington State Department of Children, Youth, and Families (DCYF) retains authority regarding these programs.
Registered Nurse Delegation in School Settings Advisory Opinion
- Is the school registered nurse (RN) allowed to delegate enteral tube feeding and related tasks to the nursing assistant registered/nursing assistant certified (NA-R/NA-C) in daycares, preschools, or head start programs?
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It depends. The school RN is allowed to delegate enteral tube feedings and related tasks such as stoma care, irrigation/flushing, aspirating for residual, and venting with a syringe or venting with a gastric venting system of a gastrostomy tube (G-tube), such as Percutaneous Endoscopic Gastrostomy (PEG) tube, Jejunostomy tube (J-tube), or Jejunostomy/Gastrostomy (J-G) tube, to the NA-R/NA-C in a daycare, preschool or head start program but would not be able to delegate medication administration in these settings via an enteral tube.
Registered Nurse Delegation in School Settings Advisory Opinion
Policy, Laws and Rules | Washington State Department of Children, Youth, and Families
Chapter 17 Enteral Tube Management - Nursing Skills - NCBI Bookshelf (nih.gov)
- Is the school registered nurse (RN) allowed to delegate enteral tube feedings, related medication administration, stoma care, irrigation/flushing, aspirating for residual, and venting with a syringe or venting with a gastric venting system of a (cont.)
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Is the school registered nurse (RN) allowed to delegate enteral tube feedings, related medication administration, stoma care, irrigation/flushing, aspirating for residual, and venting with a syringe or venting with a gastric venting system of a gastrostomy tube (G-tube), such as Percutaneous Endoscopic Gastrostomy (PEG) tube, Jejunostomy tube (J-tube), or Jejunostomy/Gastrostomy (J-G) tube, to non-credentialed staff in school settings?
Yes. The school RN is allowed to delegate G-tube feedings, related medication administration, stoma care, irrigation/flushing, aspirating for residual, and venting with a syringe or venting with a gastric venting system to a non-credentialed employee in school settings following the nurse delegation process.
Registered Nurse Delegation in School Settings Advisory Opinion
The school RN must consider the condition of the G-tube (such as maturity of stoma site, patency, and sustained skin integrity) to determine whether it’s safe to delegate. Further delegation may only occur for patients with a mature stoma site. The school RN must determine the level of monitoring needed for the individual student and the level of supervision required of the non-credentialed employee. The school RN must follow clinical practice standards.
Chapter 17 Enteral Tube Management - Nursing Skills - NCBI Bookshelf (nih.gov)
Registered Nurse Delegation in School Settings Advisory Opinion
RCW 28A.210.255: Provision of Health Services in Public and Private schools—Employee Job Description
RCW 28A.210.260: Public and Private schools—Administration of Medication—Conditions
- What circumstances would be considered unsafe for the registered nurse in a school setting to delegate to non-credentialed assistive personnel asthma-related tasks?
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The following would be considered unsafe situations in which to delegate to non-credentialed assistive personnel asthma-related tasks in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements):
- Newly diagnosed students with moderate to severe asthma, and the health care plan has not been written or approved;
- Medically fragile student with health complications or multiple health problems that require nursing assessments before performing any authorized task;
- Student with a history of non-compliance with treatment plans;
- Student who has been authorized to function independently by the health care provider, but cannot consistently demonstrate competence in asthma-related tasks in the school setting. These students should be referred back to the health care provider for further evaluation before delegating care to non-credentialed assistive personnel.
- What criteria should the school nurse consider in determining whether it is safe and appropriate to delegate asthma-related tasks to non-credentialed assistive personnel?
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The school nurse should use professional judgment and consider the following criteria to determine safe and appropriate delegation of asthma-related tasks to non-credentialed assistive personnel in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements):
- A health care plan and emergency care plan written by the school registered nurse in collaboration with the parent/guardian should be in place.
- The school registered nurse has received written orders related to the frequency of administration of bronchodilators, or other asthma-related medications, and any emergency orders.
- The delegated non-credentialed assistive personnel is competent to perform delegated asthma-related tasks.
- The delegated non-credentialed assistive personnel is certified in cardiopulmonary resuscitation (CPR) and first aid (strongly recommended).
- The parents/guardians have provided the school/school nurse with the necessary equipment and supplies to perform delegated asthma-related tasks.
