3 Colo. Code Regs. § 716-1.13

Current through Register Vol. 47, No. 22, November 25, 2024

Section 3 CCR 716-1.13 - RULES AND REGULATIONS REGARDING THE DELEGATION OF NURSING OR CERTIFIED MIDWIFE TASKS

A.STATEMENT AND BASIS OF PURPOSE

The Rules contained in this Rule 1.13 are adopted pursuant to authority granted the Board by sections 12-20-204(1) and 12-255-107(1)(j), C.R.S., and specifically pursuant to authority granted in section 12-255-131(6), C.R.S. The purpose of these Rules is to specify procedures and criteria regarding the delegation of nursing or certified midwife tasks.

The practical nurse ("PN"), professional nurse ("RN"), advanced practice registered nurse ("APRN"), certified midwife ("CM") are responsible for and accountable to each consumer of nursing care for the quality of nursing or midwifery care he or she provides either directly or through the delegated care provided by others.

B.DEFINITIONS:

For the purposes of Rule 1.13, the following terms have the indicated meaning;

1. "Board" means the State Board of Nursing.

2. "Client" means the recipient of nursing or midwifery care.

3. "Competence" is the Certified Nurse Aide's (CNA) ability to perform those tasks included in the expanded scope of practice as set forth in Section (I)(3) of Rule 1.10, with reasonable skill and safety to a client, as deemed by the RN or APRN.

4. "Continued Competence" is the CNA's ability to perform those tasks included in the expanded scope of practice as set forth in Section (I)(3) of Rule 1.10, with reasonable skill and safety to a client, as deemed by the RN, or APRN's direct observation of the CNA's clinical performance of the task to occur not less than annually after initially being deemed competent.

5. "Deemed Competent" is the RN or APRN's determination that the CNA is competent to perform the task with reasonable skill and safety to a client.

6. "Delegatee" means an individual receiving the Delegation who acts in a complementary role to the PN, RN, APRN, or CM who has been trained appropriately for the task delegated, and whom the PN, RN, APRN, or CM authorizes to perform a task that the individual is not otherwise authorized to perform.

7. "Delegation" means the assignment to a competent individual the authority to perform in a selected situation a selected nursing or selected certified midwife task included in the practice of practical nursing as defined in section 12-255-104(10), C.R.S., or in the practice of professional nursing as defined in section 12-255-104(8), C.R.S.; or the practice of a certified midwife as defined in section 12-255-104 (7.5), C.R.S.

8. "Delegator" means the PN, RN, APRN, or CM making the Delegation; the Delegator must hold a current, active license and if appropriate advanced practice registration and prescriptive authority.

9. "Developmental Disabilities Nurse (DDN) Setting" means a practice setting for a RN or APRN, employed by or contracted by community center boards, the community board's provider organizations or other agencies providing services through the Colorado Division of Developmental Disabilities.

10. Individualized Healthcare Plan ("IHP") means a plan for a specific Client that is developed by a RN or APRN employed or contracted by the Client's School, Licensed Child Care Facility, or DDN Setting in conjunction with the Client and parent or guardian and, if applicable, based on the Client's Licensed Health Care Provider's orders for the administration of Medications and/or treatments for the Client.

11. "Licensed Child Care Facility" means any facility licensed as a family child care home or child care center as defined in section 26-6-102, C.R.S.

12. "Licensed Health Care Provider" means an individual who is licensed or otherwise authorized by the state pursuant to this Title 12, or Article 3.5 of Title 25, C.R.S., to provide health care services.

13. "Medication" means any prescription or nonprescription drug as defined in section 12-280-103, C.R.S.

14. "Practitioner" means a person authorized by law to prescribe treatment, Medication or medical devices and acting within the scope of such authority.

15. "School" means any institution of primary or secondary education, including preschool and kindergarten.

16. "Supervision" means the provision of guidance and review by a PN, RN, APRN, or CM for the accomplishment of a nursing task or activity, with initial direction of the task, periodic inspection of the actual act of accomplishing the task or activity, and evaluation of the outcome.

