Standards of Practice for the Alabama Nurseanha.org/members/documents/NsgHAHOsJune2k12.pdf · ABN...

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Standards of Practice for the Alabama Nurse

Carolyn Morgan, MSN RN Nurse Consultant for Prac:ce & Con:nuing Ed

Alabama Board of Nursing

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Objectives

•  Iden:fy sec:ons of the ABN Administra:ve Code that apply to daily nursing prac:ce.

•  Apply ABN Standards of Nursing Prac:ce to specific prac:ce situa:ons.

•  List the 5 elements required in the Standardized Procedures Rule

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Abandonment De:ined

• Acceptance of a pa:ent assignment, •  thus establishing a nurse‐pa:ent rela:onship, and

•  then ending the nurse‐pa:ent rela:onship • Without giving reasonable no:ce to supervisory personnel so that others can make arrangements for con:nua:on of nursing care.

ABN Administra:ve Code Rule 610‐X‐8‐.01(1)

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Alabama Board of Nursing •  Established in 1915

•  Ini:al approach was to standardize nursing educa:on requirements

•  Voluntary registra:on

•  Prac:cal nurses first came into being aYer World War II

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Mission of the ABN

•  The mission of the Alabama Board of Nursing is •  to promote and safeguard the public health and welfare •  through licensing and approval of qualified individuals •  Adop:ng & enforcing legal standards for nursing educa:on and prac:ce

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Composition of the ABN

•  8 RN Posi:ons (1 PRACTICE vacancy beginning in 2013) •  3 (Three) must be from prac:ce or administra:on •  3 (Three) must be from nursing educa:on •  2 (Two) must be advance prac:ce nurses

•  4 LPN Posi:ons •  2 Nominated by Licensed Prac:cal Nurses Associa:on of Alabama (LPNAA) •  2 Nominated by Alabama Federa:on of Licensed Prac:cal Nurses (AFLPN)

•  1 Consumer •  No financial gain from health care and not previously a health care professional

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Nurse Consultants of ABN under Executive Of:icer, Genell Lee

•  Legal Nurse Consultants (2) • VDAP Nurse Consultant • Proba:on Nurse Consultant •  Educa:on Nurse Consultant • Advance Prac:ce Nurse Consultant • Prac:ce Nurse Consultant • Con:nuing Educa:on Nurse Consultant

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ABN Attorneys & Investigators •  ABN A_orney is a Deputy A_orney General

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Legal Foundation of Nursing Practice

• Nurse Prac*ce Act: statutes passed by legislature: broad language: provides authority for Board to pass regula:ons

• ABN Administra*ve Code: regula:ons passed by Board to clarify, amplify, and explain the statutes •  Proposed rules posted on Board’s web site •  Requires 35 day public no:ce and comment period •  If Board approves, rules become effec:ve in another 35 days aYer filing 9

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Licensure ABN Administra:ve Code

Chapter 610‐X‐4

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Licensure is Required to practice Nursing in Alabama NPA Article 2 § 34‐21‐20. •  Represents

•  Specialized knowledge

•  Independent judgment

•  Fitness and Capacity to Prac:ce

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Temporary Permit •  A first :me applicant for licensure by examina:on may request a nonrenewable temporary permit to prac:ce nursing that is valid un:l

•  The applicant fails the licensing examina:on.

•  The expira:on date on the permit is reached.

• A license is issued.

•  The applicant is denied licensure. ABN Administra:ve Code Rule 610‐X‐4‐.04

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Temporary Permit •  Signature:

– RN Program = NG‐RNP • EXAMPLE:

CMorgan NG-RNP

• LPN Program = NG‐PNP • EXAMPLE:

CMorgan NG-PNP –  Administra:ve Code § 610‐X‐4‐.04 (5)(b)

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Restrictions of Temporary Permit The Nursing Graduate •  (1) Must func:on under DIRECT Supervision of a currently licensed RN

[ABN Administra:ve Code Rule 610‐X‐4‐.04(5)(b)(i)]

•  What is Direct Supervision? Licensed RN physically present in facility and readily

accessible to designate or prescribe a course of ac:on or to give procedural guidance, direc:on, and periodic evalua:on.

[ABN Administra:ve Code Rule 610‐X‐4‐.01(7)]

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Restrictions of Temporary Permit Cont’d The Nursing Graduate •  (2) Shall NOT assume nor be assigned charge responsibili:es

[ABN Administra:ve Code Rule 610‐X‐4‐.04(5)(b)(ii)]

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License Renewal RN •  The registered nurse license shall be valid for two years

beginning January 1 of each ODD‐numbered year and expiring December 31 of each even‐numbered year.

[ABN Administra:ve Code Rule 610‐X‐4‐.08(1)(a)]

LPN •  The prac:cal nurse license shall be valid for two years beginning January 1 of each EVEN‐numbered year and expiring December 31 of each odd numbered year.

[ABN Administra:ve Code Rule 610‐X‐4‐.08(1)(b)]

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Renewal Period

• RENEWAL period ‐ shall be from September 1 to November 30 of the year the license expires.

[ABN Administra:ve Code Rule 610‐X‐4‐.08(3)(a)]

• Renewal from December 1 – December 31 results in LATE Renewal Fee + license fee

[ABN Administra:ve Code Rule 610‐X‐4‐.08(3)(b)]

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RULE: Special Circumstances ABN Administrative Code Rule 610‐X‐4‐.16

•  In the event the Governor proclaims a state of emergency impac:ng any part of Alabama, Code of Alabama, 1975 Sec:on 34‐21‐6 applies for the first thirty (30) days.