- The parents/guardians have provided the school/school nurse with the required authorization forms and emergency information.
- Consider the following when delegating non-credentialed assistive personnel to monitor or provide emergency assistance to a student prepared to perform some or all of the asthma-related tasks independently:
- Documentation from the health care provider indicating the student’s level of independent functioning;
- Nursing documentation that the student has demonstrated competence in determining the need for assistance and use of medication administration devices and/or bronchodilator use;
- Assurance the student will follow school policies and safety procedures
- Standing Orders, Verbal Orders, Electronic Orders, Triage, and Case Management
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- Can the registered nurse follow standing orders or verbal orders?
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The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from following a standing order or obtaining and carrying out a verbal order that is non-complex and routine. Standing orders and verbal orders may include medical orders or nursing orders. The licensed practical nurse may assist an authorized provider or registered nurse in carrying out a complex standing order or verbal order. The licensed practical nurse must be competent to carry specific steps identified in the standing order or verbal order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
- Can the registered nurse take verbal or telephone orders?
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The nursing laws and rules do not explicitly prohibit the registered nurse from taking a verbal or telephone order. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
- Can the registered nurse accept a verbal or written order from a physician relayed through an unlicensed person or an order that has been electronically transmitted?
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The laws and rules do not prohibit the registered nurse from accepting an order from an authorized medical provider through an unlicensed or licensed person. The registered nurse should use nursing judgment and determine whether additional verification or clarification is required. The laws and rules place accountability on the nurse who is implementing the order to implement or clarify that the order is accurate, valid, properly authorized, and is not harmful or potentially harmful to the patient, or is not contraindicated by documented information. The implementing the order is required to see clarification of the order when the registered nurse believes, or has any reason to believe one, of these contraindications exists, and to take any other action necessary to assure the safety of the patient.
- Can the registered nurse call in medication ordered by an authorized provider to a pharmacy?
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The laws and rules do not prohibit the registered nurse from calling in a medication order from an authorized medical provider. The registered nurse should use nursing judgment and determine whether additional verification or clarification is required. The laws and rules place accountability on the nurse who is implementing the order to implement or clarify that the order is accurate, valid, properly authorized, and is not harmful or potentially harmful to the patient, or is not contraindicated by documented information. Implementing the order is required to see clarification of the order when the registered believes or has any reason to believe one of these contraindications exists, and to take any other action necessary to assure the safety of the patient.
- Can the registered nurse work as a case manager or care coordinator independently?
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The nursing laws and rules do not prohibit the competent and appropriately trained registered nurse from working as a case manager or care coordinator. The registered nurse practices nursing care independently and do not require supervision or oversight from an authorized health care practitioner. The registered nurse must practice within his or her legal scope of practice.
- Can the registered nurse triage a patient or perform a Medical Screening Exam (MSE)?
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The competent and appropriately trained registered nurse can perform triage activities within the nurse’s scope of practice or under the direction of an authorized health care practitioner – this may include following standing orders. The registered nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.
The EMTALA is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide a MSE to each person presenting to the emergency department to determine if a medical emergency exists. MSE is beyond initial triage. EMTALA requires the assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. The EMTALA Interpretive Guidelines identify the licensed registered nurse to be considered qualified medical personnel who can perform the EMTALA MSE and circumstances where the registered nurse must consult with a physician. MSE requires a comprehensive assessment. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.
All nurses in Washington State are required to complete a suicide prevention training course from an approved list. For more information, see the Washington State Department of Health’s Suicide Prevention Training for Health Professionals Approved Courses.
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- Telehealth and Telemedicine Training Requirements
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- Can the registered nurse delegator use telehealth services to provide ongoing evaluation and supervision of delegated tasks to unlicensed assistive personnel (UAP) in community-based, or in home care settings?
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The nursing and nursing assistant laws and rules do not prohibit the registered nurse delegator from using telehealth services to initiate or provide ongoing evaluation, or supervision of delegated tasks to UAP. The nurse must use nursing judgment and consider what aspects of the initial and ongoing assessment, supervision, and evaluation need to be done face-to-face. Telehealth may not be appropriate in some circumstances. The most important consideration is whether it is safe for the patient to perform the initial and ongoing assessment, evaluation, or supervision using telehealth services following the nursing and delegation laws and rules (RCW 18.79, WAC 246-840, RCW 18.88A, WAC 246-841).
