Chapter XIII

RULES AND REGULATIONS REGARDING
THE DELEGATION OF NURSING TASKS

1.	Statement of Basis and Purpose

	The rules contained in this Chapter are adopted pursuant to authority granted the Board by C.R.S. 12‑38‑101 et seq., as amended, and specifically pursuant to authority granted in C.R.S. 12‑38‑132(6).

2.	The professional nurse is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she provides either directly or through the delegated care provided by others.  Supervision of personnel associated with nursing tasks is included in the legal definition of the practice of professional nursing.

3.	Definitions:  For the purposes of Chapter XIII of these rules, the following terms have the indicated meaning.

	3.1	"Board" means the State Board of Nursing.

	3.2	"Client" means the recipient of nursing care.

	3.3	"Delegatee" means an individual receiving the delegation who acts in a complementary role to the professional nurse and whom the professional nurse authorizes to perform a task that the individual is not otherwise authorized to perform.

	3.4	"Delegation" means the assignment to a competent individual the authority to perform in a selected situation a selected nursing task included in the practice of professional nursing as defined in section 12‑38‑103(10).

	3.5	"Delegator" means the professional nurse making the delegation; the delegator must hold a current, active license.

	3.6	Individualized Healthcare Plan (“IHP”) means a plan for a specific client that is developed by a professional nurse employed or contracted by the client’s school or licensed child care facility in conjunction with the client and parent or guardian and based on the practitioner’s orders for the administration of medications and/or treatments for the client.

3.7	"Licensed child care facility" means any facility licensed as a family child care home or child care center as required by C.R.S. 26-6-102.

3.8	“Medication” means any prescription or nonprescription drug as defined in C.R.S. 12-22-102.

3.9	“Practitioner” means a person authorized by law to prescribe treatment, medication or medical devices and acting within the scope of such authority.

3.10	“School” means any institution of primary or secondary education, including kindergarten.

	3.11	"Supervision" means the provision of guidance and review by a qualified professional nurse for the accomplishment of a nursing task or activity with initial direction of the task and periodic inspection of the actual act of accomplishing the task or activity, and evaluation of the outcome.

4.	Criteria for Delegation

	4.1	Any nursing task delegated by the professional nurse shall be:

		A.	Within the area of responsibility of the nurse delegating the task.

		B.	Within the knowledge, skills and ability of the nurse delegating the task.

		C.	Of a routine, repetitive nature and shall not require the delegatee to exercise nursing judgment or intervention.

		D.	A task that a reasonable and prudent nurse would find to be within generally accepted nursing practice.

		E.	An act consistent with the health and safety of the client.

		F.	Limited to a specific delegatee, for a specific client, and within a specific time frame, except for delegation in schools as described in Section 7 of this Chapter or delegation in a licensed child care facility as described in Section 9 of this Chapter.

	4.2	The delegatee shall not further delegate to another individual the tasks delegated by the professional nurse.

	4.3	The delegated task may not be expanded without the express permission of the delegating professional nurse.

	4.4	The professional nurse shall assure that the delegatee can and will perform the task with the degree of care and skill that would be expected of the professional nurse.

5.	Responsibility of the Delegator

	5.1	The decision to delegate shall be based on the delegator's assessments of the following:

		A.	The client's nursing care needs including, but not limited to, complexity and frequency of the nursing 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.

		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 availablity 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 care needs.

		E.	The availability of adequate supervision of the delegatee.
	
5.2	The delegator shall: 

A.	Explain delegation 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 task, or verify the delegatee’s competence to perform the delegated nursing task;

C.	Provide instruction on how to intervene in any foreseeable risks which may be associated with the delegated task.

	5.3	The delegator shall provide appropriate and adequate supervision to the delegatee to the degree determined by the professional nurse based on an evaluation of all factors indicated in 5.1 and if the delegated task is to be performed more than once, shall develop and employ a system for ongoing monitoring of the delegatee..

	5.4	The delegator shall evaluate on an ongoing basis the following:

		A.	The degree to which nursing care needs of the client are being met.

		B.	The performance by the delegatee of the delegated task.

		C.	The need for further instruction.

		D.	The need to continue or withdraw the delegation.

5.5	Documentation of delegation by the delegator in the client record shall adhere to generally accepted standards and minimally include, but not be limited to, the following:

A.	Assessment of the client.

B.	Identification of the task delegated, delegatee, delegator, time delegated, and time frame for which delegation is effective.