•  An individual licensed to prac:ce nursing in another state may provide emergency assistance in Alabama for up to thirty (30) days subject to verifica:on of licensure in the state where licensed.

•  Any organiza:on or individual who provides employment or volunteer opportuni:es for the licensed nurse providing nursing services is responsible to assure the validity of the nursing license.

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Special Circumstances Cont’d

•  Should an emergency con:nue past thirty days, a temporary permit to prac:ce nursing in Alabama for 90 days is required.

• An applica:on for an emergency temporary permit is required to be submi_ed to the Board either electronically or by mail.

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• Any individual licensed to prac:ce nursing in another state is required to have an Alabama license if educa:onal or consulta:ve services extend beyond 30 calendar days in one year.

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RETIRED STATUS •  A LPN or RN who re:res or ceases nursing prac:ce for any reason and has no inten:on to prac:ce in the future may apply to the Board for an inac:ve license with a “re:red” status.

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Rules of Prac:ce in Alabama

Disclaimer: ALL rules of Prac:ce will NOT be discussed or referenced. The individual nurse is responsible for the laws and rules regarding

nursing.

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Conduct and Accountability

• What is Accountability? Answerable or responsible for ac:ons

• What is Responsibility? The charge to do something that is expected performance.

•  Shall = mandatory

Administra:ve Code Rule 610‐X‐6‐.01(1)(16)(17)

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Conduct and Accountability

The RN & LPN SHALL • Have knowledge and understanding of the laws and rules regula:ng nursing.


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NURSE PRACTICE ACT

& ADMINISTRATIVE CODE

Federal Laws HIPAA, ADA, EMTALA, CLIA, OSHA, Civil Rights, etc.

Board of Medical

Examiners

Board of Pharmacy

Accrediting Bodies JCAHO, CHAPS

Other Professional Boards/Rules

Physical Therapy, Speech Therapy, etc

Facility/Agency Policies & Procedures

Federal Laws Specific to

Facility Type COPS

Rules/Laws of State Agencies (Departments) ADEM, ADPH, etc

Other Laws, Rules and Regulations can NOT weaken the Nurse Practice Act and Administrative Code but do in>luence Nursing Practice

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Non-Inclusive List

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Conduct & Accountability Scope of Practice Cont’d The RN and LPN SHALL •  Func:on within the LEGAL SCOPE of nursing prac:ce.


Scope of Prac:ce ‐ procedures and ac:ons that are permi_ed for the licensed individual

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Scope of practice Includes but is not limited to:

•  Educa:onal prepara:on, ini:al and con:nued. •  License status, including Board approval for advanced prac:ce nursing as detailed in Chapters 610‐X‐5 and 610‐X‐9 of these rules.

•  State and federal statutes, and regula:ons.

ABN Administra:ve Code Rule 610‐X‐6‐.04(3) and 610‐X‐6‐.05(3) 32

Scope of practice Includes but is not limited to: Cont’d •  State and na:onal STANDARDS appropriate to the type of prac:ce.

What are Standards of Prac:ce? •  Level of performance that is

•  Desired and •  Achievable

•  Expecta:on for nurses’ conduct and prac:ce 33

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Where do standards come from?

•  Laws and Regula:ons •  Nurse Prac*ce Act •  ABN Administra*ve Code

•  Agency/Facility Policies & Procedures

•  Nursing Educa:on •  Professional Associa:ons – including but not limited to:

•  American Nurses Associa*on (ANA) •  Infusion Nurses Society •  American Gastroenterology Associa*on •  WOCN (Wound Ostomy & Con*nence Nurses Society) •  Nephrology Nursing Associa*on

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Scope of Practice Includes but is not limited to: Cont’d

• Nursing experience.

•  Limita:ons on scope as determined by facility policy and procedure.

Part of the answer to EVERY ques:on about scope of prac:ce:

What does your Facility P&P say about this? 35

Scope of Practice Includes but is not limited to: Cont’d

• Demonstrated competence. • Knowledge, skills, and ability to manage risks and poten*al complica*ons.

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Conduct and Accountability Cont’d

•  The RN and LPN shall •  Be RESPONSIBLE AND ACCOUNTABLE for the QUALITY of nursing care delivered to pa:ents •  based on and LIMITED to

•  scope of educa:on, • demonstrated competence, and • nursing experience

Administra:ve Code Rule 610‐X‐6‐.03(4).

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The RN and LPN shall •  Accept individual RESPONSIBILITY & ACCOUNTABILITY for

•  Judgments, • Ac:ons

Administra:ve Code § 610‐X‐6‐.03(7)

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Frequent Misconceptions often resulting in Disciplinary Action

From the Nurse •  “Because a doctor told me to do a procedure (use the scalpel)/give a medica:on, it is OK.”

From the Physician •  “Because I told the nurse to do a procedure(use a scalpel) /give a medica:on, it is OK”

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Conduct and Accountability Cont’d The RN and LPN shall • Accept individual RESPONSIBILITY & ACCOUNTABILITY for • Nursing competency remaining current with

•  technology and

 Prac:cing consistent with facility policies & procedures

ABN Administra:ve Code Rule 610‐X‐6‐.03 (7)

Competency COMPETENCE in the prac:ce of nursing by an RN & in the prac:ce of prac:cal nursing by an LPN shall include, but is not limited to: •  Knowledge and compliance with:

•  Applicable statutes and regula:ons. •  Standards of nursing prac:ce.

