THE ROLE OF YOUR RN Lynne Lasater, RN March 2020

THE ROLE OF YOUR RN Lynne Lasater, RN March 2020

2020 THE YEAR OF THE NURSE

AMERICAN NURSES ASSOCIATION Nursing is defined as the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human responses; and advocacy in health care for individuals, families, communities, and populations.

ALABAMA BOARD OF NURSING LICENSE TYPES Registered Nurses RN (86,492) Licensed Practical Nurses LPN (14, 955) Certified Nurse Midwives CNM (17) Certified Registered Nurse Anesthetists CRNA (1,855) Nurse Practitioners CRNP (5, 262) Clinical Nurse Specialists (63)

ALABAMA BOARD OF NURSING REGULATIONS ON PRACTICE Nurse Practice Act Administrative Code

PRACTICE OF PROFESSIONAL NURSING (RN) The performance, for compensation, of any act in the care and counseling of persons or in the promotion and maintenance of health and prevention of illness and injury based upon the nursing process which includes systematic data gathering, assessment, appropriate nursing judgment and evaluation of human responses to actual or potential health problems through such services as case finding, health teaching, health counseling; and provision of care supportive to or restorative of life and well-being, and executing medical regimens including administering medications and treatments prescribed by a licensed or otherwise legally authorized physician or dentist. A nursing regimen shall be consistent with and shall not vary any existing medical regimen.

PRACTICE OF PRACTICAL NURSING The performance, for compensation, of acts designed to promote and maintain health, prevent illness and injury and provide care utilizing standardized procedures and the nursing process, including administering medications and treatments, under the direction of a licensed professional nurse or a licensed or otherwise legally authorized physician or dentist. Such practice requires basic knowledge of the biological, physical, and behavioral sciences and of nursing skills but does not require the substantial specialized skill, independent judgment, and knowledge required in the practice of professional nursing.

REGISTERED NURSE PRACTICE 610-X-6-.04 Care and Counseling of Patients Provision of Care Supportive to or Restorative of Life and Well Being Exercise of Appropriate Nursing Judgement

REGISTERED NURSE PRACTICE 610-X-6-.04 Promotion of Health & Prevention of Illness & Injury Conducting & Documenting Focused & Comprehensive Assessments to include the Evaluation of Patient Care

REGISTERED NURSE PRACTICE 610-X-6-.04 Documentation of Nursing Interventions & Responses to Care in an Accurate, Timely, Thorough, & Clear Manner Executing Medical Regimens according to Approved Medical Protocol, including Administering Medications & Treatments Prescribed by a Legally Authorized Prescriber

Acts designed to promote and maintain health Prevention of illness and injury Exercise of appropriate nursing judgement LICENSED PRACTICAL NURSE PRACTICE 6-X-6-.05

Conducting & Documenting Focused Nursing Assessments, to include the patient’s health status Collecting & Documenting Data Elements of a Comprehensive Assessment Administering Medications & Treatments, when ordered by a Legally Authorized Prescriber LICENSED PRACTICAL NURSE PRACTICE 6-X-6-.05

Provision of care under the direction of a registered nurse, physician, or dentist who considers the following elements: Knowledge, Skills, Experience Complexity of Assigned Task Health Status of Patient Documentation of Nursing Interventions & Responses to Care in an Accurate, Timely, Thorough, and Clear Manner LICENSED PRACTICAL NURSE PRACTICE 6-X-6-.05

COMPETENCE IN THE PRACTICE OF NURSING REGISTERED NURSE & LICENSED PRACTICAL NURSE Knowledge and Compliance with: Applicable statutes & regulations Standards of nursing practice Standardized procedures for nursing practice, including but not limited to facility Policy and Procedure (add standing orders & approved medical protocols for LPN) Maintenance of knowledge & skills in area of practice

COMPETENCE IN THE PRACTICE OF NURSING REGISTERED NURSE & LICENSED PRACTICAL NURSE Assumption for Responsibility for Recognizing Personal Limits of Knowledge & Experience Consulting with or Referring Patients to Other Healthcare Providers to Resolve Situations Beyond the Expertise of the Licensed Nurse

