Jan 23 2025 | RN Delegation as a Relationship
RN delegation in Washington’s assisted living facilities has been around since 1996; while aspects of the regulations surrounding delegation have evolved over the years to accommodate the changes in nursing services and resident needs, the premise of delegation has remained steady. However, the number of state-issued citations from nurse delegation issues continues to grow.
This article aims to clarify expectations of RN delegation that, for some RN delegators (RND), have not been well established. The questions and answers addressed here have been collected from phone calls and emails at the WHCA offices, from RN delegators, owners and employees of assisted living facilities, as well as agency personnel from the Washington state Board of Nursing (WABON) and Department of Social and Health Services (DSHS).
HOW OFTEN DOES THE RND NEED TO BE IN THE BUILDING?
That depends on how many residents are receiving delegated tasks, and how many caregivers need to demonstrate competency. When a new caregiver is hired or moved to a delegation role, the RND must train them on each delegated task, and ensure they are competent in performing the tasks. Each resident must be reassessed at least every 90 days, and the RND must ensure caregivers remain competent to perform the tasks in that timeframe as well.
CAN THE RND ASSESS A RESIDENT VIA A TELEMEDICINE VISIT?
The board of nursing has determined that a nursing assessment cannot be conducted remotely. This makes sense, given the fact that this is a formal head-to-toe nursing assessment. For those rare occasions where time is pressing and it’s difficult for the RND to arrange evaluation of staff competency, a virtual call has proven workable. Exceptions to in-person visits should be documented.
By viewing the delegation process as a relationship with four prongs – the RND, the resident, the caregiver, and the facility administrator – it stands to reason that in person evaluation of the entire process, from assessment to staff competency to discussions with the administrator about how the delegation is going, is paramount to the program’s success.
WHOSE RESPONSIBILITY IS IT TO GET THE RESIDENT’S CONSENT FOR DELEGATION?
The RN delegator must get the resident’s (or the resident’s legal surrogate decision maker’s) consent. WAC 246-840-930 (10)(a)(b) states:
If the registered nurse delegator determines delegation is appropriate, the nurse:
(a) Discusses the delegation process with the patient or authorized representative, including the level of training of the nursing assistant or home care aide delivering care.
(b) Obtains written consent. The patient, or authorized representative, must give written, consent to the delegation process under chapter 7.70 RCW. Documented verbal consent of patient or authorized representative may be acceptable if written consent is obtained within 30 days; electronic consent is an acceptable format. Written consent is only necessary at the initial use of the nurse delegation process for each patient and is not necessary for task additions or changes or if a different nurse, nursing assistant, or home care aide will be participating in the process.
This discussion, then, allows the RND to explain the benefits of delegation with the resident and/or surrogate decision maker and answer questions about the service. This is an important building block for a successful nurse delegation program in the facility, and helps in building trusting relationships with the resident/family and the RND.
WHOSE RESPONSIBILITY IS IT TO ENSURE THE CAREGIVERS ARE QUALIFIED TO PERFORM DELEGATED TASKS?
WAC 246-840-930 (8)(a)(b)(c)(d) states that the RN delegator will verify that the nursing assistant or home care aide meets the qualifications to accept delegated tasks.
WHCA has heard from facility members whose RND expects the facility’s human resources department to collect credentials and delegation certificates for the RND; likewise, we’ve heard of RNDs who expect the LPN to teach the caregivers how to perform delegated tasks. Both scenarios are aside from WAC guidance and could set the RND up for not following nurse practice regulations, and the facility for not implementing safe intermittent nursing service systems.
I’VE WORKED AT [NAME OF FACILITY] FOR THREE YEARS AND HAVE ONLY SEEN THE RND ONCE. I’M STILL PERFORMING DELEGATED TASKS. AM I IN TROUBLE?
It depends. The facility must have a system in place to ensure intermittent nursing services, including nurse delegation, are provided following WAC 246-840-910 through -970. In this case, the RND might come to the building on days when this individual is not working. However, the RND must evaluate the delegation process, including ensuring delegated caregiver competency, on a routine basis. If this has not been done the facility might be in trouble. WAC 388-78A-2320 (1)(a)(b) states:
(1) When an assisted living facility provides intermittent nursing services to any resident, either directly or indirectly, the assisted living facility must:
(a) Develop and implement systems that support and promote the safe practice of nursing for each resident; and
(b) Ensure the requirements of chapters 18.79 RCW and 246-840 WAC are met.
Likewise, WAC 246-840-930 (14) states, “delegation requires the registered nurse delegator teach the nursing assistant or home care aide how to perform the task, including return demonstration or other method of verification of competency as determined by the registered nurse delegator.” Considering this regulation, it stands to reason that this employee should have received training from the RND to perform the tasks, both new and ongoing, at some point during employment.
