Part 11.
BOARD OF NURSE EXAMINERS
Chapter 217.
LICENSURE, PEER ASSISTANCE AND PRACTICE
22 TAC §217.16
The Board of Nurse Examiners for the State of Texas (Board)
adopts amendments with changes to 22 TAC §217.16. The proposed text was
published in the November 8, 2002, issue of the
Texas Register
(27 TexReg 10533). This rule concerns the Licensure,
Peer Assistance and Practice of registered nurses (RNs) and specifically addresses
Minor Incidents.
The adopted amendments to §217.16 are primarily for clarification
of rule intent to give guidance to the exception from mandatory reporting
for minor incidents.
The Board does not view the changes as substantive, but believes the adopted
rule will promote better understanding and application of the rule. Currently
healthcare entities are undergoing a cultural change toward non-punitive reporting
of healthcare errors, especially those related to "systems" problems. The
Board receives many questions on this topic, as the general perception is
that the Minor Incident Rule conflicts with this philosophical approach, and
is interpreted as a "3-strikes and you're out" rule. The Board believes the
rule revisions will simplify the current intent of the rule, which has always
been to preclude unnecessary reporting of RNs to the Board.
The Minor Incident Rule has existed since 1994, virtually without revision.
Over time, it is clear that many organizations have struggled with the intent
and interpretation of various sections of this rule. While the Board recognizes
the increased emphasis on "systems" in relation to causative factors of errors,
it does not believe its focus on the individual RN's conduct and responsibility
for client safety is diminished.
The Board adopts the amendments to §217.16 with some changes to the
originally proposed text. The General Counsel for the Board advises that the
changes in the adopted amendments affect no new persons, entities, or subjects.
Accordingly, republication of the adopted sections as proposed amendments
is not required.
The following entities and individuals furnished comments on the proposed
amendments to §217.16: Coalition for Nurses in Advanced Practice (CNAP);
Texas Association for Home Care (TAHC); Prof. Bryan A. Liang, MD, PhD, JD,
Health Law & Policy Institute, University of Houston Law Center; Elizabeth
Shattuck, Health Care Quality and Risk Management Specialist, the University
of Texas, Office of the General Counsel; Harris Methodist Fort Worth Hospital;
the Texas Hospital Association (THA); and Texas Nurses Association (TNA).
TAHC, by and through Rachel Hammon, RN, BSN, Director of Clinical Practice,
submitted a comment generally in favor of the proposed amendments, but suggested
that §217.16(d)(7) should be corrected to read ". . . and keep the same
reports as required in subsection (d)(1), (2), and (3) of this section" in
order to correct an apparent typographical error or mis-reference. The Board
agrees with this observation and makes the change accordingly.
Bryan A. Liang, MD, PhD, JD, of Health Law & Policy Institute of University
of Houston Law Center submitted several comments concerning the proposed amendments
to §217.16 and prefaced his comments on the proposition that the minor
incident rule creates "disincentives for nurses to engage in patient safety
discussions and falls prey to policies that will lead to the hiding of error
and important system information."
Dr. Liang's comments do not suggest any alternative language in the proposed
rule. Instead, Dr. Liang appears to criticize any reporting for professional
misconduct that isn't limited to "intentional or reckless actions or for direct
violations of safety rules and ethical mandates." Dr. Liang objects to "individually-oriented
blame" and repeatedly states throughout his comments that the minor incident
rule does not provide for analysis of system errors. Dr. Liang states that
reports of minor incidents "will drive reports of error deeply underground,"
and further, any "'remedial education or corrective action' will be uninformed
due to lack of systems assessments."
The Board agrees with Dr. Liang's comments that health care delivery systems
may and do contribute to medical errors. However, the Board disagrees that
"system errors" are ignored or not considered when reviewing reports of nursing
error. The Board's primary mission is to protect the public health, safety
and welfare. In order to accomplish this mission, the Legislature has authorized
the Board to investigate reports of RN misconduct, and if warranted, impose
a variety of disciplinary actions against a person's license to practice professional
nursing. The Board's jurisdiction is over the practice of nursing. It is axiomatic
that if a medical error were caused by the "system" rather than RN competency
then there is no Board action warranted against the nursing license. The Board
agrees, however, to make specific reference to system error consideration
by adding the phrase "including systems issues" to subsection (c)(2) which
discusses the factors which may be considered in determining whether an error
is a non-reportable minor incident. This change is discussed below in the
Board's response to comments submitted by the TNA.
The Board does not agree with Dr. Liang that §217.16 should limit
reporting to only "intentional or reckless actions or for direct violations
of safety rules and ethical mandates." Dr. Liang's suggestion is not authorized
by the mandatory reporting laws and grounds for discipline contained in Texas
Occupations Code Annotated §301.401 and §301.452. Further, the Board's
experience has been that often negligent acts only, rather than reckless or
intentional conduct, confirm competency deficits in a license holder, therefore,
mandating the Board take disciplinary action in an effort to protect the public
health, safety and welfare.
Ms. Elizabeth Shattuck, Health Care Quality and Risk Management Specialist
with University of Texas System, Office of General Counsel, submitted a general
comment concerning the proposed amendments to §217.16 but did not provide
any specific wording changes. However, Ms. Shattuck noted that the University
of Texas is the recipient of a significant research grant from the Agency
of Health Care Research and Quality. The purpose of the grant is to conduct
research to "translate and implement error measurement methods from aviation."
Ms. Shattuck points out that the minor incident rule is generally perceived
as "punitive" by the nursing profession and that the Board should focus on
more positive ways to analyze errors and encourage reporting. Ms. Shattuck
suggests that an "annual competency report" is a more accurate way to identify
an individual's practice patterns. Further, Ms. Shattuck suggests reforming
nurse peer review and placing more discretion on the nurse supervisor in deciding
whether to report a nurse. Ms. Shattuck suggests that it is too arbitrary
to report practice errors to the Board based on the number of minor incidents.
The Board appreciates Ms. Shattuck's comments and is reminded that the
reporting of nursing practice errors is often perceived as punitive. However,
the mandatory reporting requirements of the Nursing Practice Act provide for
reporting even when a nurse's conduct is "likely" to expose a patient to "risk
of harm." These mandatory reporting statutes are designed to provide information
for Board evaluation even before any harm or serious injury befalls a patient.
The only discretion available under the statute to excuse a person from mandatory
reporting is the "minor incidents" provision contained in §301.419 of
the Texas Occupations Code. The Board believes through its current adoption
of the amendment to §217.16, nurses, nurse supervisors and peer review
committees will better understand that there exists discretion to evaluate
minor incidents and patterns of minor incidents without the necessity of reporting
to the Board if the evaluation shows that the incidents do not "indicate that
the continuing practice of professional nursing by an affected nurse poses
a risk of harm to a client or other person." The Board believes that §217.16
gives the type of discretion to the nurse supervisors and peer review committees
that Ms. Shattuck is suggesting.