- Can the registered nurse licensed in another state that works for a health insurance company provide nursing case management to a patient in Washington State without a Washington State nursing license?
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The registered nurse licensed in another state would not be able to provide nursing services, including case management services to patients in Washington State without a Washington State nursing license.
- Can the registered nurse licensed in Washington State provide nursing case management to a patient in another state if the nurse does not have a license in that state?
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Washington State does not have authority to define licensing requirements or scope of practice requirements in other states or countries. The registered nurse should contact that state to find out if the nurse needs a license in that state or country to provide nursing care.
- Is a registered nurse (RN), licensed practical nurse (LPN), or Advanced Registered Nurse Practitioner (ARNP) required to take telemedicine training?
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Yes, licensed nurses (RN, LPN, or ARNP) in Washington state are required to take telemedicine training if the nurse provides telemedicine services. RCW 43.70.495 requires the nurse who provides clinical services through telemedicine independently or under the direction of an authorized health care practitioner to complete telemedicine training. “Telemedicine” as defined in RCW 70.41.020(13) means, “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment [but] does not include the use of audio-only telephone, facsimile, or email.”
The Washington State Telehealth Collaborative uses the following slightly different Medicaid definition of telemedicine in the training:
“Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.” WAC 182-531-1730(1). It does not include “the use of audio-only telephone, facsimile, or email.”
- Does the training requirement apply to a nurse who provides telephone triage?
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No, the telemedicine training requirement does not apply to audio-only telephone (telephone triage), facsimile, or email. However, the Nursing Care Quality Assurance Commission (NCQAC) recommends licensed nurses complete the telemedicine training if they provide services such as; telephone triage, remote patient monitoring (“RPM”, which enables recording and monitoring health data remotely), asynchronous telehealth (such as Store and Forward technology that allows patient data to be collected, stored, and later retrieved by another professional), Mobile Health (“mHealth,” using smart devices such as smartphones and smart wearables that allow continuous data collection about a person's behavior or condition) or other types of telehealth. The telemedicine training provides a valuable overview of the roles, responsibilities, liability, and legal requirements when providing telehealth services.
- Does the nurse need to send in the certification to the Nursing Care Quality Assurance Commission (NCQAC)?
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The law, RCW 43.70.495, requires the nurse to sign and retain an attestation of completion. The nurse does not need to send the attestation or documentation to the NCQAC unless requested.
- When is completion of telemedicine training required?
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The Nursing Care Quality Assurance Commission (NCQAC) recommends telemedicine training be completed as soon as possible as a demonstration of competency. The licensed nurse (RN, LPN, or ARNP) providing telemedicine clinical services licensed prior to January 1, 2021, will need to complete telemedicine training by December 31, 2021. The newly licensed RN, LPN, or ARNP or the RN, LPN, or ARNP licensed through the endorsement process who provides clinical services will need to meet the requirement one year after the initial license is issued. The Nursing Care Quality Assurance Commission (NCQAC) recommends all Washington nurses complete the telemedicine training as a demonstration of competence as soon as practical to provide an overview of the roles, responsibilities, liability, and legal requirements for providing telehealth services.
- Does telemedicine training taken prior to January 1, 2021 meet the telemedicine training requirement?
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Telemedicine training taken prior to January 1, 2021, meets the requirement if it includes the content defined in RCW 43.70.495(2). The RN must be appropriately trained and competent to provide nursing telehealth services. To learn more about the different training options available and access additional resources, see the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training website.
- What are the options to meet telemedicine training requirements?
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To learn more about the different training options available and access additional resources, see the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training website.
- Does the training requirement apply to a nurse who provides Virtual Directed Observed Therapies (VDOT) for tuberculosis treatment?
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VDOT is the use of a videophone or other video/computer equipment to observe client’s taking their medications remotely.
Using synchronous and asynchronous VDOT for tuberculosis treatment adherence is occurring across the United States and in Washington State.
- The nurse providing synchronous (real-time audio and video) VDOT is required to take the telemedicine training.
- The nurse providing asynchronous (store-and-forward) VDOT is not required to take the training, but NCQAC recommends all nurses take the training.