C.CRITERIA FOR DELEGATION

1. Any nursing or Certified Midwife task delegated by the PN, RN, APRN, or CM shall be:

a. Within the scope of practice and the area of responsibility of the Delegator;

b. Within the knowledge, skills, ability and scope of practice of the Delegator;

c. Of a routine, repetitive nature and shall not require the Delegatee to exercise nursing or midwifery judgment or intervention;

d. A task that a reasonable and prudent nurse or certified midwife would find to be within generally accepted nursing or midwifery practice;

e. An act consistent with the health and safety of the Client; and f. Limited to a specific Delegatee, for a specific Client, and within a specific time frame, except for Delegation in Schools or Delegation in a Licensed Child Care Facility as described in Section (F) of Rule 1.13.

2. The Delegatee shall not further delegate to another individual the tasks delegated by the PN, RN, APRN, or CM.

3. The delegated task may not be expanded without the express permission of the Delegator.

4. The Delegator shall assure that the Delegatee can and will perform the task with the degree of care and skill that would be expected of the PN, RN, APRN, or CM.

5. The delegation of a nursing- or Certified Midwife task shall not limit the practice of nursing or of certified midwife as defined in sections 12-255-104 (7.5), (9) or (10), C.R.S., by any certified midwife or nurse including, but not limited to, advanced practice registered nurses.

D.RESPONSIBILITY OF THE DELEGATOR

1. The decision to delegate shall be based on the Delegator's assessments of the following:

a. The Client's nursing or midwifery care needs, including, but not limited to, complexity and frequency of the nursing or midwifery care, stability of the Client, and degree of immediate risk to the Client if the task is not carried out;

b. The Delegatee's knowledge, skills and abilities after training has been provided;

c. The nature of the task being delegated including, but not limited to, degree of invasiveness, irreversibility, predictability of outcome, and potential for harm;

d. The availability and accessibility of resources, including but not limited to, appropriate equipment, adequate supplies and appropriate other health care personnel to meet the Client's nursing or midwifery care needs; and

e. The availability of adequate Supervision of the Delegatee.

2. The Delegator shall:

a. Explain the Delegation to the Delegatee and that the delegated task is limited to the identified Client within the identified time frame;

b. As appropriate, either instruct the Delegatee in the delegated task and verify the Delegatee's competency to perform the delegated nursing or Certified Midwife task, or verify the Delegatee's competence to perform the delegated nursing or Certified Midwife task;

c. Provide instruction on how to intervene in any foreseeable risks that may be associated with the delegated task;

d. Provide appropriate and adequate Supervision to the Delegatee to the degree determined by the Delegator, based on an evaluation of all factors indicated in Section (D)(1) in Rule 1.13; and

e. If the delegated task is to be performed more than once, develop and employ a system for ongoing monitoring of the Delegatee.

3. The Delegator, on an ongoing basis, shall evaluate the following:

a. The degree to which nursing or midwifery care needs of the Client are being met;

b. The performance by the Delegatee of the delegated task;

c. The need for further training and/or instruction; and

d. The need to continue or withdraw the Delegation.

4. Documentation of the Delegation by the Delegator in the Client record shall adhere to generally accepted standards and shall minimally include, but not be limited to, the following:

a. Assessment of the Client;

b. Identification of the task delegated, the Delegatee, the Delegator, time delegated, and time frame for which the Delegation is effective;

c. Direction for documentation by the Delegatee that the task or procedure was performed and the Client's response, if appropriate; and

d. Periodic evaluation of the Client's response to the performed delegated task.

E.STANDARDS FOR THE ACCOUNTABILITY OF THE DELEGATOR

1. The Delegator shall adhere to the provisions of the Nurse and Nurse Aide Practice Act and the rules and regulations of the Board.

2. The Delegator is accountable for the decision to delegate and the assessments indicated in Section (D)(1) of Rule 1.13.

