nurse delegation program

Nurse Delegation Program

WHAT’S NEW?

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OBJECTIVES

Upon completion of this training, participants

will:

1. Learn at least one change that occurred with the Nurse Delegation Program during the last two years

2. Verbalize at least two changes that will occur within the near future

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OBJECTIVES

3. State at least one change made to the nurse practice act for Alabama during 2009

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In Review 2008-2009

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OUR NEW NUMBER

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610-X-7-.06

Effective, December 2009, the ABON revised their regulations

– The ABON Regulation that applies to ADMH Residential Programs was:

» 610-X-6-.15

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610-X-7-.06

The current number for the ABON Regulation that applies to ADMH

Residential Programs is

610-X-7-.06

The title of the regulation remains the same

ADMH Residential Community Programs

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610-X-7-.06(9)

The Commissioner of the ADMH shall submit a report(s) to the ABON in a format specified but the Board upon request to include but not limited to:

1. Total # or residential programs (Contractors should include subcontractors)

2. Total # of consumers served

3. Total # of RNs

4. Total # of LPNs

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610-X-7-.06

5. Total # of MAC Workers trained (current # of MAC Workers at agency)

6. Total # of MAC Workers trained during the reporting period (April 1 previous year – March 31, current year)

7. Total # of medication errors in each category (Address each personnel category – RN, LPN, MAC, Pharmacist AND each error type – Wrong med, person, time, reason, route, documentation, dose, missed dose or other (explain)

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7 Rights of Medication Administration

610-X-6-.07(1)(j)

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7 Rights

1. Right person

2. Right medication

3. Right time

4. Right dose

5. Right route

6. Right reason

7. Right documentation

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RIGHT REASON

What is the medical condition requiring the medication?

Ex.• For “severe” agitation• For sleep• For glaucoma• For temp > 101

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Right Reason

In the future, all medication orders will include the “purpose” or “expected therapeutic benefit of the medication, however, it is currently best practice for all “as needed” (PRN) medications to include a specific purpose

The precise circumstances for which the drug is to be given.

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Right Reason• SAFETY TIPS• Medication• Important information you need to know• WHAT YOU NEED TO KNOW• ABOUT EACH MEDICINE YOU TAKE• What is the name of each• medication?

• What is it for?• What time should you take it?• How much of it should you take• each time?• How should you take it?• Should you take it with food?• How long should you take it?• What should you do if you miss a• dose?• Are there any side effects? What• should you do if you have any?• Is it safe to take with other• medications you are taking,• including over-the-counter• medication, vitamins or herbals?• What food, drink or activities• should you avoid while taking it?• Alabama Hospital Association• 500 North East Blvd. Montgomery, AL 36117• (334) 272-8781

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Right Reason

• All PRN prescriptions should specify:– dose (not a range of doses),– frequency, – maximum daily dose and– the precise circumstances for which the drug

is to be given. A time period for the prescription must also be

stated (stop order)

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Right Reason

All PRN medication administered should bedocumented in the clinical notes with details of thename of • Name of drug administered,• Date and time of administration,• dose of drug,• the specific symptoms and conditions which resulted in

the drug being administered and• a description of the patients response to the medication.

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Right Reason

Universal Medication Form

• Date• Name of medication/dose • Directions• Date stopped

• Reason for taking• Name of MD

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RIGHT DOCUMENTATION

IF IT IS NOT DOCUMENTED;

IT DID NOT HAPPEN!

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RIGHT DOCUMENTATION

BLANKS ON THE MARs ARE NOW

LEVEL I MEDICATION ERRORS

(PE/PI NOTE: What percentage of your agency’s Level I medication errors are due to “lack of documentation” on the MAR?)

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REPORTING MEDICATION ERRORS

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2008

1st ADMH Report to the ABON

Study Period: April 1, 07-April 1, 2008

Reporting according to Levels

ADMH Totals

Level 1 1535

Level II 13

Level III 0

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2009

2nd ADMH Report to the ABONStudy Period:April 1, 2008-April 1, 2009

Reporting requirements:• Levels• Personnel

– RN– LPN– MAC

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2009

Level I

ADMH Total 2945

RN 70

LPN 133

MAC 2742

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2009

Level II

ADMH Total 14

RN 1

LPN 1

MAC 12

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2009

Level III

ADMH Total 0

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2010

3rd ADMH Report to the ABON

Study Period: April 1, 2009-March 31, 2010Reporting Requirements:

• Med error per Level• Med error per personnel• Med error per type:Wrong med Wrong dose Wrong personWrong route Wrong time Missed doseWrong purpose Other Documentation

error

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2010

Letter delineating report requirements will be emailed and slow mailed during the week

of May 17-21, 2010

Due Date:

June 18, 2010

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OTC Medications

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OTCs

610-X-7-.06(5)

“The task of assisting with the delivery of prescribed eye, ear, nose, oral, topical, inhalant, rectal or vaginal medication s may only be delegated to a mental health worker……………”

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OTCs

All medications, including “as needed” medication (PRN) shall be ordered by a legal prescriber specifying the reason

for which the medication any be given.