It is the facility’s responsibility to ensure the RND is following the nurse delegation regulations and laws; policies and procedures as well as frequent check-ins with the RND will prove helpful.
WHAT ARE THE EXPECTATIONS OF THE RND ENSURING THE RESIDENT’S ASSESSMENT AND NSA ARE ACCURATE REGARDING DELEGATION?
It depends on whether there is another RN employed or contracted by the facility to fulfill this expectation. For any resident requiring nurse delegation services, the act of delegation is considered an “intermittent nursing service” and thus an RN is responsible for completing that part of the resident’s assessment (WAC 388-78A-2090 (3)) and developing, implementing, and amending that part of the resident’s negotiated service agreement (WAC 388-78A-2140 (c)). This might be the RND, or another RN involved in the resident’s care. For more on intermittent nursing service systems, see WAC, here.
WHOSE RESPONSIBILITY IS IT TO ENSURE THE DELEGATION DOCUMENTATION IS FILED IN THE CORRECT LOCATION? OUR RND EMAILS US THE UPDATED DOCUMENTS AND WE’RE EXPECTED TO FILE THEM IN THE DELEGATION MANUAL.
While WAC 246-840-930 (11)(12)(a-l) discusses expectations of the RND to document in the resident’s record, the WAC is silent on how those documents get to the resident’s record.
Best practice would include the RND filing/storing the necessary documents in specific location(s) for access by the delegated care staff, as well as by state agency staff. A time gap between the RN’s documentation of the necessary actions and tasks, and the storage of those for staff and agency retrieval, could result in lost documents, delayed documentation, and failed facility practice.
SOMETIMES OUR RND COMES TO THE FACILITY AND UPDATES DELEGATION, BUT WE DON’T GET UPDATED PAPERWORK FOR TWO WEEKS. WHAT ARE WE SUPPOSED TO DO, WHEN THE PAPERWORK WE HAVE IS OUTDATED?
Supervision and associated documentation must occur at least every 90 days; initial insulin delegation requires supervision and accompanying documentation every two weeks for the first four weeks, then at least every 90 days.
Delays in getting documentation could potentially lead to delegated staff administering medication or treatment using outdated directions or continuing with a delegated task that the RND has discontinued. Likewise, outdated documents could result in facility citations. It is suggested, then, that the facility work with the RND to set up a system to ensure timely receipt of delegation documents including resident assessments, tasks/directions, staff competency evaluations, and other documentation supporting a safe delegation program.
I’M A CONTRACTED RND, AND I’VE GIVEN A MONTH’S NOTICE THAT I’M LEAVING. THE FACILITY ADMINISTRATOR WON’T SHARE WITH ME THE CONTACT INFORMATION FOR THE RN WHO WILL REPLACE ME, SO WE CAN ENSURE SMOOTH TRANSITION FROM ONE RND TO THE OTHER. WHAT SHOULD I DO?
Because the entire delegation process is a relationship, it’s important for the administrator to work collaboratively with the RND to ensure the residents receive the services they need without interruption. WAC 246-840-950 (3)(a)(b)(c) outlines the safe process of transferring delegation to another registered nurse; overlap in RNs at this juncture is crucial to allow the oncoming RND time to assess the resident, determine competency of the delegated caregivers, and ensure the delegation plan of care is complete.
In this instance, the current RND needed to explain to the facility administrator regarding the need for transition and contact with the new RND and document her efforts in order to minimize an allegation of abandonment should she leave without a viable replacement. Alternatively, she might have needed to rescind the delegation all together; the WAC requires, in these situations, that the rescinding RN initiate and participate in developing an alternative plan to provide continuity of the task or assume the responsibility for performing the tasks.
SUMMARY
RN delegation is a relationship among four players: the RND, the resident, the delegated caregivers, and the facility’s administrator. These individuals must communicate effectively with and between one another for the delegation program to be a successful one. The RND holds accountability to follow the nurse practice act and demonstrate sound nursing judgment. The role of the delegated caregiver involves following the RND’s written and oral instructions, and reporting to the RND and supervisor when there is a change that warrants update to the delegation. The role of the administrator is a big part of the overall success of the program; this individual must understand the delegation process and ensure delegation is being implemented following sound policies and procedures and current regulations. The facility is ultimately responsible for compliance; DSHS licensors and complaint investigators will cite the facility for failures in the nurse delegation system.
To learn more about the role of the RN in nurse delegation, WHCA has developed 15 short videos. These videos are available, free of charge, to anyone wanting to explore aspects of RN delegation. For more questions about nurse delegation, email Vicki McNealley or call 360-352-3304 extension 107.