ABN Administra:ve Code Rules 610‐X‐6‐.04(2) and .05(2)

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Competency Cont’d COMPETENCE in the prac:ce of nursing ….SHALL Include •  Standardized procedures for nursing prac:ce, including but not limited to facility policies and procedures.

• Maintenance of knowledge & skills in the area of prac:ce

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The RN and LPN shall •  Accept individual RESPONSIBILITY &

ACCOUNTABILITY for

– Recognition

–  and

– Appropriate nursing action following a change in the patient’s mental or physical status

ABN Administrative Code Rule 610-X-6-.03(8) 43

Conduct and Accountability Cont’d The RN and LPN shall •  Prac:ce in compliance with current CDC standards of standard precau:ons and infec:on control, including asep:c technique.

ABN Administra:ve Code Rule 610‐X‐6‐.03(9) 44


The RN and LPN shall •  Prac:ce without discrimina:on on the basis of

•  age, •  race, •  religion, •  gender, •  na:onal origin, •  sexual orienta:on, •  pa:ent diagnosis or •  disability. 45

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Conduct and Accountability Cont’d •  Respect the dignity and rights of pa*ents and their significant others including, but not limited to: •  Privacy. •  Safety. •  Protec:on of confiden:al informa:on, unless disclosure is required by law.

•  Freedom from exploita:on of physical, mental, sexual, or financial boundaries.

•  Protec:on of real and personal property.

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Conduct and Accountability Cont’d The RN and LPN shall •  Respect the dignity and rights of pa:ents and their significant others including, but not limited to:  Behavior that is therapeu:c and places the pa:ent’s interests before the nurse’s interest.

•  Accept individual accountability and responsibility to avoid personal disrup:ve behaviors that nega:vely impact pa:ent care

ABN Administra:ve Code Rule 610‐X‐6‐.03(11 f)(13) 47

Professional Boundary De:ined

• Behavior of the licensed nurse in maintaining a therapeu:c rela:onship with a pa:ent for the pa:ent’s benefit rather than behavior that lessens the pa:ent’s care and shiYs the focus to the licensed nurse.

ABN Administra:ve Code 610‐X‐6‐.01(14)

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Mandatory Reporting

The RN & LPN SHALL • Accept individual RESPONSIBILITY & ACCOUNTABILITY for :mely repor:ng of •  Illegal •  Substandard • Unethical • Unsafe •  Incompetent nursing care DIRECTLY to the Board of Nursing

ABN Administra:ve Code Rule 610‐x‐6‐.03(14) 49

Complaints to ABN

• Must be in wri:ng •  Email ([email protected]) •  Le_er (Address on back of license card) •  Form (website under Forms & Other Informa:on)

•  Employer ‐Employers Report of Possible Viola:on Form •  Consumer ‐Consumers Report of Possible Viola:on Form

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Documenta:on Standards

ABN Administra:ve Code 610‐X‐6‐.06

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Conduct & Accountability re: Documentation

The RN and LPN shall Accept individual RESPONSIBILITY & ACCOUNTABILITY for

•  accurate, •  complete and •  legible documenta:on related to:

•  Pa:ent care records. •  Health care employment. •  Licensure and other creden:als. •  Con:nuing educa:on records.


Documentation

• Documenta:on standards……regardless of the documenta:on format

• Documenta:on of nursing care SHALL be: •  Legible •  Accurate •  COMPLETE

ABN Administra:ve code Rule 610‐X‐6‐.06

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Complete Documentation includes

• Repor:ng & documen:ng on appropriate records a pa:ent’s status including •  Signs & Symptoms •  Responses •  Treatments • Medica:ons •  Other nursing care rendered •  Communica:on of per:nent informa:on to other health team members

•  Unusual occurrences involving the pa:ent •  Signature of the writer, whether electronic or wri_en, is REQUIRED 57

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Complete Documentation Cont’d •  Timely

•  Charted at the :me or aYer the care, including medica:ons is provided.

•  Char:ng prior to care being provided, including medica:ons, violates principles of documenta:on.

•  Documenta:on of pa:ent care that is not in the sequence of the :me the care was provided shall be recorded as a “late entry” including a date and :me the late entry was made as well as the date & :me the care was provided.

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Mistaken Entry & 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.

• Correc:ons to a record by a licensed nurse shall have the name or ini:als of the individual making the correc:on.

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Rules on Documentation Cont’d

The Prac:ce of PROFESSIONAL NURSING includes •  Conduc:ng and documen*ng comprehensive assessments and evalua:ons of pa:ents and focused nursing assessments

•  Documenta*on of nursing interven:ons and responses to care in an accurate, :mely, thorough and clear manner.

The Prac:ce of PRACTICAL NURSING includes •  Conduc:ng and documen*ng focused nursing assessments of the health status of pa:ents.

•  Conduc:ng and documen*ng data elements of the comprehensive assessment.

•  Documenta*on of nursing interven:ons and responses to care in an accurate, :mely, thorough and clear manner

ABN Administra:ve Code 610‐X‐6‐.04 & .05 .

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Grounds for Disciplinary Action regarding

Documentation

•  Failure to make entries (NEVER discard pages from PERMANENT pa:ent record)

•  Destroying or altering entries (Recopy, for legibility, and label the page: keep old and new pages together)

•  Pre‐char*ng ‐ Char:ng BEFORE assessment or delivery of care •  Medica:on •  Treatment •  Assessment

ABN Administra:ve Code Rule 610‐X‐8‐.03(6g,h)

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Medica'on Administra'on & Safety

ABN Administra've Code Rule 610‐X‐6‐.07

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Medication Administration

•  Prac:ce of Professional Nursing includes…. Execu:ng medical regimens including administering medica:ons and treatments prescribed by a licensed or otherwise legally authorized prescriber.