3. The Delegator is accountable for monitoring, outcome evaluation, and follow-up of each Delegation.

4. The Delegator is accountable for the act of delegating and supervising.

F.DELEGATION OF THE ADMINISTRATION OF MEDICATIONS IN SCHOOLS AND LICENSED CHILD CARE FACILITIES

1. A RN or APRN employed or contracted by a School or Licensed Child Care Facility may delegate the administration of prescription and non-prescription medication with an order from an appropriate health care provider to a specific Delegatee(s) who has successfully completed appropriate training for the population of a School or Licensed Child Care Facility, within a specific time frame not to exceed one school year.

2. A RN or APRN employed by or contracted by a School, school district or Licensed Child Care Facility may delegate the administration of prescribed emergency medications to one or more specific Delegatee(s) who have successfully completed appropriate training. The professional nurse must provide to the Delegatee a specific written protocol for each specific Client as determined in the IHP.

3. A professional nurse shall not delegate to a delegatee the administration of any medication that requires nursing assessment, judgment, or evaluation before, during or immediately after administration.

4. Nothing in this Section (F) of Rule 1.13 shall be construed to prohibit a professional nurse or advanced practice registered nurse from delegating a specific nursing task to a specific Delegatee for a specific Client in the School or Licensed Child Care Facility setting, as otherwise provided for and governed by the provisions of Rule 1.13.

5. The administration of stock Epinephrine and/or Naloxone by designated personnel is not a delegated nursing function and is described in Section (H)(4) of Rule 1.13.

G.DELEGATION OF INSULIN AND GLUCAGON ADMINISTRATION IN THE SCHOOL SETTING, LICENSED CHILD CARE FACILITY OR DDN SETTING

1. The administration of insulin or glucagon is a nursing task that may be delegated in accordance with the requirements of Rule 1.13. The selection of the type of insulin and dosage levels shall not be delegated.

2. An IHP shall be developed for any Client receiving insulin in the School, Licensed Child Care Facility or DDN Setting. Delegation of tasks for Clients with diabetes shall be confined to procedures that do not require nursing assessment, judgment, evaluation or complex skills.

a. By example, but not limited to the following list, the IHP may include:

(1) Carbohydrate counting

(2) Glucose testing

(3) Activation or suspension of an insulin pump

(4) Usage of insulin pens

(5) Medical orders

(6) Emergency protocols related to glucagon administration

3. Insulin administration by the Delegatee shall only occur when the Delegatee has followed the guidelines of the IHP.

a. Dosages of insulin may be administered by the Delegatee as designated in the IHP.

b. Non-routine, correction dosages of insulin may be given by the Delegatee only after:

(1) Following the guidelines of the IHP; and

(2) Consulting with the Delegator, as designated in the IHP, and verifying and confirming the type and dosage of insulin being administered.

c. Under Section (G)(3) of Rule 1.13, insulin administration by the Delegatee is limited to a specific Delegatee, for a specific Client and for a specific time.

4. When the Delegator determines that the Client is capable of self-administration, as documented in the IHP, the Delegator may delegate to the Delegatee as designated in the IHP the verification of insulin dosage via pump or other administration route.

5. When the Client is not capable of self-administration, routine daily meal boluses of insulin, based on carbohydrate counts and blood glucose levels, may be administered via the insulin pump by the Delegatee as designated in the IHP.

H.EXCLUSIONS FROM THE RULE 1.13

1. Any person registered, certified, licensed, or otherwise legally authorized in this state under any other law engaging in the practice for which such person is registered, certified, licensed, or authorized.

2. Any person performing a task legally authorized by any person registered, certified, or licensed in this state under any other law to delegate the task.

3. The professional nurse who teaches the Medication Administration Instructional Program as approved by the Colorado Department of Human Services shall not be considered to be delegating as defined by Rule 1.13.

4. The professional nurse or advanced practice registered nurse who teaches stock epinephrine auto-injection and/or stock Naloxone administration to designated school staff that act in an emergency situation to assist a Client shall not be construed to be delegating as defined by Rule 1.13.