Phyllis Norman, RN (Vice President, Patient Care Services), Iris Torvik,
RN (Nurse Peer Review Committee), and Brenda C. Hagan (Director, Risk Management)
jointly submitted a comment on behalf of Harris Methodist, Fort Worth Hospital.
The commentors requested that the Board should eliminate the "three minor
incident requirements" as a way "to achieve free and open reporting by nurses."
The commentors state that peer review should be reserved for only serious
practice issues. They question the purpose of tracking "minor incidents" for
reporting to peer review. The commentors state that they have never had a
nurse go to peer review on the basis of three minor incidents.
The Board appreciates the comments, but feels that in an effort to promote
public health and safety there must exist a mechanism to review multiple or
serial practice errors of a nurse even if the errors are viewed as minor when
taken individually. The Board has concluded, based on its experience, that
repeated or multiple minor incidents of a professional nurse often highlight
and expose serious competency issues which could lead to unnecessary or likely
harm if the deficiencies remained unaddressed or unreported. However, the
Board has also observed that a series of minor incidents may not necessarily
demonstrate concern for a nurse's ability to practice safely. Section 217.16
is designed to allow preliminary evaluation of multiple minor incidents and
provide that reports to the Board should be those practice patterns which
must be evaluated by the Board for purposes of public policy protection. The
Board believes that the rule provides the precise balance to reporting sought
by the commentors.
Ms. Elizabeth N. Sjoberg, RN, J.D., Associate General Counsel, Texas Hospital
Association (THA), submitted her comments to §217.16 stating that the
"rules and guidelines likely will not address the confusion related to the
reporting of minor incidents due to the mandatory reporting provisions currently
stated in the Nursing Practice Act." Ms. Sjoberg requested that the BNE convene
a meeting of stakeholders prior to the start of the 78th Legislative Session
to address new legislative initiatives that will solve the confusion. The
Board appreciates Ms. Sjoberg's suggestion, but believes it is more appropriate
to implement these clarifications now and thereafter await legislative action
since the public policy debate relating to mandatory reporting is currently
very dynamic.
The Coalition for Nurses in Advanced Practice, by and through Lynda Woolbert,
MSN, RN, CPNP, Director of Public Policy, submitted comments applauding the
Board's effort in clarifying §217.16 and supporting additional comments
submitted by the TNA. The comments submitted by TNA and supported by CNAP
are addressed below with the Board's response to TNA's comments and will not
be reiterated here. The only other recommendation of CNAP was that the term
"feels" used in subsection (d)(5)(B) be substituted with the more deliberative
word: "determines." The Board agrees with this substitution and has incorporated
the suggested change into the adopted rule.
The Texas Nurses Association, by and through Jim H. Willmann, JD, General
Counsel and Director of Governmental Affairs, submitted several comments seeking
to further clarify §217.16. TNA's comments were both editorial and substantive
in nature. In addition to its comments, TNA requested a public hearing on
the amendments to §217.16. However, TNA has since withdrawn its request
for public hearing and has suggested the Board consider the non-substantive
comments if substantive changes were beyond the scope of what the Board intended.
The Board has focused its responses to the non-substantive comments received
from TNA and has agreed to most of these suggestions.
TNA has requested the Board remove references to "employing" or "employment
setting" to clarify that the rule is not limited to employment settings or
applies only to employed RNs. The Board agrees that the terms "practice" and
"practice setting" are more appropriate terms and will incorporate these changes
in the final rule in subsections (a), (d)(1), (d)(4), and (d)(7).
TNA has requested that the Board amend subsection (c) to clarify and make
it consistent with terminology used in subsection (b). TNA made the following
suggested amendment to subsection (c):
(c) Other factors to be considered in determining whether a minor incident
should be reported to the Board are:
(1) the extent to which the RN's conduct relates directly to the potential
risk of harm identified in Subsection (c)(1); and.
(2) the presence of contributing or mitigating circumstances, including
system issues, in relation to the RN's conduct.
The Board agrees that the changes suggested to subsection (c) and (c)(2)
further improve the rule and give clarity. The Board agrees to incorporate
them into the adopted rule. However, the Board disagrees that the suggested
change in subsection (c)(1) would be clearer than in the manner proposed and
declines this change.
TNA requests the Board delete or generalize references to "nurse manager"
to avoid implication that the rule applies only to settings that have nurse
"managers." CNAP joins in TNA's requested change because advance practice
nurses may have supervisors but ordinarily do not have nurse managers in their
practice settings and "the references may be confusing."
The Board agrees to a limited extent that the rule should give guidance
and offer direction to any type of supervisor, but as a practical matter the
Board can only enforce this rule against registered nurses. The Board agrees
to change or eliminate references to "nurse manager" in subsection (d)(2)
and (3). However, in practice settings where there is a peer review committee
or where no peer review committee exists, it would appear that most often
only a nurse supervisor would have the regulatory responsibility to maintain
the referenced report. Nevertheless, the Board agrees to modify subsection
(d)(4) and (7) in a manner which provides a more general application and guidance
to any type of supervisor.
TNA requests that the Board delete the phrase "is required to" in subsection
(d)(7), so that facilities not required to have peer review may voluntarily
elect to have peer review and those facilities may be able to use peer review
to review RNs committing three or more minor incidents. The Board agrees to
this non-substantive change.
TNA suggests that subsection (b)(2) be modified as follows to clarify the
ambiguous phrase "poor practice":
(2) the incident is a singular event with no pattern indicating the RN's
continuing practice would pose a risk of harm to clients or others;
The Board agrees that TNA's suggested modification adds clarity and is
adopted as suggested.
TNA's remaining comments propose significant substantive revisions to §217.16
and exceed the Board's intent as originally outlined in its notice of the
proposed rule,
Texas Register
(27 TexReg 10533),
that "[t]he proposed amendments . . . are primarily for clarification of rule
intent" and that "[t]he Board does not view the proposed changes as substantive.
. . ." TNA requested several new sections to the rule which would have added
a section concerning a "Chief Nursing Officer's responsibility" and a section
on "how the Board will handle minor incidents that get reported directly to
the Board." TNA suggested that a new separate subsection be added which would
have discussed only medication errors because "[h]ow medication errors are
addressed appears to be a significant source of concern for RN's about the
minor incident rule." TNA submitted a significant proposed revision to subsection
(d)(4) and requested the Board adopt section headings for each subsection
of §217.16. The Board views the suggestions and revisions as unnecessary
to the understanding and application of §217.16 or too substantive to
be adopted as a clarification. The Board declines the remaining suggested
changes submitted by TNA.
The adopted amendment of this section is done pursuant to Texas
Occupations Code §301.151 which authorizes the Board to adopt rules necessary
for the performance of its duties and Texas Occupations Code §301.419(b)
which specifically authorizes the Board adopt rules to minimize unnecessary
duplicative reporting and the reporting of minor incidents.
§217.16.Minor Incidents.