For more information go to the Washington State Department of Health Tuberculosis Website (this site is accessible only to LHJs at this time).
- Urological and Hemodialysis
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- Can the registered nurse perform bladder instillation therapy?
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It is within the scope of practice of an appropriately prepared and competent registered nurse to perform bladder instillation therapy under the direction of an authorized health care practitioner, following clinical practice standards. Examples include instillation of dimethyl sulfoxide (DSMO), chemotherapy (e.g. Mitomycin C), and Bacillus Calmette-Guérin (immunotherapy) drugs. There must be an order from an authorized provider. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform hemodialysis in the home setting?
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It is within the scope of practice of an appropriately prepared and competent registered nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, following clinical practice standards. The procedure may be performed in a home setting or an in-center setting. A prescription or order from an authorized provider is required. This includes preparing and monitoring the dialysis machine, accessing an arteriovenous (AV) fistula or graft or a central venous catheter, initiating or discontinuing hemodialysis, collecting specimens, catheter site care, and performing tubing or adaptor changes. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse perform peritoneal dialysis?
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It is within the scope of practice of an appropriately prepared and competent registered nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, following clinical practice guidelines. A prescription or order from an authorized health care practitioner is required. This includes initiating or discontinuing therapy using pre-mixed medicated peritoneal dialysis bags, collecting specimens, catheter site care, and performing tubing or adaptor changes. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Can the registered nurse replace a suprapubic catheter?
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It is within the scope of practice of an appropriately prepared and competent registered nurse to replace a suprapubic in an established tract under the direction of an authorized health care practitioner, following clinical practice standards. There must be an order from an authorized provider. In general, the first change in a non-established tract is usually done by an authorized provider. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.
- Is it acceptable practice for the registered nurse to withhold medications prior to dialysis without an order from an authorized provider?
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Withholding medications, primarily anti-hypertensives, prior to dialysis is not uncommon. Due to the frequent tendency for patients to become hypotensive during treatment, and also the “pulling off” of medications during the dialysis procedure, nurses often withhold medications. It has often been considered a ‘community practice’ and has been taken for granted that medications could be withheld whether written orders by an authorized health care practitioner are obtained or not. Then the withheld medications are given post dialysis, usually with communication to the provider on the patient’s tolerance and outcomes for a successful dialysis and the provider’s determination of the next dialysis. It is not acceptable for the registered nurse to routinely withhold any medication prior to dialysis without an order from an authorized provider. This order may be written for an individual patient or through a standing order. The NCQAC’s Standing Orders and Verbal Orders Advisory Opinion and Verbal Orders provides additional guidance and recommendations.
Nurse Technician (NTEC)
- Prevention and Treatment of Opioid-Related Overdoses
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- What opioid antagonists are commonly prescribed to reverse the effects of opioid overdose?
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Opioid antagonists reverse the effects of an opioid overdose. Naloxone (Narcan®) is the current standard of treatment for opioid overdose. The Food and Drug Administration (FDA) approves administration by intravenous, intramuscular, or subcutaneous routes; a hand-held auto-injector (Evzio®) for intramuscular or subcutaneous injection; and, in 2018, approved the first generic Naloxone Hydrochloride nasal spray. These are legend drugs, and not categorized as a controlled substance. Naloxone has not been shown to produce tolerance or cause physical or psychological pain. It will produce withdrawal symptoms. Severity and duration of the withdrawal relate to the dose of naloxone and the degree and type of opioid dependency. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Is the Nursing Technician required to carry naloxone?
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RCW 69.41.095 does not require the Nursing Technician to carry an opioid antagonist, such as naloxone. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Nursing Technician administer naloxone to a patient who has a prescription for a suspected opioid overdose?
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The Nursing Technician may administer an opioid antagonist (such as naloxone) by injection or by the intranasal route. The Nursing Technician must have a valid prescription, either in the Nursing Technician's name, in the name of an entity, in the name of a person/patient, or following a standing order approved by an authorized health care practitioner. For more information, go to the Washington State Department of Overdose Education and Naloxone Distribution Website.
- Can the Nursing Technician carry naloxone for emergent administration for suspected overdose and administer it to an unknown person?