5. The issuance by an advanced practice registered nurse with prescriptive authority of standing orders and protocols for the use of epinephrine auto-injectors for emergency use to designated school staff shall not be construed to be delegating as defined by Rule 1.13.

6. Any child care provider as defined in section 26-6-102(6), C.R.S., acting in compliance with Section 26-6-119, C.R.S., and any rules enacted pursuant to that section. Such child care provider must:

a. Have successfully completed a medication administration instructional program that is approved by the Colorado Department of Human Services;

b. Have daily physical contact with the parent or guardian of the client to whom medications are administered;

c. Administer only routine medications and only in compliance with rules promulgated by the state Board of Human Services;

d. In emergency situations requiring the administration of unit dose epinephrine, comply with any protocols written by the prescribing health care professional; and

e. Administer a nebulized inhaled medication only in compliance with protocols written by the prescribing health care professional that identify the need for such administration.

7. School personnel that volunteer to administer or assist in the administration of medical marijuana in non-smokeable form to any student with a valid recommendation for medical marijuana pursuant to section 22-1-119.3, C.R.S.

I.CNA EXPANDED SCOPE OF PRACTICE / NOT CONSIDERED DELEGATION OF NURSING TASKS

1. The following tasks included in the CNA's expanded scope of practice as set forth in section 12-255-206(1)(a), (b), and (c), C.R.S., are not considered delegated nursing tasks provided that a RN or APRN has deemed the CNA competent to perform such tasks:

a. Digital stimulation, insertion of a suppository, or the use of an enema, or any other medically acceptable procedure to stimulate a bowel movement for clients/patients with stable health conditions and are not considered high risk;

b. Gastrostomy-tube and jejunostomy-tube feedings for clients/patients with stable health conditions and are not considered high risk; and

c. Placement in a client's mouth of presorted medication that has been boxed or packaged by a PN, RN, or APRN, or a Pharmacist for clients/patients with stable health conditions and are not considered high risk.

(1) The CNA may only perform this task if the boxed or packaged medication has been stored in a secure manner and showing no sign of tampering.

(2) The CNA will report any medication not placed in the client's mouth in a timely manner but not more than two hours after the medication was due.

(3) In the case of liquid medication that has been sorted by the minor's parent or guardian, such medication must be in its original sealed container and a standard measuring device must be used.

(4) The first dose of an antibiotic sorted by a minor's parent or guardian must be under the observation of a professional nurse, physician, podiatrist, or dentist who is present in the same patient care area.

(5) Administration of oxygen as authorized by a health care provider.

(6) Changing ostomy bags.

2. The CNA, pursuant to the definition of nurse aide at section 12-255-104 (8.5), C.R.S., requires supervision of tasks by an Licensed Health Care Provider acting within the scope of the license or certificate.

3. A RN or APRN who in good faith determines that a CNA is competent to perform the tasks listed in Section (I)(1) of Rule 1.13 is not liable for the actions of the CNA in the performance of the tasks.

a. The RN or APRN deeming a CNA competent to perform tasks listed in Section (I)(1) of Rule 1.13 will have the knowledge, skills and ability to perform such skills and teach such skills.

b. For the purposes of this Rule, "is not liable" means the actions of the CNA in the performance of the expanded scope listed in Section (I)(1) of Rule 1.13 shall not form the basis for discipline for the RN or APRN pursuant to 12-255-120(1), C.R.S.

4. A RN or APRN may determine a CNA is competent to perform the tasks listed in Section (I)(1) of Rule 1.13 by teaching such task, demonstration of clinical performance of the task followed by return demonstration of the performance of the task by the CNA:

a. Teaching of the procedure to perform the task;

b. RN or APRN demonstration of the steps to perform the task;

c. Review of risks associated with performance of the task;

d. Identification of what to report to the supervising healthcare professional; and

e. Return demonstration of the clinical performance of the task.

f. Digital stimulation, insertion of a suppository, or the use of an enema, or any other medically acceptable procedure to stimulate a bowel movement for clients/patients with stable health conditions and are not considered high risk;

(1) The RN will include within the teaching of this task that it will only be performed for clients/patients with stable health conditions and are not considered high risk.

g. Gastrostomy-tube and jejunostomy-tube feedings for clients/patients with stable health conditions and are not considered high risk;

(1) The RN or APRN will include within the teaching of this task that it will only be performed for clients/patients with stable health conditions and are not considered high risk.

h. Placement in a client's mouth of presorted medication that has been boxed or packaged by a PN, RN, APRN, or a Pharmacist for clients/patients with stable health conditions and are not considered high risk.