(a)
The Board believes protection of the public is not enhanced
by the reporting of every minor incident that may be a violation of the Texas
Nursing Practice Act. This is particularly true when there are mechanisms
in place in the RN's practice setting to take corrective action, remediate
deficits and detect patterns of behavior. This rule is intended to clarify
both what constitutes a minor incident and when a minor incident need not
be reported to the board.
(b)
A "minor incident" is defined by Texas Occupations Code §301.419(a)
as "conduct that does not indicate that the continuing practice of professional
nursing by an affected nurse poses a risk of harm to the client or other person."
A RN involved in an incident which is determined to be minor need not be reported
to the Board or the Peer Review Committee if all of the following factors
exist:
(1)
the potential risk of physical, emotional or financial
harm to the client due to the incident is very low;
(2)
the incident is a singular event with no pattern indicating
the RN's continuing practice would pose a risk of harm to clients or others;
(3)
the RN exhibits a conscientious approach to and accountability
for his/her practice; and
(4)
the RN appears to have the knowledge and skill to practice
safely.
(c)
Other factors which may be considered in determining whether
a minor incident should be reported to the Board are:
(1)
the significance of the RN's conduct in the particular
practice setting; and
(2)
the presence of contributing or mitigating circumstances,
including systems issues, in relation to the RN's conduct.
(d)
A single minor incident need not be reported to the Board
or the Peer Review Committee. When a decision is made that the incident is
minor, the following steps are required:
(1)
an incident/variance report shall be completed according
to the facility's policy;
(2)
a record shall be maintained of each minor incident;
(3)
the incident/variance report shall contain a complete description
of the incident, patient record number, witnesses, RN involved, and the action
taken to correct or remedy the problem;
(4)
In practice settings where a Peer Review Committee exists,
the nurse manager or supervisor shall report a RN to the Peer Review Committee
if three minor incidents involving the RN are documented within a one-year
(any 12 consecutive month) time period; and
(5)
the Peer Review Committee shall review the three minor
incidents and make a determination as to whether a report to the Board is
warranted in accordance with Texas Occupations Code Annotated §301.403
(NPA). The committee need not report to the Board when they determine that:
(A)
The nurse's actions in the three incidents considered together
continue to meet the criteria of subsection (b)(1) - (4) of this section,
relating to criteria for "minor incidents; and
(B)
the committee determines remediation and monitoring of
the RN's knowledge and/or skills can be accomplished without referral to the
Board.
(6)
If additional practice related errors are committed by
the RN after peer review is conducted, the information on the first three
errors shall be given new consideration in combination with subsequent incidents
occurring after this initial review process.
(7)
In practice settings where no Peer Review Committee exists,
the nurse manager or supervisor shall review minor incidents involving those
RNs under his/her supervision and keep the same reports as required in paragraphs
(1) - (3) of this subsection. A nurse manager or supervisor shall report any
RN involved in three minor incidents within one year to the Board.
(e)
Nothing in this rule is intended to prevent reporting of
a potential violation directly to the Board.
(f)
Failure to classify an event appropriately in order to
avoid reporting may result in violation of the mandatory reporting statute.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on January 30, 2003.
TRD-200300768
Katherine Thomas
Executive Director
Board of Nurse Examiners
Effective date: February 19, 2003
Proposal publication date: November 8, 2002
For further information, please call: (512) 305-6823
22 TAC §217.18
The Board of Nurse Examiners adopts an amendment with changes
to 22 TAC §217.18, concerning Registered Nurse First Assistants. The
Board met on October 24, 2002, and approved to adopt on a permanent and an
emergency basis an amendment to §217.18 that addresses the minimum requirements
for registered nurses functioning as first assistants in surgical settings.
The emergency amendment was published in the November 15, 2002, issue of the
HB 803, passed in the 77th Legislative Session, amended the Nursing Practice
Act by adding §301.1525. The section defines a "nurse first assistant"
as a registered nurse who is certified in perioperative nursing by an organization
recognized by the Board and has completed a nurse first assistant program
approved by an organization recognized by the Board. The new section grants
the Board authority to develop rules relating to RNFAs, and current rule 217.18
was subsequently adopted in March 2002.
In the past, the Board determined that RN first assisting is within the
scope of practice of the registered nurse (adopted at January 1995 Board meeting).
It was determined that RNs who elect to function in such a role should meet
the requirements that are outlined in the Association of Perioperative Registered
Nurses' (AORN's) position statement relating to RNFAs. The position statement
and other RNFA information can be located at www.aorn.org/clinical/rnfainfo.htm.
Since the adoption of rule 217.18, however, staff has received numerous phone
calls from interested parties regarding the content of the rule. Many of the
calls are from registered nurses who do not meet the educational and/or certification
requirements specified in the Nursing Practice Act and reiterated in the rule.
Board staff further discussed the issue and maintained the interpretation
that §301.1525 and rule 217.18 apply to all RNs who elect to function
as first assistants. Nothing in the language implies the restriction of its
application to the use of the RNFA title or to reimbursement. The Board has
maintained that the current statute and rule are consistent with the educational
and certification requirements in its previous position on the issue of first
assisting which was adopted in January 1995 and in the interpretive statement
adopted by the Board in July 2002.
The Texas Nurses Association, Texas Hospital Association, Texas Council
of Perioperative RNs, and Texas RNFA Network had jointly requested that the
Board suspend its previously held policy and delay implementation of the requirements
for those RNs who meet certain defined criteria. They expressed concern that
RNs who were first assisting without having met the requirements stated in
the Board's previous position statement would be replaced by individuals who
are potentially less qualified and requested the Board adopt an alternate
set of requirements that must be met by those RNs who are safe practitioners
but who do not currently meet the criteria as specified in §301.1525
of the Nursing Practice Act and §217.18 of the Board's rules. These alternate
criteria would permit these RNs to continue to first assist until January
1, 2005. After that date, all RNs who elect to first assist must meet the
criteria specified in the Nursing Practice Act.
Since the emergency rule became effective, multiple inquiries were received
on the requirements for operating room experience listed in §217.18(b)(4).
Subsection (A) states that the RN must be "CNOR eligible (meets qualifications
to apply and sit for the national certification examination in perioperative
nursing (CNOR)). . . ." A number of individuals have stated that this requirement
does not define who is responsible for developing CNOR eligibility criteria.
Individuals inquired whether the Board intends to develop its own criteria
or recognize operating room experiences not recognized by the Certification
Board Perioperative Nursing (CBPN) as eligible experiences. The Board adopted
an addition to subsection (A) that clarifies that CNOR-eligibility criteria
are defined by the CBPN. Numerous inquiries were also received regarding §217.18(b)(4)(B)
that requires the RN to have "[o]ne year or 500 hours of experience first
assisting as of March 1, 2002. . . ." Many RNs are uncertain whether they
meet this requirement as they believe that "one year" is too vague and cannot
be quantified. One individual queried whether first assisting in two or three
cases over the course of twelve months meant that he could continue first
assisting if he meets all other criteria. The Board believes that the intent
of this language is to view one year as equivalent to 500 hours first assisting;
however, the current statement does not specify how much experience first
assisting is required during the one year time period. It is possible that
the Board would have to consider permitting this individual to continue to
first assist with only this limited experience if the rule is adopted in its
current format. The Board eliminated the one year time period in favor of
the more specific 500 hours, as the period of one year permits broad interpretation
that may not meet the intent of the requirement.
