Medication Administration and Nurse Delegation in Assisted Living

WHAT IS MEDICATION ADMINISTRATION?

Legally, medication administration, accomplished by either a licensed nurse or a qualified credentialed caregiver, is the only medication service level that requires the involvement of a nurse. The term “administer” is defined by the pharmacy board as “the direct application of a legend drug whether by injection, inhalation, ingestion, or any other means, to the body of the patient … by a practitioner ….”

There are occasional instances when a resident requires medication administration. In one situation, the resident’s cognition does not allow for the understanding that s/he is taking a medication. In another situation, the resident is unable to get the medication where it needs to go with assistance, cueing, or prompting and cannot accurately direct. In some instances, both situations would apply to the resident.

When medication administration is required, a registered or licensed practical nurse must administer the medication(s), or a qualifying caregiver can administer via the nurse delegation process. Staff must document medications taken and refused, following standard best practice and facility systems.

The full resident assessment prompts the facility assessor to determine which medications fall into which medication service category (independent, assistance, assistance via accurately directing others, or administration). There are times when a resident could receive medications using some or all the categories at any given time. For example, a resident might keep a rescue inhaler at the bedside and be considered independent with that medication, accurately direct the application and removal of a medicated patch, receive all oral medications via medication assistance, and have a vitamin B12 shot administered once a month by an LPN.

Whenever a resident requires medication administration, this rises to the level of needing intermittent nursing services and a registered nurse must perform this specific part of the resident assessment and the development, implementation, and amendments to the medication management component of the negotiated service agreement. Staff must be aware of the service levels each resident is in, so that medications are offered in such a way to promote independence and ensure staff works within their individual scope of practice.

WHAT IS NURSE DELEGATION?

When a nurse is not available to administer medications or apply healthcare treatments per a resident’s assessed needs, or the facility/company opts to have qualified and trained caregivers perform these tasks, formal nurse delegation comes into play. RN delegation has been in law since the mid-1990s and has allowed many residents in assisted living to remain in the least restrictive, homelike environment while receiving needed nursing care and services.

With the current nursing shortage in Washington State, nurse delegation services have increased significantly in assisted living; many facilities that had not previously explored nurse delegation as an option for providing medication administration and healthcare treatments have begun offering this cost-effective option.

The assisted living facility’s Disclosure of Services form outlines whether nurse delegation is offered in the building and, if so, any limitations associated with this service.

Registered nurses who are responsible for nurse delegation programs in assisted living are not required to take any special training prior to starting the process. RCW 18.79.260 outlines the basics of RN practice regarding nurse delegation, and WAC 246-840-910 through -970 outlines step-by-step regulations on the topic. A delegation decision tree is included in the WAC, and can provide a level of clarity to any RN who may be questioning whether a particular aspect of the delegation process is safe given the situation at hand.

While there is not a list of allowable tasks that a RN can delegate, the WAC does clearly define what a RN cannot delegate. Those include:

*Tasks that require nursing judgment can be a gray area and oftentimes misinterpreted by RNs as well as facility administrators. Perhaps the best way to define “nursing judgment” would be to change the word “judgment” to “assessment.” So, in order to perform the task, if a nursing assessment must occur first, then the task cannot be delegated. An example might include a physician’s order that reads, “Increase Lasix to 40 milligrams each morning whenever the resident experiences 3+ pitting edema in the lower extremities.” A caregiver cannot assess to determine the extent of a resident’s edema, and, therefore, this task should not be delegated. The order might be clarified to remove any need for nursing judgment, or a nurse would need to administer that medication.

With the “cannot delegate” list provided in WAC, one can explore the commonly delegated tasks that include (but are not limited to):

There are a few highlights of nurse delegation that must be addressed for anyone new to RN delegation. First, the residents who are recipients of delegated tasks must be deemed “stable and predictable.” That means the resident does not need the frequent presence or frequent evaluation of a registered nurse. Both the assisted living WACs and the nurse practice act call out the fact that residents with a terminal illness may be deemed stable and predictable, as can residents on sliding scale insulin and residents with short-term illnesses that are likely to heal within 14 days, provided the facility staff can manage the resident’s illness. Second, each credentialed caregiver performing delegated tasks must have completed formal nurse delegation training (9-hour Nurse Delegation Core training and, if administering insulin, the 3-hour Focus on Diabetes delegation course). The RN delegator must also train the caregiver on how to perform the task, specific to the given task and specific to the resident. Finally, there can be no coercion regarding delegation; the RN chooses whether or not delegation is safe for the resident.

DSHS has a “nurse delegation program” website where training and resources are offered. This program, however, is designed for RN delegators who will be contracting with DSHS to provide nurse delegation services to Medicaid recipients living in adult family homes and supported living environments, not RNs delegating in assisted living settings. While expectations are different for RN delegators in assisted living settings (namely, assisted living facilities pay the RN delegator directly, the DSHS forms are optional, and DSHS training is not required), DSHS does post delegation forms on their website along with educational material outlining nurse delegation regulations. Members of WHCA can access sample delegation task sheets in Word format from the Documents Library in the members-only section of the WHCA website. If you need assistance logging into the members-only section, please contact the WHCA office.

Questions about medication administration and/or RN delegation? Email Vicki McNealley or call at 1 (800) 562-6170 ext. 107.