ABN Administra:ve Code Rule 610‐X‐6‐.04 (1)(g)

•  Prac*ce of Prac*cal Nursing includes…. Administering medica:ons and treatments when ordered by a legally authorized prescriber.

ABN Administra:ve Code Rule 610‐X‐6‐.05(1)(e)] 63

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Medication Administration Cont’d The RN or LPN SHALL have applied knowledge of medica:on administra:on & safety including but not limited to: • Drug ac:on

• Classifica:ons

•  Expected therapeu:c benefit of medica:on

•  Expected monitoring

•  Indica:ons based on exis:ng pa:ent illness or injury processes

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Medication Administration Cont’d

• Contraindica:ons based on presence of addi:onal known pa:ent illnesses, disease processes, or pre‐exis:ng condi:ons

• Possible side effects and interven:ons for same

• Adverse reac:ons & interven:ons for same

•  Emergency interven:ons for anaphylac:c reac:ons

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• Right pa:ent

• Right medica:on

• Right :me

• Right dose

• Right route

• Right reason

• Right documenta:on

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• Safety precau:ons including but not limited to:

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•  Interac:ons with other drugs, foods or complementary therapies

• Calcula:on of drug dosages

•  Federal and state legal requirements related to storage of controlled substances

• Pa:ent educa:on specific to medica:on. 67


The RN or LPN shall exercise decision making skills when administering medica:ons to include but not limited to: •  If medica:ons should be administered

• Assessment of pa:ent’s health status and complaint prior to and aYer administering medica:ons including PRNs 68

Medication Administration Cont’d Cont’d….skills when administering medica:ons • When to contact the prescriber

• Medica:on educa:on of pa:ent, family and caregiver

• Physical ability to open medica:on packaging and access delivery systems

• Read, write and comprehend English 69

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Medication Administration Cont’d Cont’d….skills when administering medica:ons •  Read, write, and comprehend scien:fic phrases relevant to administra:on of medica:on

• Measuring medica:on dosages

• Math calcula:ons

•  Routes of administra:on

•  Proper usage of technical equipment for medica:on administra:on 70

Medication Administration Cont’d Cont’d…..skills when administering medica:ons • Documenta:on of medica:on administra:on

•  shall comply with the principles of documenta:on and

•  include safety precau:ons of •  medica:on administra:on, •  controlled drug records per federal and state law, and

•  facility policy 71


•  Topical, intradermal, subcutaneous, or IM administra:on of a local anesthe:c agent in a specific amount….

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•  IV CHEMOTHERAPEUTIC AGENTS may be administered by RN following par:cipa:on in •  Organized program of study •  Supervised clinical prac:ce •  Demonstrated clinical competence •  Annual Evalua:on of competence

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ABN ADMINISTRATIVE CODE RULE 610‐X‐6‐.11

Assignment, Delega:on & Supervision

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Conduct & Accountability: Assignment

The RN & LPN SHALL • Accept individual RESPONSIBILITY AND ACCOUNTABILITY for the assignment of tasks to others


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ASSIGNMENT ‐ de:ined •  To Licensed Nurse ‐ The transfer of responsibility and accountability for nursing ac:vi:es from one licensed nurse to another.

•  To Unlicensed Individual ‐ the designa:on of tasks from a licensed nurse to unlicensed assis:ve personnel. The licensed nurse making the assignment retains accountability for accurate and :mely comple:on and outcome of the tasks

ABN Administra:ve Code Rule 610‐X‐6‐.01(4)(5) 76

Conduct & Accountability: Assignment

The RN & LPN SHALL •  Assess individual competency when assigning selected components of nursing care to other health care workers including but not limited to: •  (a) Knowledge, skills and experience.

•  (b) Complexity of assigned tasks.

•  (c) Health status of the pa:ent.


Conduct & Accountability: Assignment Cont’d The RN shall be ACCOUNTABLE AND RESPONSIBLE for the assignment of nursing ac:vi:es and tasks to other health care workers based on but not limited to: •  (a) Knowledge, skills and experience.

•  (b) Complexity of assigned tasks.

•  (c) Health status of the pa:ent.

ABN Administra:on Code Rule 610‐X‐6‐.11(1)

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Conduct & Accountability: Assignment Cont’d •  Assignments may not exceed the scope of an individual RN or LPN’s scope of prac:ce including, but not limited to: •  Educa:onal prepara:on, ini:al and con:nued. •  License status. •  State and federal statutes, and regula:ons. •  State and na:onal standards appropriate to the type of prac:ce. •  Nursing experience. •  Demonstrated competence. •  Considera:on for pa:ent safety. •  Knowledge, skills, and ability to manage risks and poten:al complica:ons.


DELEGATION: de:ined

•  The act of authorizing a competent individual to perform selected nursing ac:vi:es suppor:ve to RNs or LPNs in selected situa:ons while retaining the accountability for the outcome if the delega*on is to an unlicensed individual


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Conduct & Accountability: DELEGATION Cont’d

The RN & LPN SHALL •  Accept individual responsibility and accountability for

•  proper DELEGATION of nursing care ac:vi:es to other health care workers.


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Delegation to UNLICENSED persons Tasks delegated to unlicensed assis:ve personnel may NOT include tasks that require: •  The exercise of independent nursing judgment or interven:on.

•  Invasive or sterile procedures. •  Finger s:cks are NOT an invasive or sterile procedure within the meaning of these rules.