Educational preparation, initial and continued License status, including Board approval for advanced practice nursing State and federal statutes and regulations SCOPE OF A LICENSED NURSE State and nation standards appropriate to the type of practice Nursing Experience Limitations on scope, as determined by facility policy and procedure Demonstrated Competence Knowledge, skills, and ability to manage risks and potential complications

BOARD OF NURSING DEPARTMENT OF PUBLIC HEALTH REGULATIONS

ALABAMA STATE BOARD OF HEALTH REGULATIONS ON PRACTICE Assisted Living Specialty Care

ALF Page 5 420-5-4-.01 (2)(r) SCALF Page 4 420-5-20-.01 (2)(q) ADPH REGULATIONS "Licensed Practical Nurse" (LPN) means a person currently licensed as a Licensed Practical Nurse by the State of Alabama Board of Nursing in accordance with Code of Ala. 1975, Sections 3421-1, et. seq. ALF Page 6 420-5-4-.01 (2)(aa) SCALF Page 6 420-5-20-.01 (2)(z) "Registered Professional Nurse” (RN) means a person currently licensed as a Registered Professional Nurse by the State of Alabama Board of Nursing in accordance with Code of Ala. 1975, Section 34-21-21.

ALF Page 23 420-5-4-.03 (2)(d)2 & SCALF Page 22 420-5-20-.03 (2) (d)2 ADPH REGULATIONS An assisted living facility/Specialty Care Assisted Living shall obey all applicable federal, state, and local laws, ordinances, and regulations.

ADPH REGULATIONS ALF Page 51 420-5-4-.06 (5)(d) Nothing in these rules shall preclude a facility from using a licensed nurse employed by the facility or nursing agency to administer medications to any resident. A RN or LPN shall administer medications to residents in the assisted living facility only in accordance with physician orders and the Nurse Practice Act. SCALF Page 52 420-20-5-.06(5)(d) Medication administration, as defined in these rules, shall be conducted only by a physician or an RN or LPN. A RN or LPN shall administer medications to residents in the SCALF only in accordance with physician orders and the Nurse Practice Act.

SCALF Page 26 420-5-20-.04 (7) ADPH REGULATIONS Each facility shall have at least one RN. An RN may also serve as the administrator or as the care coordinator, but not as both. In all instances where the facility’s RN is assigned other duties as an administrator or care coordinator the facility must assure that the RN devotes sufficient time and effort to all clinical duties.

SCALF Page 26-27 420-5-20-.04 (7) (a) Responsibility. The RN shall be responsible for oversite and coordination of resident care. ADPH REGULATIONS (b) Care Coordinator. There shall be a care coordinator who will manage the daily routine delivery of resident care. This person shall be an LPN or RN. An LPN care coordinator shall work under the supervision of the RN in the management and delivery of resident care.

ADPH REGULATIONS ON RN DUTIES 420-5-20-.04 (7) Initial Assessment The RN shall assess the resident in the specialty care assisted living facility PSMS and Behavior Screen Focused Assessments Comprehensive Assessment Monthly Assessment

ADPH REGULATIONS ON RN DUTIES 420-5-20-.04 (7) The RN shall develop, document and evaluate resident plans of care At Admission With changes in medications, personal services, & change of condition Evaluate implementation of interventions & resident response & modify as necessary Coordinate with outside provider plans of care

ADPH REGULATIONS ON RN DUTIES 420-5-20-.04 (7) The RN shall consult with the Administrator on all issues of resident safety, health, and well being. The RN shall identify staff training needs and ensure needed training is appropriately provided. The RN shall communicate significant changes to the resident physician & sponsor. The RN shall direct the practice of any practical nurse.