(1) The RN or APRN will include within the teaching of this task that it will only be performed for clients/patients with stable health conditions and are not considered high risk.

i. When the RN or APRN deems the CNA competent to perform a task, a competency document will be completed. The competency document will be signed, dated and retained for at least one year by the RN determining competency. The competency document will be signed, dated and retained permanently by the CNA deemed competent to perform such tasks.

j. Within thirty days of being deemed competent to perform the tasks in Section (I)(1) of Rule 1.13 the CNA will update the expanded scope questions on the Healthcare Professions Profile (HPPP) indicating the tasks the CNA has been deemed competent to perform, the name and license number of the RN or APRN that deemed the CNA competent, along with the date deemed competent.

5. The RN or APRN must deem the CNA competent to perform the tasks in Section (I)(1) of Rule 1.13 as evidenced by a competency document as described in Section (I)(4) of Rule 1.13 signed, dated and retained for at least one year by the RN or APRN determining competence. The competency document will be signed, dated and retained permanently by the CNA deemed competent to perform such task. The competency document will be produced upon Board request.

6. Continued Competence of the CNA to perform tasks in Section (I)(1) of Rule 1.13

a. Not less than annually the CNA must demonstrate continued competence under the direct clinical observation of the RN or APRN to perform the tasks in Section (I)(1) of Rule 1.13. Upon determination of the continued competence and the CNA demonstrating continued competence an updated competency document will be signed, dated and retained for at least one year by the RN or APRN determining continued competence. The updated competency document will be signed, dated and retained permanently by the CNA demonstrating continued competence. The competency document will be provided to the Board upon request.

b. Within thirty days of the completion of the updated competency document the CNA will update the expanded scope questions on the HPPP indicating the tasks the CNA has continued competence to perform, along with the name and license number of the RN or APRN that deemed continued competence and the date of such completion.

7. Nothing in this Section (I) of Rule 1.13 will be construed to prohibit or impede a facility, agency or employer from establishing policies and procedures for the tasks set forth in Section (I)(1) of Rule 1.13, provided these minimum requirements are met.

Adopted: April 28, 2010

Effective: June 30, 2010

Revised: April 22, 2014

Effective: June 14, 2014

Revised: July 21, 2015

Effective: September 14, 2015

Revised: April 26, 2017

Effective: 6/14/2017

Revised: October 27, 2021

Effective: December 30, 2021

Revised: January 24, 2024

Effective: March 16, 2024

3 CCR 716-1.13

38 CR 16, August 25, 2015, effective 9/14/2015

38 CR 20, October 25, 2015, effective 11/14/2015

38 CR 22, November 25, 2015, effective 12/30/2015

40 CR 10, May 25, 2017, effective 6/14/2017

40 CR 16, August 25, 2017, effective 9/14/2017

40 CR 16, August 25, 2017, effective 9/14/2017

42 CR 04, February 25, 2019, effective 3/17/2019

42 CR 04, February 25, 2019, effective 3/17/2019

44 CR 10, May 25, 2021, effective 6/14/2021

44 CR 22, November 25, 2021, effective 12/15/2021

45 CR 20, October 25, 2022, effective 9/22/2022

45 CR 23, December 10, 2022, effective 11/11/2022

46 CR 01, January 10, 2023, effective 12/10/2022

45 CR 22, November 25, 2022, effective 12/15/2022

46 CR 02, January 25, 2022, effective 1/9/2023

47 CR 04, February 25, 2024, effective 3/16/2024