•  Peripheral venous phlebotomy for laboratory analysis is NOT an invasive or sterile procedure within the meaning of these rules.

•  The assistance with medica:ons except as provided in Chapter 610‐X‐7.


SUPERVISION: de:ined DIRECT Supervision: responsible licensed nurse •  physically present in facility and •  readily accessible to designate or prescribe a course of ac:on or

•  to give procedural guidance, direc:on, and periodic evalua:on. Direct supervision by RN is required for new graduates prac:cing on a temporary permit.


Supervision: de:ined Cont’d INDIRECT Supervision: Responsible licensed nurse is •  available for periodic inspec:on and evalua:on through •  physical presence, •  electronic or •  telephonic communica:on for direc:on, consulta:on, and collabora:on


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Conduct and Accountability: Supervision Cont’d The RN or LPN shall be responsible and accountable for

•  the quality of nursing care delivered to pa:ents by nursing personnel under the individual nurse’s supervision


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Conduct and Accountability: Supervision Cont’d •  Supervision shall be provided to individuals to whom nursing func:ons or responsibili:es are delegated or assigned.

•  The prac:ce of LPN shall be directed by a RN or physician or den:st.

• A LPN or unlicensed individual may not supervise, direct, or evaluate the nursing care provided by the RN.

ABN Administra:ve Code Rule 610‐X‐6‐.11 (5‐7) 86

ASSESSMENT STANDARDS

ABN Administra:ve Code Rule 610‐X‐6‐.09

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Assessment The prac:ce of professional nursing includes but is not limited to: •  Conduc:ng & documen:ng

•  COMPREHENSIVE assessments •  EVALUATIONS of pa:ents •  FOCUSED assessments

ABN Administra:ve Code Rule 610‐X‐6‐.04(1) (e)

The prac:ce of prac:cal nursing includes but is not limited to: •  Conduc:ng & documen:ng FOCUSED nursing assessments of the

health status of pa:ents •  Conduc:ng & documen:ng DATA ELEMENTS of the comprehensive

assessment ABN Administra:ve Code Rule 610‐X‐6‐.05(1)(d)(e) 88

COMPREHENSIVE ASSESSMENT: de:ined Assessment, COMPREHENSIVE: the systema:c collec:on and analysis of data including the •  physical, •  psychological, •  social, •  cultural and •  spiritual aspects of the pa:ent by the RN for the purpose of judging a pa:ent’s health and illness status and actual or poten:al health needs.


COMPREHENSIVE ASSESSMENT: de:ined Cont’d COMPREHENSIVE assessment includes •  PATIENT HISTORY,

•  PHYSICAL EXAMINATION

•  ANALYSIS of the data collected,

•  DEVELOPMENT of the pa:ent plan of care, •  IMPLEMENTATION AND EVALUATION of the plan of care.

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FOCUSED Assessment : de:ined Assessment, FOCUSED: An appraisal of a pa:ent’s status and specific complaint through •  OBSERVATION and

•  COLLECTION of objec:ve and subjec:ve DATA by the RN or LPN.

ABN Administra:ve Code 610‐X‐6‐.01(3)

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FOCUSED Assessment : de:ined Cont’d FOCUSED assessment involves

•  IDENTIFICATION of normal and abnormal findings,

• ANTICIPATION AND RECOGNITION OF CHANGES OR POTENTIAL CHANGES in pa:ent’s health status, and

• MAY CONTRIBUTE to a comprehensive assessment performed by the RN.

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Assessment RN SHALL conduct & document comprehensive & focused nursing assessments of the health status of pa:ents by •  Collec:ng objec:ve & subjec:ve data from

•  Observa:ons

•  Physical examina:ons

•  Interviews

• Wri_en records In an accurate & :mely manner as appropriate to the pa:ent’s health care needs

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Assessment by RN Cont’d RN SHALL conduct •  ANALYSIS & REPORTING of data collected

•  DEVELOPING plan of care based on pa:ent assessment

•  MODIFYING the plan of care based upon the evalua:on of pa:ent responses to the plan of care including:

•  An:cipa:ng & recognizing changes or poten:al changes in pa:ent status

•  IDENTIFYING signs & symptoms of devia:on from current health status

•  IMPLEMENTING CHANGES in interven:ons 94

LPN’s Assessment Role LPN SHALL conduct & document FOCUSED nursing assessments of the health status of pa:ents by: •  Collec:ng objec:ve & subjec:ve data from

•  Observa:ons

•  Nursing examina:ons

•  Interviews

•  Wri_en records

In an accurate & :mely manner as appropriate to the pa:ent’s health care needs

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LPN’s Assessment Role Cont’d LPN SHALL collect data •  Dis:nguishing ABNORMAL FROM NORMAL data

•  RECORDING & REPORTING the data

•  An:cipa:ng & recognizing changes or poten:al changes in pa:ent status: Iden:fying signs & symptoms of devia:on from current health status

•  REPORTING FINDINGS of the FOCUSED nursing assessment to the •  RN •  licensed physician, •  advanced prac:ce nurse or •  Den:st

•  IMPLEMENTING the Plan of Care 96

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Pa:ent Care Orders


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Orders Alabama Nurse Prac:ce Act states •  “A nursing regimen shall be consistent with and shall not vary any exis:ng medical regimen.”

•  LPNs func:on “under the direc:on of a licensed professional nurse or a licensed or otherwise legally authorized physician or den:st.”