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RCW 69.41.095 allows the Nursing Technician, or any person, to carry and administer an opioid antagonist (such as naloxone) to a person suspected of experiencing an opioid overdose in any setting. The Nursing Technician must have a valid prescription, either in the Nursing Technician's name, in the name of an entity, in the name of a person/patient, or following a standing order approved by an authorized health care practitioner.
- Can the Nursing Technician get a prescription for Naloxone?
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The Nursing Technician may get a prescription from a pharmacist with a Collaborative Drug Therapy Agreement (CDTA), or use the Washington State Department of Health Statewide Standing Order to Dispense Naloxone. Anyone can take this standing order to a pharmacy to get a prescription. The Nursing Technician may also get a prescription in their own name from their health care practitioner. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Nursing Technician distribute naloxone?
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RCW 69.41.095 allows the Nursing Technician with a prescription, or following standing orders, to possess, store, deliver, distribute, or administer an opioid antagonist (such as naloxone) to a person at risk of experiencing an opioid related overdose. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Is the Nursing Technician required to have a special certification or specific training to distribute or administer naloxone for a suspected drug opioid overdose?
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The Nursing Technician is not required to have a specific training course or certification. Stop Overdose.com offers education, resources, and technical assistance for individuals, professionals, and communities in Washington State who want to learn to prevent and respond to overdose and improve the health of people who use drugs. An employer or institution may have specific training or certification requirements. For more information and training resources, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Nursing Technician get a prescription to carry and administer naloxone in a non-work setting?
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RCW 69.41.095 allows the Nursing Technician to have a prescription for an opioid antagonist (such as naloxone) in the Nursing Technician's name to carry and administer in the non-work setting. The Nursing Technician may carry and administer an opioid antagonist in a suspected opioid overdose whether the person is a family member, friend, stranger, or a patient. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Is direct supervision by the Nurse Technician's supervising nurse required for the Nurse Technician to administer naloxone to a patient for a suspected opioid overdose?
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RCW 69.41.095 provides an exception to the nursing delegation laws and rules and does not require the Nurse Technician's supervising nurse to provide direct supervision for a Nurse Technician to administer naloxone. The Nurse Technician assistant may administer an opioid antagonist (such as naloxone) to an assigned patient by intranasal spray or injection without direct supervision. This may be done for the patient with a prescription, using an entity's prescription, or using the Nurse Technician's personal naloxone prescription. Any person or entity may lawfully possess, store, deliver, distribute, or administer an opioid overdose reversal medication with a prescription or standing order. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Telemedicine Training Requirements
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- Is the nursing technician (NT) required to take telemedicine training?
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The NT is not required to take telemedicine training. It is not within the scope of practice of the NT to function as the clinical provider for the purpose of diagnosis, consultation, or treatment. The NT must function under the direction and supervision of the registered nurse who agrees to act as a supervisor of the NT. The NT may function in the role of telepresenter to facilitate the visit including supporting communications, clinical (within their scope of practice), and technical workflows through the tele-encounter process.
RCW 43.70.495 requires health care professionals who provide clinical services through telemedicine independently or under the direction of an authorized health care practitioner to complete telemedicine training. “Telemedicine” as defined in RCW 70.41.020(13) means, “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment [but] does not include the use of audio-only telephone, facsimile, or email.”
Nursing Assistant (NA)
- Nursing Delegation
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- Is the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) required to have current cardiopulmonary resuscitation (CPR) and first aid certification, and if so, what type of CPR (Health Care Provider or Basic Life Support)?
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CPR is considered a basic core competency for the NA-R/NA-C, but the type of CPR and first aid certification is not specified in Chapter 246-841A WAC. The requirement for CPR is generally described in facility laws and rules. Most do not specify what type of CPR. The employer or institution can require the type of CPR required to work in a particular setting.
- Can the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) perform cardiopulmonary resuscitation (CPR) independently?
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Yes. Chapter 246-841A WAC describes the core competencies of the NA-R/NA-C, that includes allowing the NA-R/NA-C to perform CPR independently.
- Can the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) perform the Heimlich maneuver for choking independently?
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Yes. Chapter 246-841A WAC describes the core competencies of the NA-R/NA-C, that includes allowing the NA-R/NA-C to perform the Heimlich maneuver independently.
- Can the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) follow instructions in the Portable Order for Life Sustaining Treatment (POLST) independently?