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OTCs

A MAS RN/LPN may place a prescribed, factory labeled and sealed, single dose, over-the-counter, as needed

(PRN) medications in a plastic bag with a closure.

The bag shall be labeled with the consumers’ name, facility/program name; date single dose meds were

placed in the bag by the MAS RN/LPN.

The MAS RN/LPN shall check expiration dates on all single dose packages, initial the plastic bag and

enclose a copy of the MD standing orders inside the bag with the factory sealed single dose over-the-

counter medications

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MAS TRAINING

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MAS Training

In November 2009 the MAS Training Program was revised

• Length of training changed from 4 hours to 6.5 hours

• Standardized agenda developed

• Training points to re-enforce developed

• PowerPoint Presentation Developed

• Level II/III Med Error Report Form

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MAS Training

If your agency has a MATT RN, he/she must utilize the following at a minimum

1. Standardized agenda,2. Evaluation form,3. List of training points to re-enforce,4. Training/testing form to be sent to NDP Office,5. Training DVDs and PowerPoint Presentation 6. Level II/III Med Error Form

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MAS Training

1st MATT RN UPDATE DEVELOPED AND PRESENTED NOVEMBER 2009

Quarterly MATT RN meetings open to other nurses/persons

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MAS Training

ANNUAL MATT RN UPDATE PLANNED FOR EACH YEAR, WITH RNs WHO WILL BE INSTRUCTING OTHER NURSES, IN

NOVEMBER TO FOCUS ON THE CHANGES THAT HAVE OCCURRED OR

CHANGES THAT ARE ANTICIPATED

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FUTURE CHANGES

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FUTURE CHANGES

• NDP Regulations

• MAC DVD

• Question Board

• Standardized Forms

• All Manuals revised/update

• All test revised/updated

• Updated Website

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OTHER CANGES to the ALBAMA NURSE PRACTICE ACT

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DEFINITIONS

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Definitions

Accountability

Answerable or responsible for action

Responsibility

The charge to do something that is expected performance

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Definitions

Delegation

The act of authorizing a competent individual to perform selected nursing activities supportive to RNs or LPNs in selected situations while retaining the accountability for the outcome if the delegation is to an unlicensed individual

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Definitions

Legally Authorized Prescriber

• Licensed physician (MD),• Dentist (DDS),• Certified Registered Nurse Practitioner (CRNP),• Certified Nurse Midwife (CNM) and• Physician Assistant (PA)

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Definitions

• MayPower, privilege or right retained by

theBoard

• May notProhibition

• ShallDuty, requirement or condition

precedent

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Definitions

Direct Supervision

Responsible licensed nurse physically present in facility and readily accessible to designate or prescribe a course of action or to give procedural guidance, direction and periodic evaluation.

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Definitions

Indirect Supervision

Responsible licensed nurse is available for periodic inspection and evaluation through physical presence, electronic or telephonic communication for direction, consultation and collaboration.

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Definitions

AssessmentsComprehensiveThe systematic collection and analysis of data

including the physical, psychological, social, cultural and spiritual aspects of the patient by the RN for the purpose of judging a patient’s health and illness status and actual or potential health needs. Comprehensive assessment includes patient history, physical examination, analysis of the data collected, development of the patient plan of care, implementation and evaluation of the plan of care.

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Assessment Standards

610-X-6-.09(2)(a)-(d)The RN shall conduct and document

comprehensive and focused nursing assessments of the health status of patients by:

1. Collecting objective and subjective data from:– observations,– physical examinations,– interviews and– written records in an accurate and timely manner as appropriate to the

patient’s health care needs

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Assessment Standards

2. Analysis and reporting of data collected

3. Developing plan of care based upon the patient assessment

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Assessment Standards

4. Modifying the plan of care based upon the evaluation of patient responses to the plan of care, including:– Anticipating and recognizing changes or

potential changes in patient status– Identifying signs and symptoms of deviation

from current health status– Implementing changes in interventions

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Definitions

AssessmentsFocusedAn appraisal of the patient’s status and specific

complaint through observation and collection of objective and subjective data by the RN OR LPN. Focused assessment involves identification of normal and abnormal findings, anticipation and recognition of changes or potential changes in patient’s health status and may contribute to a comprehensive assessment performed by the RN.