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Orders cont’d The Prac:ce of Professional Nursing includes….. •  Execu:ng medical regimens including administering medica:ons and treatments prescribed by a licensed or otherwise legally authorized prescriber.

ABN Administra:ve Code 610‐X‐6‐.04(1)(g)

The Prac:ce of Prac:cal Nursing includes…. •  Administering medica:ons and treatments when ordered by a legally authorized prescriber

ABN Administra:ve Code 610‐X‐6‐.05(1)(f)

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Patient Care Orders The RN AND LPN may receive orders from the legally authorized prescriber RELAYED by •  another LICENSED or REGISTERED Health Care Professional &

•  REGISTERED or CERTIFIED medical assistant The RN AND LPN may implement VERIFIABLE standing orders at the direc:on of a legally authorized prescriber.


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Legally Authorized Prescriber: de:ined •  “Legally Authorized Prescriber”

•  Licensed physician or den:st •  CRNP •  CNM •  LICENSED PA

REMEMBER that CRNPs & CNM may NOT order narco:c medica:ons


Prac:ce Beyond Basic Nursing Educa:on ‐ Standardized

Procedures

ABN Administra:ve Code 610‐X‐6‐.12

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Educational Preparation for Nursing Practice

• BASIC Nursing Prac:ce • Within basic educa:on program

• BEYOND BASIC Educa:on •  Requires Standardized Procedure

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Basic vs. Beyond Basic

BASIC Educa:on •  Foley catheter Inser:on

•  Tracheostomy CARE

•  Hanging IV Piggybacks

BEYOND Basic Ed •  Suprapubic Catheter: Reinser:on of Mature

•  Tracheotomy: Reinser:on of Mature

•  IV Pushes

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Standardized Procedure: de:ined A standardized procedure is a

• wri_en policy or protocol •  establishing the permissible func:ons, ac:vi:es, and level of supervision of registered nurses and licensed prac:cal nurses

• within a licensed hospital seyng (legal defini:on)

•  that are beyond basic nursing educa:on prepara:on.

ABN Administra:ve Code 610‐X‐6‐.01(21) 105

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Legal De:inition of “Hospital”

Facility which has

•  an organized medical staff or

•  employs services of a medical director who is a physician licensed to prac:ce medicine in Alabama.

Alabama Code 1975 § 22‐21‐20(1)

ABN Administra:ve Code §610‐X‐6‐.01(8)

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“Licensed Hospital” •  Includes but not limited to:

•  Acute and Long Term Care Hospitals

• Long Term Care Facili:es (nursing homes)

•  Home Health Agencies •  Hospice Agencies •  Ambulatory Surgery Centers •  ESRDs •  Medical Transport Companies (helicopter, fixed wing and ground)

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Looking at the SP Rule

•  For prac:ce beyond basic educa:on that has NOT BEEN PREVIOUSLY APPROVED by the Board, a standardized procedure is required for the RN or LPN in ANY prac:ce seyng.

How do you know if a procedure has been previously approved by the ABN?

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109

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112

Components of Standardized Procedure

•  Applica:on, if required •  Policy and Procedure

•  Organized Program of Study

•  Plan for Supervised Clinical Prac:ce

•  Plan for Demonstra:on of Competency •  Ini:ally and •  At Periodic Intervals 113

Agency/Facility Documentation For each procedure beyond basic educa:on, the agency/facility must maintain a copy of •  Policy and procedure •  Organized program of study •  Evidence of supervised clinical prac:ce •  Evidence of competency determina:on

•  Ini:ally •  Periodic Intervals

•  Applica:on submi_ed to ABN, if applicable •  Signed le_er for approval from ABN, if applicable and ADD the procedure to next year’s Annual Report of Standardized Procedures

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Where can you receive training for a new procedure?

Resources include but are not limited to:

•  Manufacturer (PICCs, Insulin Pumps, Glucometers, Gastrostomy tubes, Inhalers)

•  Pharmaceu:cal Companies (Epi pens, medica:ons)

•  Hospital/Medical Center Educa:on Departments

•  Doctor’s office

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REMINDER: Standardized Procedures are facility/agency/company speci:ic

• Nurse (RN or LPN) working in Facility A that has approval to apply and manage a wound vac can NOT perform that procedure in Facility B if Facility B does not have approval from the ABN &/or their policies do not allow nurses to perform that procedure.

116

REMINDER: Standardized Procedures are Speci:ic to the APPROVED Application

•  If Facility A’s standardized procedure is for the nurse to perform a selected procedure (wound vac applica:on) in the Demen:a unit, the nurse can NOT perform that procedure outside the Demen:a unit.

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Standards for WOUND Assessment and CARE


118

WOUND CARE It is within the scope of a RN or LPN to perform wound assessments including, but not limited to, •  STAGING of a wound and

•  Making determina:ons as to whether wounds are PRESENT ON ADMISSION to a healthcare facility •  pursuant to an approved standardized procedure, outlined in Rule 610‐X‐6‐.12, Standardized Procedures, including supervised clinical prac:ce and demonstrated clinical competence, ini:ally and at periodic intervals.

119

Wound Care: Minimum Training Cont’d

The minimum training for the RN or LPN assessment and care shall include: •  Anatomy, physiology and pathophysiology. •  Fluid and electrolyte balance. •  Equipment and procedures used in wound assessment and care.

•  Chronic wound differen:a:on. •  Risk iden:fica:on. •  Measurement of wound. •  Stage of wound

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•  Condi:on of the wound bed including: •  Tissues. •  Exudate. •  Edges. •  Infec:on.

•  Skin surrounding the wound.