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It depends. The NA-R/NA-C may independently follow instructions in Section A of the POLST Form indicated “CPR/Attempt Resuscitation” or “Do Not Attempt Resuscitation (DNAR) – Allow Natural Death” when a patient is non-responsive or has no heartbeat. The NA-R/NA-C may follow directions in section B of the POLST Form within their core competencies (Chapter 246-841A WAC) under the direction and supervision of the RN or LPN. Some tasks (not in the NA-R/NA-C’s core competencies) identified in Section B of the POLST Form may require RN delegation (e.g., tube feedings, selective medications, oxygen administration, continuous positive airway pressure (CPAP) procedures, or airway suctioning). See the Portable Order for Life Sustaining Treatment (POLST) Advisory Opinion and the Portable Orders for Life Sustaining Treatment (POLST) | Washington State Department of Health Website for more information.
- Can the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) administer injectable epinephrine?
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It depends. The laws and rules do not permit the registered nurse (RN) to delegate administration of injectable epinephrine to the NA-R/NA-C in any setting. However, the NA-R/NA-C may administer epinephrine if the facility or employer is an “authorized entity” pursuant to RCW 70.54.440. This statute allows authorized facilities or employers to obtain stock epinephrine injectors with a prescription in the name of the entity and identify employees, who have completed required training, to administer epinephrine via autoinjectors. See the Washington State Department of Health’s Epinephrine Autoinjectors and Anaphylaxis Training and Reporting for Authorized Entities Frequently Asked Questions for more information.
- Is the registered nurse (RN) allowed to delegate to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) administration of injectable glucagon?
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No. The laws and rules do not permit the RN to delegate administration of injectable glucagon to NA-R/NA-C in any setting.
- Is the registered nurse (RN) allowed to delegate to the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) administration of intranasal glucagon?
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Yes, in some settings. The laws and rules allow the RN to delegate administration of intranasal glucagon to NA-R/NA-C only in community-based (adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities) and in-home care settings.
The following statute and WACs are applicable to nurse delegation in community-basedand in-home care settings:
RCW 18.79.260: Registered Nurse—Activities Allowed—Delegation of Tasks
WAC 246-840-940: Community-Based and In-Home Care Nursing Delegation Decision Tree
WAC 246-840-950: How to Make Changes to Delegated Tasks
- Can the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) give injectable naloxone for a suspected opioid drug overdose?
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Yes. Although the laws and rules do not allow the registered nurse to delegate injectable naloxone for a suspected opioid drug overdose to the NA-R/NA-C, the NA-R/NA-C may administer injectable naloxone to anyone that they suspect is having an opioid overdose in any setting (RCW 69.41.095) when prescribed by an authorized health care practitioner. See the Washington State Board of Nursing’s Prevention and Treatment of Opioid-Related Overdoses Advisory Opinion and the Overdose Prevention, Recognition, and Response | Washington State Department of Health Website for more information.
- Can the nursing assistant-registered/nursing assistant-certified (NA-R/NA-C) give intranasal naloxone for a suspected opioid drug overdose?
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Yes. The NA-R/NA-C the NA-R/NA-C may administer intranasal naloxone to anyone that they suspect is having an opioid overdose in any setting (RCW 69.41.095) without registered nurse (RN) delegation when prescribed by an authorized health care practitioner. Administration of intranasal naloxone may also be delegated (although it is not required) by the RN in community-based (adult family homes, assisted living facilities, and residential homes for individuals with developmental disabilities) and in-home care settings, because in these settings the RN may delegate medication administration if it does not involve puncturing of the skin. See the Washington State Board of Nursing’s Prevention and Treatment of Opioid-Related Overdoses Advisory Opinion and the Overdose Prevention, Recognition, and Response | Washington State Department of Health Website for more information.
- Is the nursing assistant-registered/nursing-assistant-certified (NA-R/NA-C) protected under the “Good Samaritan” law if they choose to administer injectable emergency medications such as glucagon or injectable epinephrine to a patient during hours (cont.)
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Is the nursing assistant-registered/nursing-assistant-certified (NA-R/NA-C) protected under the “Good Samaritan” law if they choose to administer injectable emergency medications such as glucagon or injectable epinephrine to a patient during hours of employment?