FACILITY SUPPORT FOR RN ROLE Staffing Job Description Resident Care Supervision of Staff Policy and Procedures

POLICY ON RN OVERSIGHT Who Provides RN Oversight Frequency of RN Oversight How Oversight is Provided Directly Monitoring Responsibility Indirectly

ASSIGNMENT, DELEGATION & SUPERVISION 610-X-6-.01 (4)(5)(6) Assignment, Licensed Nurse Assignment, Unlicensed Individuals Delegation

ASSIGNMENT, DELEGATION & SUPERVISION 610-X-6-.11 (1) The registered nurse shall be accountable and responsible for the assignment of nursing activities and task to other health care workers based on, but not limited to: Knowledge, skills, and experience Complexity of assigned tasks Health status of the patient

Assignments may not exceed the scope of an individual licensed nurse’s scope of practice, including, but not limited to: ASSIGNMENT, DELEGATION & SUPERVISION 610-X-6-.11 (2) Educational preparation, initial & continued License Status State and Federal statutes & regulations State & national standards appropriate to the type of practice Nursing experience Demonstrated competence Consideration for patient safety Knowledge, skills, & ability to manage risks & potential complications

The licensed nurse shall delegate only after considering various factors, including but not limited to: ASSIGNMENT, DELEGATION & SUPERVISION Knowledge, skills, and experience of the person receiving the delegation 610-X-6-.11 (3) Complexity of the delegated tasks Health status of the patient

ASSIGNMENT, DELEGATION & SUPERVISION 610-X-6-.11 (5)(6)(7) Supervision shall be provided to individuals to whom nursing functions & responsibilities are delegated or assigned. The practice of licensed practical nursing shall be directed by a registered nurse, physician or dentist A licensed practical nurse or unlicensed individual may not supervise, direct, or evaluate the nursing care provided by the registered nurse.

THE RN SHALL DIRECT THE PRACTICE OF ANY PRACTICAL NURSE

BEST PRACTICES FOR RN OVERSIGHT Follow Facility Policy and Procedure Document the Supervision and Note any practice issues observed Understand Direct and Indirect Supervision Demonstrated Competence Provide Training for any noted practice issues Schedule Follow Up Supervision Visit to ensure resolution of practice issues

POLICY AND PROCEDURE

Definition: DIRECT SUPERVISION 610-X-6-.01 (19) Responsible licensed nurse is physically present in the facility and readily accessible to designate or prescribe a course of action or to give procedural guidance, direction, and periodic evaluation. Direct supervision by a registered nurse is required for new graduates practicing on a temporary permit.

DIRECT SUPERVISION: BEST PRACTICES Facility Rounds Observe Nurse Interactions with Residents Observe Resident Needs are Met Observation of Medication Pass Confidentiality Infections Control Timeliness Accuracy Documentation Audit of Medication Cart &/or Storage Areas

DIRECT SUPERVISION: BEST PRACTICES Oxygen Storage and Administration Shadow/Observe the Nurse while conducts routine task: Assessments Transcribes orders Implements orders / care plans Communicates with MD / sponsors Privacy with Confidentiality Accuracy with documentation

Definition: INDIRECT SUPERVISION 6-X-10-6-.01 (20) Responsible licensed nurse is available for periodic inspection and evaluation through physical presence, electronic or telephonic communication for direction, consultation, and collaboration.

INDIRECT SUPERVISION: BEST PRACTICES Establish Protocols When Licensed Nurse Consults with RN Documents to be Sent to RN for Review/Input Review Nurse Documentation Initial Assessments Focused/Comprehensive Assessments Monthly Assessments Weights Care Plans 3 Way Medication Reconciliation

SUPERVISION DIRECT Med Pass – documentation timely Assessment Resident properly assessed Hands washed Privacy Protected Documentation Timely INDIRECT MAR Review – documentation complete Assessment – documentation complete

RN OVERSIGHT BEST PRACTICES Documentation of Supervision & Note of Any Practice Issue Provide Training for Any Noted Practice Issue Schedule Follow Up Supervision Visit to Ensure Resolution of Practice Issue

COMPETENCIES New Hire Training Demonstrated Skills Periodic Supervision Annual Competency