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Assessment Standards

610-X-6-.09(3)(a)-(f)The LPN shall conduct and documentfocused nursing assessments of the healthstatus of patients by:1.Collecting objective and subjective data from

– observations– Nursing examinations,– Interviews and– Written recordsIn an accurate and timely manner as appropriate to the

patient’s health care needs.

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Assessment Standards

2.Distinguishing abnormal from normal data

3.Recording and reporting the data

4.Anticipating and recognizing changes or potential changes in patient status; identifying signs and symptoms of deviation from current health status

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Assessment Standards

5.Reporting findings of the focused nursing assessment to the RN, MD, CRNP OR DDS

6.Implementing the plan of care

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Practice of Practical Nursing

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Practice of Practical Nursing

610-X-6-.05(1)(g)(i)-(iii)

The practice of practical nursing includes,

but is not limited to:

Provision of care under the direction of a RN, MD or DDS, who considers the following elements:

• Evaluation of knowledge, skills and experience of the LPN

• Complexity of the assigned tasks• Health status of patient

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DOCUMENTATION

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Documentation

610-X-6-.06(2)

Documentation of nursing care shall be:

• Legible

• Accurate

• Complete

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DocumentationComplete Documentation

Includes reporting and documenting on appropriate records a patient’s:• status, including signs and symptoms,• responses,• treatments,• medications,• other nursing care rendered,• communication of pertinent information to other health team

members and• unusual occurrences involving the patient.

A signature of the writer, whether electronic or written, is require in other for the documentation to be considered complete.

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Documentation

610-X-6-.06(2)(c)(i)

Timely Documentation

• Charted at the time or after the care.

Charting prior to care being provided, including medications, violates

principles of documentation

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Documentation

610-X-6-.06(2)(C)(ii)

Timely Documentation

Documentation of patient care that is not in the sequence of the time the care was provided shall be recorded as a “late

entry” including a date and time the late entry was made as well as the date and

time the care was provided.

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Documentation

610-X-6-.06(2)(e)

Documentation Corrections

A mistaken entry in the record by a licensed nurse shall be corrected by a

method that does not obliterate, white-out or destroy the entry

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Documentation

610-X-6-.06(2)(f)

Documentation Corrections

Corrections to a record by licensed nurse shall have the name or initials of the

individual making the correction

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MEDICATION ADMINISTRATION AND SAFETY

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Medication Administration and Safety

610-X-6-.07(4)

Documentation of medication administration shall comply with the principles of documentation and include safety

precautions of medication administration, controlled drug records per Federal

and State law and facility policy

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PATIENT CARE ORDERS

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Patient Care Orders

610-X-6-.10(1)-(2)

• The RN/LPN may receive medical orders from the legally authorized prescriber relayed by another licensed or registered health care professional and registered or certified medical assistant

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Patient Care Orders

• The RN/LPN may implement verifiable standing orders at the direction of a

legally authorized prescriber

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ASSIGNMENT, DELEGATION and SUPERVISION

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Assignment, Delegation and Supervision610-X-6-.11(1)

• The RN shall be accountable and responsible for the assignment of nursing activities and tasks to other health care workers based on but not limited to:– Knowledge, skills and experience– Complexity of assigned tasks– Health status of the patient

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Assignment, Delegation and Supervision610-X-6-.11(3)

The RN/LPN shall delegate only afterconsidering various factors including but not limited to:• Knowledge, skills and experience of the

person receiving the delegation• Complexity of the delegated tasks• Health status of the patient

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Assignment, Delegation and Supervision

610-X-6-.11(4)(a)-(c)

Tasks delegated to unlicensed assistive

personnel may not include tasks:

• Exercise independent nursing judgment or intervention

• Invasive Procedures

• Assistance with medication except as provided in Chapter 610-X07

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SUMMARY

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Summary

Changes from 2008-2010• Increase MAS Training hours• New Regulation Number• MAS RN/LPN can bag factory sealed and

labeled OTCs• Reporting med errors by

– Level– Personnel– Type

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Summary

Future Changes

• Standardized Forms

• NDP Regulations

• MAC DVD

• Revised Manuals – Administrative Guidance,– MAS Instructor– MAC Training

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Summary

• Revised Test– MAC– MAS– MATT

• Updated Webpage

• Question Board for Nurses

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Summary

Changes to the Nurse Practice Act• New Number• Comprehensive Assessment• Focused Assessments• Seven Rights of Medication Administration• Documentation• Supervision• Data Request

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References

Guidelines For The Prescribing and Administration of PRN (Pro Re Nata)

Psychotropic Medication Medicines Committee March 2007

Med Safety Toolkit by AlaHA Quality Task Force

ABON Standards of Practice