One written comment was received in response to the proposed amendment
to §217.18. Texas Nurses Association (TNA) submitted a comment supporting
the revisions.
The amendment is adopted under the authority of Texas Occupations
Code §301.151 and §301.1525 that authorizes the Board of Nurse Examiners
to adopt and enforce rules consistent with its legislative authority under
the Nursing Practice Act including rules relating to registered nurses seeking
approval of RNFAs.
§217.18.Registered Nurse First Assistants.
(a)
Qualifications for registered nurse first assistants (RNFAs):
(1)
A registered nurse who wishes to function as a first assistant
(RNFA) in surgery shall submit an application and all applicable fees to the
Board and shall submit evidence including, but not limited to, the following:
(A)
Current licensure as a registered nurse in the State of
Texas or reside in any party state and hold a current, valid registered nurse
license in that state;
(B)
Current national certification (CNOR) in perioperative
nursing; and
(C)
Completion of a nurse first assistant educational program
approved by an organization recognized by the Board; or
(D)
Current certification as a registered nurse first assistant
(CRNFA) by a national certifying body recognized by the Board.
(2)
After review by the Board, notification of registration
shall be mailed to the RNFA informing him/her that the registration process
has been completed.
(3)
The registered nurse whose functions include acting as
a first assistant in surgery shall know and conform to the Texas Nursing Practice
Act; current Board rules, regulations, and standards of professional nursing;
and all federal, state and local laws, rules, and regulations affecting the
RNFA specialty area. When collaborating with other health care providers,
the RNFA shall be accountable for knowledge of the statutes and rules relating
to RNFAs and function within the scope of the registered nurse.
(4)
A registered nurse functioning as a first assistant in
surgery shall comply with the standards set forth by the AORN.
(b)
A registered nurse not qualifying under subsection (a)
of this section may first assist until January 1, 2005 if he/she:
(1)
Has current licensure as a registered nurse in the State
of Texas or resides in any party state and holds a current, valid registered
nurse license in that state;
(2)
Was actively engaged in first assisting as of March 1,
2002;
(3)
Does not use any titles to imply that the person is a nurse
first assistant or otherwise hold him/herself out as a nurse first assistant;
(4)
Has operating room experience that meets the following
criteria:
(A)
CNOR eligible (meets qualifications to apply and sit for
the national certification examination in perioperative nursing (CNOR) as
defined by the Certification Board Perioperative Nursing) and
(B)
500 hours of experience first assisting as of March 1,
2002; and
(5)
Complies with BNE Standards of Professional Nursing Practice
Rule 217.11(12) requiring RNs to accept only assignments that take into consideration
patient safety and that are commensurate with the RN's educational preparation,
experience, knowledge and physical and emotional ability;
(c)
Effective January 1, 2005, the exceptions outlined in subsection
(b) of this section no longer apply, and any registered nurse first assisting
must meet the requirements outlined in subsection (a).
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on January 31, 2003.
TRD-200300792
Katherine Thomas
Executive Director
Board of Nurse Examiners
Effective date: February 20, 2003
Proposal publication date: November 15, 2002
For further information, please call: (512) 305-6823
22 TAC §§218.1 - 218.11
The Board of Nurse Examiners for the State of Texas (BNE
or Board) adopts the repeal of the current Chapter 218, §§218.1
- 218.11, pertaining to Delegation of Selected Nursing Tasks by Registered
Professional Nurses to Unlicensed Personnel, and concurrently adopts two new
chapters 22 TAC Chapter 224, relating to delegation in acute care environments
or for acute conditions, and Chapter 225, relating to delegation in independent
living environments for clients with stable and predictable conditions. The
proposed repeal was published in the November 22, 2002, issue of the
The 77th Texas Legislature (2001) passed House Bill 456, charging the BNE
to form a task force to review the BNE's current delegation chapter (22 TAC
Chapter 218) and make recommendations regarding the provision of health maintenance
tasks to persons with functional disabilities in independent living environments.
Membership on the task force was specified in the bill language. The Assistance
with Functional Disabilities (AFD) Task Force was appointed in November of
2001. The task force met five times during the 2002 calendar year. Based on
recommendations from the AFD task force and discussion at the Board meeting
on October 24, 2002, the Board hereby adopts the repeal of the current 22
TAC Chapter 218, and concurrently adopts two new chapters 22 TAC Chapters
224 and 225.
No comments were received on the proposed repeal of this rule.
The repeal of Chapter 218 is adopted under the authority of Texas
Occupations Code §301.151 and §301.152 which authorize the Board
of Nurse Examiners to adopt, enforce, and repeal rules consistent with its
legislative authority under the Nursing Practice Act.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on January 30, 2003.
TRD-200300759
Katherine Thomas
Executive Director
Board of Nurse Examiners
Effective date: February 19, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 305-6823
22 TAC §221.4, §221.5
The Board of Nurse Examiners for the State of Texas adopts
the amendment as proposed without changes to 22 Texas Administrative Code §221.4(b)
and §221.5, relating to Advanced Practice Nurses and the requirement
that they obtain national certification in the appropriate advanced practice
role and specialty within two years of program completion. This amendment
was proposed in the December 27, 2002, issue of the
Texas Register
(27 TexReg 12163).
Since 1996, advanced practice nurses have been required to obtain national
certification in the appropriate advanced role and specialty area. The sections
of the rule pertaining to full and provisional authorization (new graduates)
clearly state that the individual must have obtained national certification
within two years of the program completion date.
In the recent past, the Board has received a number of requests for waiver
of the requirement that advanced practice nurses obtain national certification
within two years of the program completion date from individuals who completed
advanced educational programs and practiced in other jurisdictions where national
certification is not a requirement. The Board directed the Advanced Practice
Nursing Advisory Committee composed of advanced practice nurses in practice,
advanced practice nurse educators, and representatives of advanced practice
nursing organizations to review the time limitation for meeting the national
certification requirement and make a recommendation regarding changes to these
sections. The committee recommended elimination of the time limitation as
well as additional changes in the requirements for provisional authorization.
The additional changes to the requirements for provisional authorization were
suggested as a result of the impact of eliminating the two year time limitation
and analysis of the successfulness of current requirements, such as the requirement
for sponsored practice after the first examination failure. Due to these amendments,
advanced practice nurses will no longer be subject to the two year completion
time limitation and the effect of the provisional authorization requirements
have been revised.
No comments were received on the proposed amendments to these sections.
The amendment is adopted under the authority of the Texas Occupations
Code §301.151 and §301.152 that authorizes the Board of Nurse Examiners
to adopt and enforce rules consistent with its legislative authority under
the Nursing Practice Act including rules relating to registered nurses approved,
or seeking approval, as an advanced practice nurse.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on January 31, 2003.