RCW 4.24.300: Immunity from Liability for Certain Types of Medical Care, commonly referred to as the “Good Samaritan” law provides protection for individuals who are not compensated to provide emergency care. The NA-R/NA-C is not covered under the “Good Samaritan” law if giving care during regular employment and receiving compensation for giving this care. In addition, with limited exceptions, nurse delegation is never allowed for tasks that require piercing of the skin.
- Portable Orders for Life Sustaining Treatment
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- What is a Portable Order for Life Sustaining Treatment (POLST) form?
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POLST is a set of portable medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals.
POLST is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year. Advanced care planning is thoughtful conversations between health care professionals, the patient and/or surrogate.
It is within the scope of the appropriately prepared and competent LPN to discuss end-of-life care with the patient or surrogate under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse (RN).
For more information and resources on POLST, go to:
- Advisory Opinion: Portable Order for Life Sustaining Treatment (POLST) (PDF)
- DOH: Portable Orders for Life Sustaining Treatment (POLST)
- WSMA: Advance Care Planning
- WSMA: POLST Form & Brochure
- May a nursing assistant follow a POLST order stating DNAR?
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Yes. Nursing Assistants may follow the CPR/DNAR order in Section A of the POLST. Nursing assistants and other non-credentialed UAP may use nursing judgment in emergency situations. A patient without a heartbeat, even if death is expected, is in an emergency situation. A nursing assistant with appropriate training may assess the patient's vital signs and decide if a heartbeat is present. If there is no heartbeat, a nursing assistant may follow a patient's POLST order Section A to start CPR or to provide comfort measures and allow a natural death, depending on the patient's POLST.
- May a nursing assistant follow orders in Sections B and D of POLST?
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Section B of a POLST include orders on medical interventions, including use of oxygen, suction, IV fluids, airway support and advanced interventions such as intubation, mechanical ventilation, and other intensive care-related procedures. Section D includes non-emergency treatment decisions including whether the patient should receive antibiotics, medically assisted nutrition and hydration, and dialysis. Some of these POLST orders may indicate medical interventions outside the scope of a nursing assistant. Specific activities may require delegation of certain medical interventions identified in the POLST sections B and D, depending on the task, equipment available, and competency of the nursing assistant.
- What training about POLST is available for nursing assistants and unlicensed assistive personnel?
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The Washington State Department of Social and Health Services (DSHS) and POLST stakeholders have developed a short training video for home care aides and other bedside caregivers. The video includes instruction on how these staff should respond when they find a resident who is nonresponsive. This video will be part of a continuing education program which DSHS plans to approve in 2015.
- May nursing assistants perform nursing activities that require nursing judgment?
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Yes. Nursing assistants and other UAP may perform activities that require nursing judgment only in emergency situations. When a patient has no heartbeat, it is an emergency situation in which a nursing assistant may use nursing judgment to follow a POLST order to either perform CPR or to provide comfort care while allowing natural death to occur.
- In many community settings (i.e. assisted living facilities) personal care may be given by nursing assistants without nurse direction or supervision. Can a nursing assistant follow POLST instructions if a nurse is not directing and supervising the care?
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An individual is working under their nursing assistant credential only when being directed and supervised by a nurse. In situations where the nurse is not directing and supervising the care, the individual is not working under the nursing assistant credential. The employer or facility should have policies and procedures in place to address this situation.
- What should nursing assistants do if they find a patient who is non-responsive or has no heartbeat?
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- They should call the nursing supervisor, 911, or hospice for emergency help, and stay with the patient. This plan should be made in advance as part of the patient plan of care.
- If the POLST says DNAR, nursing assistants should not initiate CPR. They should provide comfort care and wait for assistance to arrive.
- If the POLST says CPR/Attempt Resuscitation, nursing assistants should begin CPR and continue until help arrives.
- Prevention and Treatment of Opioid-Related Overdoses
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- What opioid antagonists are commonly prescribed to reverse the effects of opioid overdose?
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Opioid antagonists reverse the effects of an opioid overdose. Naloxone (Narcan®) is the current standard of treatment for opioid overdose. The Food and Drug Administration (FDA) approves administration by intravenous, intramuscular, or subcutaneous routes; a hand-held auto-injector (Evzio®) for intramuscular or subcutaneous injection; and, in 2018, approved the first generic Naloxone Hydrochloride nasal spray. These are legend drugs, and not categorized as a controlled substance. Naloxone has not been shown to produce tolerance or cause physical or psychological pain. It will produce withdrawal symptoms. Severity and duration of the withdrawal relate to the dose of naloxone and the degree and type of opioid dependency. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Is the Nursing Assistant required to carry naloxone?