•  Pain. 121


•  Complica:ons, preven:on, and nursing interven:on. •  Iden:fica:on of any contribu:ng factors including but not limited to: •  Perfusion/oxygena:on •  Nutri:onal status •  Infec:on •  Medica:ons •  Diabetes

• Photographing wounds. 122

WOUND Assessment and CARE Cont’d

The RN & LPN may provide wound care beyond their basic educa:on in accordance with •  an order from an authorized prescriber

AND AFTER SUCCESSFUL COMPLETION OF •  an organized program of study, •  supervised clinical prac:ce and •  demonstrated clinical competence, ini:ally and at periodic intervals.

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Minimum Training for SELECTED TASKS •  Dressing changes including authorized prescriber ordered medica:on or topical treatment or topical dressing including •  Chemical debridement. •  Enzyma:c debridement. •  Autoly:c debridement. •  Applica:on & maintenance of wound vac therapy

•  Systemic support including but not limited to •  Adequate diet. •  Hydra:on. •  Turning and reposi:oning. •  Reducing shear and fric:on with movement.

•  Incon:nence Care 124

Sharp Debridement

•  Sharp debridement is reserved for RNs with NATIONAL CERTIFICATION that included •  didac:c instruc:on, •  supervised clinical prac:ce AND •  demonstra:on of competency, ini:ally and at periodic intervals.

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Intravenous (IV) Therapy by Licensed Practical Nurses

ABN Administra:ve Code Chapter 610‐X‐6‐.14

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PICC

Peripherally Inserted CENTRAL CATHETER

Other Central Catheters: Groshong, Hickman

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IV Therapy by LPNs

MINIMUM Requirements for LPN to perform IV therapy includes •  Successful comple:on of an organized program of study

•  Supervised clinical prac:ce

•  Demonstra:on of competency, ini:ally & at periodic intervals

128

IV Therapy by LPNs cont’d

MINIMUM TRAINING includes •  Anatomy and physiology. •  Fluid and electrolyte balance. •  Equipment and procedures u:lized in intravenous therapy

•  Complica:ons, preven:on, and nursing interven:on. •  Introducing a peripheral intravenous device on an adult pa:ent.

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Minimum training cont’d

•  Set‐up, replacement, and removal of intravenous tubing for gravity flow and/or pump infusion.

•  Intravenous fluid infusion calcula:ons, and adjustment of flow rates on intravenous fluids, and administra:on of intravenous medica:ons by piggyback.

•  Procedures for recons:tu:ng and administering intravenous medica:ons via piggyback including but not limited to pharmacology, compa:bili:es and flow rates.

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IV therapy by LPNs Cont’d

•  Medica:ons may be administered by LPNs through a PERIPHERAL intravenous catheter by intravenous push provided the following criteria are met:

•  A complete standardized procedure applica:on is submi_ed and approved by the Board PRIOR to implementa:on.

•  The medica:on(s) does not require the substan:al skill, judgment, and knowledge of a registered nurse.

•  Documented one year of experience with IV therapy,

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IV Therapy by LPNs cont’d

•  On site supervision by a RN at any :me IV push medica:on therapy is performed by a LPN •  The RN is required to be physically present and immediately available in the facility

•  Heparin (10 units:1 ml) flush or saline flush via a PERIPHERAL IV line is not a medica:on within the meaning of these rules.

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Prohibited IV Tasks for all LPNs Cont’d

•  Ini:a:on of IV therapy in a neonate • Administra*on of

•  Solu:ons requiring :tra:on – statement re: heparin drips

•  Blood or blood components •  Plasma volume expanders •  GP‐II‐B‐III‐A inhibitors (platelet‐aggregate inhibitors) •  Hyperalimenta:on by routes other than PERIPHERAL

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•  Administra:on of •  IV meds for purposes of procedural seda:on or anesthesia

•  IV medica:ons via push or bolus through a CENTRAL line

•  IV push insulin or chemotherapeu:c agents •  Does not preclude hanging a pre‐mixed bag of fluids containing addi:ves except for insulin & chemotherapeu:c agents

•  Any other drugs deemed to be inappropriate by the facility 134


• Accessing or programming an implanted IV infusion pump

• Repairing a central venous route access device • Performance of therapeu:c phlebotomy

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• Accessing a central venous route access device including but not limited to •  implanted ports and •  lines used for hemodynamic monitoring. •  CENTRAL venous catheters & devices including

•  Groshong catheters •  Hickman catheters •  PICC

•  These rules do NOT prohibit LPN from administering medica:ons via PIGGYBACK or in SECONDARY solu:ons via Central Lines

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Telecommunication for Pronouncement of Patient

Death ABN Administra:ve Code Rule 610‐X‐6‐.15

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Pronouncement of Patient Death • Code of Alabama 22‐31‐2, Public Health Law • Only physician can ‘pronounce’ cause of death

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Pronouncement of Patient Death Cont’d

•  The RN or LPN may RECEIVE a pronouncement of a pa:ent’s death FROM a physician via telecommunica:on without a physical examina:on of the pa:ent by that physician.

•  A facility policy shall specify the PERMISSIBLE PATIENT CONDITIONS for which the RN or LPN in a specific health care facility or agency may receive the pronouncement of a pa:ent’s death by telecommunica:ons.

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What reports must be sent to the ABN by the Chief Nursing Officer?

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Annual Report of Licensure

ABN Administra:on Code Rule 610‐X‐4‐.15

•  The director of nursing or other appropriate authority shall submit an annual report that includes all persons employed as LPNs or RNs according to guidelines provided by the Board.