TRD-200300793
Katherine Thomas
Executive Director
Board of Nurse Examiners
Effective date: February 20, 2003
Proposal publication date: December 27, 2002
For further information, please call: (512) 305-6823
22 TAC §§224.1 - 224.11
The Board of Nurse Examiners for the State of Texas (BNE
or Board) adopts Chapter 224, §§224.1 - 224.11, pertaining to Delegation
of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel
for Clients with Acute Conditions or in Acute Care Environments, concurrent
with the repeal of the current 22 TAC Chapter 218, and the adoption of new
Chapter 225, relating to RN Delegation to Unlicensed Personnel and Tasks not
Requiring Delegation in Independent Living Environments for Clients with Stable
and Predictable Conditions. Sections 224.4, 224.8, and 224.9 are adopted with
changes to the proposed text as published in the November 22, 2002 issue of
the
Texas Register
(27 TexReg 10868). Sections
224.1 - 224.3, 224.5 - 224.7, 224.10, and 224.11 are adopted without changes
and the text will not be republished. The current delegation chapter was last
reviewed and amended in May 2000. The adopted new delegation rules will be
listed sequentially.
The 77th Texas Legislature (2001) passed House Bill 456, charging the BNE
to form a task force to review the BNE's current delegation chapter (22 TAC
Chapter 218) and make recommendations regarding the provision of health maintenance
tasks to persons with functional disabilities in independent living environments.
Membership on the task force was specified in the bill language. The Assistance
with Functional Disabilities (AFD) Task Force was appointed in November of
2001. The task force met five times during the 2002 calendar year.
As the AFD task force was given the charge of looking at the concept of
delegation in the independent living environment, the members in general were
not comfortable making amendments to the acute care rule. Since some rearrangement
of sections and content was necessary after pulling §218.8 from the chapter,
however, Board staff reworked the current chapter which is now adopted new
chapter 224. This new chapter would apply under two conditions: either the
client is in an acute care setting; or the client's condition, in relation
to the task to be delegated, is acute, i.e. unstable and/or unpredictable.
Because either the setting or the client's status is more acute, the concept
of exempting any tasks from the delegating authority of the RN is not permitted
in this rule. Thus, with the new chapter 224, the RN must determine only whether
or not to delegate a task to an unlicensed person.
Comments were received from: Texas Nurses Association (TNA), Disability
Policy Consortium (DPC), Texas Society for Respiratory Care (TSRC), and Texas
Association for Home Care (TAHC).
DPC commented that it agrees with the preamble statement that "there will
be no anticipated cost to small businesses or individuals as a result of this
chapter" and DPC recommends the addition of language that further illustrates
this point focusing on the cost savings incurred when unlicensed personnel
perform tasks versus RNs. The Board declines to make this revision part of
the new rules because the preamble statement is not part of rule language.
A cost analysis is required by the Administrative Procedures Act and the preamble
satisfies the analysis. The Board would hope the rules do result in a beneficial
cost savings but inclusion of this statement is not necessary.
TNA recommended the addition of a new paragraph (3) to §224.1 as follows:
(3) Delegation occurs relative to a condition or in an environment not
governed by Chapter 225, relating to delegation in independent living environments.
TNA wishes to ensure that there will be no delegation situations that somehow
would not be covered by either Chapter 224 or Chapter 225. TNA believes that
further clarification is warranted to make readers aware that Chapter 224
applies to delegation situations unless the situation meets the requirements
for Chapter 225.
It is the Board's opinion that between the rule language in §224.1
and §225.1(b), it is amply clear that either one delegation rule applies
or the other given each rule's criteria for application. In addition, TNA's
proposed language is somewhat confusing. Therefore, the Board declines to
include TNA's proposed amendment.
TNA additionally provided a comment recommending alteration of the definition
of "client" in §224.4(2) to "the individual receiving care" with deletion
of the reference to "family and significant others". TNA contends that whenever
the term "client" is used in the rule, it solely refers to the recipient of
care, unless otherwise specified by designating the involvement of the family
and significant others. The Board agrees that the use of the term "client"
throughout Chapter 224 is exclusively referring to the individual receiving
care; therefore, the Board accepts the suggested wording of TNA's recommendation.
TNA further suggests the revision of §224.8(c)(5) pertaining to the
delegation of medications by adding the qualifier "...except by medication
aides as permitted under §224.9". TNA suggests that without this qualifier
rule language, §224.8(c)(5) contradicts language in §224.9. The
Board agrees with TNA's statements and thereby adds the qualifier to §224.8(c)(5).
Both TNA and TAHC submitted suggestions for revision of §224.9(b),
relating to tasks that may not be delegated to medication aides. Both agencies
suggest alternate wording intending to increase the rule's clarity. The Board
appreciates TNA's and TAHC's efforts to make the rule language more succinct
and understandable; however, most of their proposed revisions border on substantive
changes that would unreasonably delay the adoption of a beneficial and long-awaited
rule. The Board agrees that some nonsubstantive changes could be made to reduce
cross-referencing between Chapters 224 and 225 thereby reducing reader confusion.
In lieu of interjecting the potentially substantive revisions proposed by
TNA and TAHC, the Board has deleted unnecessary language that appears in §224.9(b)(3)
and (4) and added clarifying language to these paragraphs as follows:
(3) administration of medications by an injectable route except as permitted
for administration of insulin under §225.11 of this title (relating to
Delegation of Administration of Medications From Pill Reminder Container and
Administration of Insulin);
(4) administration of medications used for intermittent positive pressure
breathing or other methods involving medication inhalation treatments except
as described for unit dose medication administration by way of inhalation
for prophylaxis and/or maintenance in permitted in §225.10(10)(E) of
this title (relating to Tasks That May Be Delegated).
The Board views these revisions as nonsubstantive and believes they provide
greater clarification.
The adoption of Chapter 224 is adopted under the authority of
the Texas Occupations Code §301.151 and §301.152 which authorize
the Board of Nurse Examiners to adopt, enforce, and repeal rules consistent
with its legislative authority under the Nursing Practice Act, including rules
relating to RN delegation to unlicensed personnel.
§224.4.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise.
(1)
Activities of daily living--Limited to the following activities:
bathing, dressing, grooming, routine hair and skin care, meal preparation,
feeding, exercising, toileting, transfer/ambulation, positioning, and range
of motion.
(2)
Client--the individual receiving care.
(3)
Delegation--Authorizing an unlicensed person to provide
nursing services while retaining accountability for how the unlicensed person
performs the task. It does not include situations in which an unlicensed person
is directly assisting a RN by carrying out nursing tasks in the presence of
a RN.