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RCW 69.41.095 does not require the Nursing Assistant to carry an opioid antagonist, such as naloxone. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Nursing Assistant administer naloxone to a patient who has a prescription for a suspected opioid overdose?
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The Nursing Assistant may administer an opioid antagonist (such as naloxone) by injection or by the intranasal route. The Nursing Assistant must have a valid prescription, either in the Nursing Assistant's name, in the name of an entity, in the name of a person/patient, or following a standing order approved by an authorized health care practitioner. For more information, go to the Washington State Department of Overdose Education and Naloxone Distribution Website.
- Can the Nursing Assistant carry naloxone for emergent administration for suspected overdose and administer it to an unknown person?
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RCW 69.41.095 allows the Nursing Assistant, or any person, to carry and administer an opioid antagonist (such as naloxone) to a person suspected of experiencing an opioid overdose in any setting. The Nursing Assistant must have a valid prescription, either in the Nursing Assistant's name, in the name of an entity, in the name of a person/patient, or following a standing order approved by an authorized health care practitioner.
- Can the Nursing Assistant get a prescription for naloxone?
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The Nursing Assistant may get a prescription from a pharmacist with a Collaborative Drug Therapy Agreement (CDTA), or use the Washington State Department of Health Statewide Standing Order to Dispense Naloxone. Anyone can take this standing order to a pharmacy to get a prescription. The Nursing Assistant may also get a prescription in their own name from their health care practitioner. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Nursing Assistant distribute naloxone?
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RCW 69.41.095 allows the Nursing Assistant with a prescription, or following standing orders, to possess, store, deliver, distribute, or administer an opioid antagonist (such as naloxone) to a person at risk of experiencing an opioid related overdose. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Is the Nursing Assistant required to have a special certification or specific training to distribute or administer naloxone for a suspected drug opioid overdose?
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The Nursing Assistant is not required to have a specific training course or certification. Stop Overdose.com offers education, resources, and technical assistance for individuals, professionals, and communities in Washington State who want to learn to prevent and respond to overdose and improve the health of people who use drugs. An employer or institution may have specific training or certification requirements. For more information and training resources, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Nursing Assistant get a prescription to carry and administer naloxone in a non-work setting?
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RCW 69.41.095 allows the Nursing Assistant to have a prescription for an opioid antagonist (such as naloxone) in the Nursing Assistant's name to carry and administer in the non-work setting. The Nursing Assistant may carry and administer an opioid antagonist in a suspected opioid overdose whether the person is a family member, friend, stranger, or a patient. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Is Registered Nursing Delegation required for the Nursing Assistant to administer naloxone to a patient for a suspected opioid overdose?
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RCW 69.41.095 provides an exception to the nursing delegation laws and rules and does not require Registered Nursing delegation to the Nursing Assistant to administer naloxone. The Nursing Assistant may administer an opioid antagonist (such as naloxone) to an assigned patient by intranasal spray or injection without delegation. This may be done for the patient with a prescription, using an entity's prescription, or done using the Nursing Assistant's personal naloxone prescription. Any person or entity may lawfully possess, store, deliver, distribute, or administer an opioid overdose reversal medication with a prescription or standing order. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Telemedicine Training Requirements
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- Is the Nursing Assistant required to take telemedicine training?
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The nursing assistant-registered (NA-R)/nursing assistant-certified (NA-C) is not required to take telemedicine training. It is not within the scope of practice of the NA-R/NA-C to function as a clinical provider for the purpose of diagnosis, consultation, or treatment. The NA-R/NA-C must function under the direction and supervision of a nurse. The NA-R/NA-C may function in the role of telepresenter to facilitate the visit including supporting communications, clinical (within their scope of practice), and technical workflows through the tele-encounter process.
RCW 43.70.495 requires health care professionals who provide clinical services through telemedicine independently or under the direction of an authorized health care practitioner to complete telemedicine training. “Telemedicine” as defined in RCW 70.41.020(13) means, “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment [but] does not include the use of audio-only telephone, facsimile, or email.”