•  Subscrip:on to the Board’s group online license verifica:on service shall serve as the annual report of employing agencies.

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Annual Report of Standardized Procedures ABN Administra:on Code Rule 610‐X‐6‐.12(6)

•  The chief nursing officer shall submit an annual report to the Board in a format specified by the Board.

142

Annual Report of Standardized Procedures

•  The chief nursing officer shall submit an annual report to the Board in a format specified by the Board.


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Purpose of Annual Report of Standardized Procedures

•  To iden:fy procedures in current nursing prac:ce

•  To promote congruence between nursing prac:ce and nursing educa:on

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Components of Annual REPORT of Standardized Procedures

•  Name of Procedure

•  Nurses allowed to perform that procedure in your facility/agency (RN, LPN, CRNP, CNS, CNM, CRNA, RNFA, SANE)

•  Limita:ons/Restric:ons

•  Supervision

•  Presence of Policy in facility

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No:ce of Annual Report of Standardized Procedures

•  Delivered to CNOs in late January via –  CNO Email Address List Serve – Weekly Round‐up

•  EXTREMELY Important that we have your correct email address

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Due Date April 15/16

What happens to what we send in? •  Data Compiled

– Procedures tallied per facility type

– Top Procedures per facility type reported • Hospitals by Licensed Bed Capacity

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2011 Annual Report of Care in Alabama Nursing & Rehabilita:on

Facili:es (Nursing Homes) Reflec:ng Care in 2010

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Nursing Homes RANKING in YEARLY REPORTS

Procedures 2011 2010 2009 2008 2007

Suprapubic Catheters: Reinsertion of Mature 1 2 2 3 2

Gastrostomy Tubes: Reinsertion of Mature 2 1 1 1 1

Central Lines, Ports & PICCs: Access, Management & Removal of PICC by RNs 3 3 3 2 3

Wound Vac: Application & Management 4 4 4 4 5

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Nursing Homes Cont’d RANKING in YEARLY REPORTS Procedures 2011 2010 2009 2008 2007 Nasogastric Tube: Insertion & Removal by LPN 6 5 5 5 4 Tracheotomy Tubes: Changing & Reinsertion Mature 5 6 6 6 7

Debridement of Pressure Ulcers: Chemically, Enzymatically & by ET Nurse 7 7 7 7 6

Wound Assessment: Staging & Measurement 8 8 9 9

out of top 10

Colostomy/Ostomy Management 9 9 8 8 9

Hyperalimentation, Adding Peripheral 10 10

out of top 10

out of top 10

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ADJUDICATION OF DISCIPLINE

Discipline, Removal from Prac:ce and

Readmission to Prac:ce

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Process •  Docketed in database

•  Reviewed by Execu:ve Officer

•  No:ce of Inves:ga:on sent to Nurse

•  Acknowledgment sent to Complainant

•  Subpoena(s) issued

•  Inves:gated

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NON‐Discipline Op:ons

•  No viola:on: Leeer of closure

•  No provable viola:on but conduct inappropriate: Leeer of Admonishment

•  VDAP – Drugs/Alcohol abuse & dependency – Mental Illness –  Impairment

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Discipline Op:on: Viola:on CAN be Proven

•  Informal vs. Formal Disposi:on –  INFORMAL:

• Consent Order • Voluntary Surrender (self‐revoca:on by nurse)

– FORMAL: Administra:ve Hearing

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Types of Discipline

•  Reprimand

•  Reprimand and Fine

•  Proba:on –  Fine –  Un:l condi:ons met –  Specific :me period (1‐5 years)

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Types of Discipline Cont’d •  Suspension:

–  Fine –  Un:l condi:ons met

•  Educa:on •  Chemical dependency evalua:ons

–  Certain :me period –  One year: automa:c revoca:on clause in consent orders if suspension extends beyond 12 months

•  Revoca:on –  Voluntary Surrender: Self‐revoca:on

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Con:nuing Educa:on

ABN Administra:ve Code Chapter 610‐X‐10

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Con:nuing Educa:on

24 contact hours required for license renewal unless license received within the earning period.

2 Types of PROVIDERS: •  ABN Approved Providers of CE •  Recognized Providers of CE

–  ABN Administra:ve Code Chapter 610‐X‐10 defines recognized providers.

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Con:nuing Educa:on Cont’d

To determine if a CE Provider is RECOGNIZED by ABN, ask the following ques:ons: IS THE PROVIDER •  A state board of nursing in the US or its territories? •  Accredited by a na:onal CE body such as ANCC or IACET? •  A na:onal nursing organiza:on that approved PROVIDERS of

CE? •  An Alabama Regulatory Board? •  Approved by the Accredita:on Council for Con:nuing Medical

Educa:on (ACCME)?

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Recognized Providers Cont’d

•  A standardized na:onal course APPROVED by a na:onal organiza:on?

•  A state nurses’ associa:on? •  A college or university that is accredited by an organiza:on

recognized by the US Department of Educa:on & have CE as part of their mission?

If the answer is YES, then the provider is recognized by the ABN If the answer is NO, then the provider is NOT recognized by the ABN

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IMPORTANT DIFFERENCES for the Nurse

ABN APPROVED PROVIDERS – Contact Hours must be electronically transmi_ed by the provider

RECOGNIZED PROVIDERS – •  Nurse must have a cer:ficate that includes at a minimum

the PRINTED name of course & provider, accredita:on statement, date of course and CONTACT Hours

•  Nurse must enter the contact hours manually into their Individual CE Record on the ABN website

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