(4)
Unlicensed person--An individual, not licensed as a health
care provider:
(A)
who is monetarily compensated to provide certain health
related tasks and functions in a complementary or assistive role to the RN
in providing direct client care or carrying out common nursing functions;
(B)
including, but is not limited to, nurse aides, orderlies,
assistants, attendants, technicians, home health aides, medication aides permitted
by a state agency, and other individuals providing personal care/assistance
of health related services; or
(C)
who is a professional nursing student, not licensed as
a RN or LVN, providing care for monetary compensation and not as part of their
formal educational program shall be considered to be unlicensed persons and
must provide that care in conformity with this chapter.
§224.8.Delegation of Tasks.
(a)
Tasks Which are Most Commonly Delegated. By way of example,
and not in limitation, the following nursing tasks are ones that are most
commonly the type of tasks within the scope of sound professional nursing
practice to be considered for delegation, regardless of the setting, provided
the delegation is in compliance with §224.6 of this title (relating to
General Criteria for Delegation) and the level of supervision required is
determined by the RN in accordance with §224.7 of this title (relating
to Supervision):
(1)
non-invasive and non-sterile treatments;
(2)
the collecting, reporting, and documentation of data including,
but not limited to:
(A)
vital signs, height, weight, intake and output, capillary
blood and urine test for sugar and hematest results,
(B)
environmental situations;
(C)
client or family comments relating to the client's care;
and
(D)
behaviors related to the plan of care;
(3)
ambulation, positioning, and turning;
(4)
transportation of the client within a facility;
(5)
personal hygiene and elimination, including vaginal irrigations
and cleansing enemas;
(6)
feeding, cutting up of food, or placing of meal trays;
(7)
socialization activities;
(8)
activities of daily living; and
(9)
reinforcement of health teaching planned and/or provided
by the registered nurse.
(b)
Discretionary Delegation Tasks.
(1)
In addition to General Criteria for Delegation outlined
in §224.6 of this title, the nursing tasks which follow in paragraph
(2) of this subsection may be delegated to an unlicensed person only:
(A)
if the RN delegating the task is directly responsible for
the nursing care given to the client;
(B)
if the agency, facility, or institution employing unlicensed
personnel follows a current protocol for the instruction and training of unlicensed
personnel performing nursing tasks under this subsection and that the protocol
is developed with input by registered nurses currently employed in the facility
and includes:
(i)
the manner in which the instruction addresses the complexity
of the delegated task;
(ii)
the manner in which the unlicensed person demonstrates
competency of the delegated task;
(iii)
the mechanism for reevaluation of the competency; and
(iv)
an established mechanism for identifying those individuals
to whom nursing tasks under this subsection may be delegated; and
(C)
if the protocol recognizes that the final decision as to
what nursing tasks can be safely delegated in any specific situation is within
the specific scope of the RN's professional judgment.
(2)
the following are nursing tasks that are not usually within
the scope of sound professional nursing judgment to delegate and may be delegated
only in accordance with, §224.6 of this title and paragraph (1) of this
subsection. These types of tasks include:
(A)
sterile procedures--those procedures involving a wound
or an anatomical site which could potentially become infected;
(B)
non-sterile procedures, such as dressing or cleansing penetrating
wounds and deep burns;
(C)
invasive procedures--inserting tubes in a body cavity or
instilling or inserting substances into an indwelling tube; and
(D)
care of broken skin other than minor abrasions or cuts
generally classified as requiring only first aid treatment.
(c)
Nursing Tasks Prohibited from Delegation By way of example,
and not in limitation, the following are nursing tasks that are not within
the scope of sound professional nursing judgment to delegate:
(1)
physical, psychological, and social assessment which requires
professional nursing judgment, intervention, referral, or follow-up;
(2)
formulation of the nursing care plan and evaluation of
the client's response to the care rendered;
(3)
specific tasks involved in the implementation of the care
plan which require professional nursing judgment or intervention;
(4)
the responsibility and accountability for client health
teaching and health counseling which promotes client education and involves
the client's significant others in accomplishing health goals; and
(5)
administration of medications, including intravenous fluids,
except by medication aides as permitted under §224.9 of this title (relating
to The Medication Aide Permit Holder).
§224.9.The Medication Aide Permit Holder.
(a)
A RN may delegate to medication aides the administration
of medication to clients in long term care facilities and home health agencies
if:
(1)
the medication aide holds a valid permit issued by the
appropriate state agency to administer medications in that facility or agency;
(2)
the RN assures that the medication aide functions in compliance
with the laws an regulations of the agency issuing the permit; and
(3)
the route of administration is oral, via a permanently
placed feeding tube, sublingual or topical including eye, ear or nose drops
and vaginal or rectal suppositories.
(b)
The following tasks may not be delegated to the Medication
Aide Permit Holder unless allowed and in compliance with Chapter 225 of this
title (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring
Delegation in Independent Living Environments for Clients with Stable and
Predictable Conditions):
(1)
calculation of any medication doses except for measuring
a prescribed amount of liquid medication and breaking a tablet for administration,
provided the RN has calculated the dose;
(2)
administration of the initial dose of a medication that
has not been previously administered to the client;
(3)
administration of medications by an injectable route except
as permitted for administration of insulin under §225.11 of this title
(relating to Delegation of Administration of Medications From Pill Reminder
Container and Administration of Insulin);
(4)
administration of medications used for intermittent positive
pressure breathing or other methods involving medication inhalation treatments
except as permitted in §225.10(10)(E) of this title (relating to Tasks
That May Be Delegated).
(5)
administration of medications by way of a tube inserted
in a cavity of the body except as stated in §225.11 of this title.
(6)
responsibility for receiving verbal or telephone orders
from a physician, dentist, or podiatrist; and
(7)
responsibility for ordering a client's medication from
the pharmacy.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on January 30, 2003.
TRD-200300760
Katherine Thomas
Executive Director
Board of Nurse Examiners
Effective date: February 19, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 305-6823
22 TAC §§225.1 - 225.14
The Board of Nurse Examiners for the State of Texas (BNE
or Board) adopts new Chapter 225, §§225.1 - 225.14, pertaining to
RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in
Independent Living Environments for Clients with Stable and Predictable Conditions,
concurrent with the proposed repeal of the current 22 TAC Chapter 218, and
the adoption of new Chapter 224, relating to Delegation of Nursing Tasks by
Registered Professional Nurses to Unlicensed Personnel for Clients with Acute
Conditions or in Acute Care Environments. Section 225.6 and §225.11 are
adopted with changes to the proposed text as published in the November 22,
2002, issue of the
Texas Register
(27 TexReg
10868). Sections 225.1 - 225.5, 225.7 - 225.10, and 225.12 - 225.14 are adopted
without changes and will not be republished.
The 77th Texas Legislature (2001) passed House Bill 456, charging the BNE
to form a task force to review the BNE's current delegation chapter (22 TAC
Chapter 218) and make recommendations regarding the provision of health maintenance
tasks to persons with functional disabilities in independent living environments.
Membership on the task force was specified in the bill language. The Assistance
with Functional Disabilities (AFD) Task Force was appointed in November of
2001. The task force met five times during the 2002 calendar year. Proposed
Chapter 225 language drafted by a subcommittee of AFD members was submitted
to the full AFD Task Force at a September 23, 2002, meeting. The basic underlying
assumptions of the proposed rules are that in order for a RN to apply the
criteria in the rule, the client must first be in an independent living environment,
and the client's condition must be stable and predictable in relation to the
task(s) under the RN's consideration for delegation to an unlicensed person(s).
Based on recommendations from the AFD task force and discussion at the Board
meeting on October 24, 2002, the Board hereby adopts new Chapter 225.
In review and discussion of House Bill 456 and Chapter 218, Task Force
members recognized that the public preference in the provision of health care
services includes the desire for greater client choice and control in the
community-based setting, where the traditional "illness" model is too limiting.
Through several meetings, the task force moved forward with the concept that
if the client or client's responsible adult is capable of directing an unlicensed
person in the performance of certain basic, health-maintenance tasks, the
RN can determine that the task(s) does not need to be delegated. Assuming
the RN uses good professional judgment in making this determination, the RN
is not responsible for the non-delegated tasks performed by the unlicensed
assistive person (UAP). The RN does not need to assess the unlicensed person's
skill in relation to "tasks that do not require delegation" as the client
or client's responsible adult is capable of both directing the UAP and determining
minimal competency in performance of the task. Three levels of tasks are proposed:
1) Activities of Daily Living (ADLs): such as bathing, grooming, toileting;
2) Health Maintenance Activities (HMAs): these are tasks that are higher-level
than ADLs but are of a daily or routine nature for the client. Task examples
include medication administration or I&O (in and out) catheterization;
3) Nursing Tasks: these are tasks that constitute nursing and could, therefore,
only be done by a UAP if delegated by a RN. Some nursing tasks cannot be delegated
as they require independent nursing judgment, and therefore, only a RN may
perform these functions (see proposed §225.12 relating to Tasks Prohibited
From Delegation). Examples of tasks that may not be delegated include nursing
assessment, formulation of a nursing care plan, and initial health teaching.
Based on several factors delineated in this proposed rule, the RN can determine
that ADLs and/or HMAs do not require delegation for a given client. Flexibility
is built into the rule such that if the client's condition becomes acute or
unstable in relation to one task, this does not preclude the RN from continuing
to exempt other tasks being done by the UAP from delegation; only the task
related to the client's acute condition would require RN delegation.
Comments were received from: Texas Nurses Association (TNA), Disability
Policy Consortium (DPC), Texas Society for Respiratory Care (TSRC), and Texas
Association for Home Care (TAHC).
TNA requested that §225.6(a), paragraphs (1) and (2) be switched to
more accurately track the delegation process. The Board agrees that the proposed
revision is beneficial to the rule and makes the revision.
TNA also suggests that the Board revise the second sentence in §225.6(c)
to read, "The assessment...does not require the RN to know either the specific
unlicensed person who will perform the tasks or the specific qualifications
of the unlicensed person who will perform the tasks." The Board agrees that
this revision further clarifies the intent of the rule language and has revised
the sentence to read, "The assessment under this section does not require
the RN to know either the specific unlicensed person who will perform the
tasks or the specific qualifications of the unlicensed person who will perform
the tasks, thus the RN is not required to determine the competency of the
unlicensed person."
TNA then comments that the RN's duty to re-assess the client is not adequately
identified in the proposed rule language and suggests the addition of a subsection
(d) to §225.6 that addresses the re-assessment requirement and what is
involved, as follows:
(d) If an unlicensed person will perform tasks for the client over time,
the RN, shall periodically re-assess the client to determine that the tasks
performed by the unlicensed person continue to qualify as either i) ADLs under §225.7
or HMAs under §225.8 that do not need to be delegated or ii) tasks appropriately
delegated under §225.9. This re-assessment shall be made in consultation
with the client if 16 or older and when appropriate the client's responsible
adult.
The Board agrees that TNA's comment adds clarity to the rule in that there
is a need to highlight the RN's duty to re-assess the client. However, the
BNE received comments that strongly opposed this language from other stakeholders
who believe that this is a substantive change. Therefore, to avoid divergent
interpretations and because re-assessment is assumed under §225.6(b)(6),
the Board declines to add this proposed language at this time.
TNA and TAHC requested that in §225.7(a)(2), change the term "any
unlicensed person" to "an unlicensed person". TNA and TAHC state that the
term "any" suggests that the unlicensed person could be an "incompetent person."
In the opinion of the Board, there is no meaningful distinction between the
articles "any" and "an." In keeping with the BNE mission to protect and promote
the welfare of the people of Texas, the Board believes no reasonable and prudent
RN would assume that an incompetent person could perform health care activities
under this rule, thereby posing risk of harm to the public. The Board does
not believe use of the agreed term "any" expand the rule to include incompetency.
Therefore, the Board will retain the language approved by AFD and the Board
declines to make the revision.
TNA proposes a clarifying change and suggests rewriting the first sentence
in §225.11(a) to read, "In addition to complying with all previous criteria...the
RN must...". The Board accepts the suggested wording of TNA's recommendation.
The revision has been incorporated to better clarify the rule's meaning and
is not viewed as substantive.
TNA proposes a clarifying change and suggests rewriting the first sentence
in §225.11(b) to read, "In addition to complying with all previous criteria...the
RN must...". The Board accepts the suggested wording of TNA's recommendation.
The revision has been incorporated to better clarify the rule's meaning.
DPC poses a question regarding the difference between the intermittent
urinary catheterization that may be performed as a health maintenance activity
under §225.4(8)(B) and intermittent urinary catheterization that must
be delegated under §225.10(6)(A) and (B). DPC suggests that the BNE add
some clarifying language if the tasks differ. It is the Board's opinion, given
much deliberation by the AFD, that intermittent urinary catheterization is
considered a health maintenance activity as defined in §225.4(8)(B).
Should the RN be unable to assure that the relevant rule criteria are satisfactorily
met, the task may be considered for delegation under §225.10(6)(A). The
irrigation of a urinary catheter (indwelling or intermittent) is considered
a delegation task under §225.10(6)(A) and (B). The Board believes that
this distinction is clearly stated in the rule and declines to add further
clarifying language.
The TSRC submitted a comment in essence objecting to the safety and prudence
of allowing a RN to delegate to an unlicensed person the administration of
inhaled medications. The TSRC does not specifically suggest amendments or
changes to the proposed rule other than suggesting that the administration
of inhaled medication should not be delegated. The Board has reviewed TSRC's
concerns and believes the adoption of the new delegation rules provide the
fundamental protection of public safety consistent with the RN's scope of
practice. Furthermore, the rule adoption is consistent with the intent and
purpose of House Bill 456 and achieves the appropriate standards for delegation
of nursing tasks in independent living environments including administration
of inhaled medications.
The new Chapter 225 is adopted under the authority of the Texas
Occupations Code §301.151 and §301.152 which authorizes the Board
of Nurse Examiners to adopt, enforce, and repeal rules consistent with its
legislative authority under the Nursing Practice Act, including rules relating
to RN delegation to unlicensed personnel.
§225.6.RN Assessment of the Client.
(a)
The RN, in consultation with the client if 16 or older,
and when appropriate the client's responsible adult, must make an assessment
to determine if the care:
(1)
qualifies as an ADL or HMA not requiring delegation;
(2)
can be delegated to an unlicensed person; or
(3)
should not be delegated.
(b)
In making this determination, the RN shall consider each
of the following elements of assessment to develop an overall picture of the
client's health status:
(1)
the ability of the client or client's responsible adult
to participate in the health care decision and ability and willingness to
participate in the management and direction of the task;
(2)
the adequacy and reliability of support systems available
to the client or client's responsible adult;
(3)
the degree of the stability and predictability of the client's
health status relative to which the task is performed;
(4)
the knowledge base of the client or client's responsible
adult about the client's health status;
(5)
the ability of the client or client's responsible adult
to communicate with an unlicensed person in traditional or non-traditional
ways; and
(6)
how frequently the client's status shall be reassessed.
(c)
While each element must be assessed, strength in one factor
may compensate/offset a weakness in another factor. The assessment under this
section does not require the RN to know either the specific unlicensed person
who will perform the tasks or the specific qualifications of the unlicensed
person who will perform the tasks, thus the RN is not required to determine
the competency of the unlicensed person.
§225.11.Delegation of Administration of Medications From Pill Reminder Container and Administration of Insulin.
(a)
In addition to complying with all previous criteria listed,
when delegating the administration of oral unit dose medications from the
client's daily pill reminder container, the RN must:
(1)
ensure that the unit dose medication(s) are placed in the
client's daily reminder pill container, from properly dispensed prescription
bottle(s), by the RN or a person mutually agreed upon by the RN and client
or client's responsible adult who has demonstrated the ability to complete
the task properly;
(2)
instruct the client or client's responsible adult and the
unlicensed person involved in such delegation activity about each medication
placed in such a container with regard to distinguishing characteristics of
each medication, proper time, dose, route and adverse effects which may be
associated with the medication;
(3)
provide to the client, client's responsible adult if applicable,
and the unlicensed person(s) instructions to contact the RN before the medication
is administered when there are questions concerning the medications or changes
in the client's status related to the medication being given. An example is
when the medications appear to be rearranged or missing.
(4)
make supervisory visits in the event there are changes
in the client's status related to the medication being given and determine
the frequency of supervisory visits in consultation with the client or the
client's responsible adult to assure that safe and effective services are
being provided; and
(5)
ensure the client or client's responsible adult acknowledges
in writing that the administration of medication(s) under this section will
be delegated to an unlicensed person.
(b)
In addition to complying with all previous criteria listed,
when delegating administration of insulin subcutaneously, nasally, or via
insulin pump the RN must:
(1)
arrange for a RN to be available on call for consultation/intervention
24 hours each day;
(2)
provide teaching of all aspects of insulin administration,
subcutaneously, nasally, or via insulin pump to the client and the unlicensed
person to include, but not limited to proper technique for determination of
the client's blood sugar prior to each administration of insulin, proper injection
technique, risks, side effects and the correct response(s). The RN must leave
written instructions for the performance of the administration of insulin
subcutaneously, nasally, or via insulin pump, including a copy of the physician's
order or instructions, for the unlicensed person, client, or client's responsible
adult to use as a reference.
(3)
delegate the administration of insulin subcutaneously,
nasally, or via insulin pump to an unlicensed person, specific to one client.
The RN must teach that the administration of insulin subcutaneously, nasally,
or via insulin pump is to be performed only for the patient for whom the instructions
are provided and instruct the unlicensed person that the task is client specific
and not transferable to other clients or providers;
(4)
delegate the administration of insulin subcutaneously,
nasally, or via insulin pump to additional unlicensed persons providing care
to the specific client provided the registered nurse limits the number of
unlicensed persons to the number who will remain proficient in performing
the task and can be safely supervised by the registered nurse;
(5)
make supervisory visits to the client's location at least
3 times within the first 60 days (one within the first two weeks, one within
the second two weeks and one in the last 30 days) to evaluate the proper medication
administration of insulin by the unlicensed person(s). After the initial 60
days, the RN, in consultation with the client or client's responsible adult,
shall determine the frequency for supervisory visits to assure the proper
and safe administration of insulin by the unlicensed person(s). Separate visits
shall be made for each unlicensed person administering insulin;
(6)
make supervisory visits in the event there are changes
in the client's status; and
(7)
ensure that the client or client's responsible adult acknowledges
in writing that the administration of medication(s) under this section will
be delegated to an unlicensed person.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on January 30, 2003.
TRD-200300761
Katherine Thomas
Executive Director
Board of Nurse Examiners
Effective date: February 19, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 305-6823
Chapter 231.
ADMINISTRATION
Subchapter A. DEFINITIONS
22 TAC §231.1
The Board of Vocational Nurse Examiners adopts an amendment
to § 231.1 definitions relating to mutually agreeable agent as related
to 237.17 (a) (3) Temporary Permits with a correction to read 235.17 (a) (3)Temporary
Permits without changes to the text as published in the December 27, 2002,
issue of the
Texas Register
(27 TexReg 12164)
and will not be republished.
The adopted amendment will address language to define mutually agreeable
agent to support the new adopted language to rule 237.17 (a) (3) with correction
to read 235.17 (a) (3).
No comments were received relative to the adoption of this rule.
The amendment is adopted under Chapter 302, Texas Occupations
Code, Subchapter D, Section 302.151 (b), which provides the Board of Vocational
Nurse Examiners with the authority to make such rules and regulations as may
be necessary to carry in effect the purpose of the law.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on January 27, 2003.
TRD-200300672
Terrie Hairston, RN, CHE
Executive Director
Board of Vocational Nurse Examiners
Effective date: February 16, 2003
Proposal publication date: December 27, 2002
For further information, please call: (512) 305-7653
Chapter 218.
DELEGATION OF SELECTED NURSING TASKS BY REGISTERED PROFESSIONAL NURSES TO UNLICENSED PERSONNEL
Chapter 221.
ADVANCED PRACTICE NURSES
Chapter 224.
DELEGATION OF NURSING TASKS BY REGISTERED PROFESSIONAL NURSES TO UNLICENSED PERSONNEL FOR CLIENTS WITH ACUTE CONDITIONS OR IN ACUTE CARE ENVIRONMENTS
Chapter 225.
RN DELEGATION TO UNLICENSED PERSONNEL AND TASKS NOT REQUIRING DELEGATION IN INDEPENDENT LIVING ENVIRONMENTS FOR CLIENTS WITH STABLE AND PREDICTABLE CONDITIONS
Part 12.
BOARD OF VOCATIONAL NURSE EXAMINERS
Chapter 240.
PEER REVIEW AND REPORTING