C.	Direction for documentation by the delegatee that the task or procedure was performed and the client’s response, if appropriate.

D.	Periodic evaluation of client’s response to the performed delegated task.

6.	Standards for the Accountability of the Delegator

	6.1	The delegator shall adhere to the provisions of the Nurse Practice Act and its rules and regulations.

	6.2	The delegator is responsible for the decision to delegate and assessments indicated in 5.1.

	6.3	The delegator is responsible for monitoring, outcome evaluation, and follow‑up of each delegation.

	6.4	The delegator is accountable for the act of delegating and supervising.

7.	Delegation of Administration of Oral, Topical and Inhaled Medications in Schools

7.1	A professional nurse employed or contracted by a school may delegate the administration of oral, topical (including eye and ear drops) and inhaled medications to a specific delegatee(s) for the population of a school, within a specific time frame not to exceed one school year.

7.2	A professional nurse employed by or contracted by a school district may delegate to one or more specific delegatee(s) who have successfully completed appropriate training the administration of emergency medications, prepackaged in unit dose preparations, including but not limited to injectable epinephrine where there is an emergency need for such treatment.  The professional nurse must provide to the delegatee a specific written protocol for each client as determined in the IHP.

7.3	The delegator shall not delegate the administration of medications in schools to any client where the route of medication administration is not included in 7.1 or 7.2. 

7.4	The delegator shall not delegate the administration of medications in schools where the administration requires the delegatee to exercise the judgment required of a professional nurse.

7.5	Medication administration must occur within the context of generally accepted standards, including authorization by an individual authorized by statute to prescribe, appropriate storage of medications, administration procedures including the use of pharmacy or pharmaceutical company labeled medications and documentation.

7.6	Nothing in this Section 7 shall be construed to prohibit a professional nurse from delegating a specific nursing task to a specific delegatee for a specific client in the school setting, as otherwise provided for and governed by the provisions of this Chapter XIII.

8.	Delegation of Insulin and Glucagon Administration in the School Setting and Licensed Child Care Facility

8.1	The injection of insulin or glucagon is a nursing task that may be delegated in accordance with the requirements of these rules.  The selection of the type of insulin and dosage level shall not be delegated.

8.2	An IHP shall be developed for any client receiving insulin in the school or licensed child care facility setting and shall include the training requirements for any delegatee involved in the injection of insulin or glucagon.  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:
a.	Carbohydrate counting
b.	Glucose testing
c.	Activation or suspension of an insulin pump
d.	Usage of insulin pens
e.	Medical orders
f.	   Emergency protocols related to glucagon administration

8.3	Insulin injection by the delgatee shall only occur when the delegatee has followed the guidelines of the IHP.

A.	Standard, invariable dosages of insulin may be injected by the delegatee as designated in the IHP after meeting the training requirements designated in the IHP to perform the injection.

B.	Variable, sliding scale or non-routine correction dosages of insulin, may be given by the delegatee only after:
a.	Following the guidelines of the IHP;
b.	Consulting with the delgator, parent or guardian, as designated in the IHP; and
c.	Verifying and confirming the type and dosage of insulin being injected. 

C.	Under Section 8.3, B, the injection by the delegatee is limited to a specific delegatee, for a specific client and for a specific time.

8.4	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 injection.

9.	Delegation of Administration of Medications in Licensed Child Care Facilities

9.1	A professional nurse employed or contracted by a licensed child care facility may delegate the administration of oral, topical, including eye and ear drops, and inhaled medication to a specific delegatee(s) for the population of the facility, within a specific time frame not to exceed one year.

9.2	A professional nurse employed or contracted by a licensed child care facility may delegate to one or more specific delegatee(s) who have successfully completed appropriate training in the administration of emergency medications, prepackaged in unit dose preparations, including but not limited to injectable epinephrine, where there is an emergency need for such treatment.  The professional nurse must provide to the delegatee a specific written protocol for each client as determined in the IHP.

9.3	The delegator shall not delegate the administration of medication in child care facilities to any client where the route of medication administration is not included in 8.1 and 8.2.

9.4	The delegator shall not delegate the administration of medications in child care facilities where the administration requires the delegatee to exercise the judgment required of a professional nurse.

9.5	Medication administration must occur within the context of generally accepted standards, including authorization by an individual authorized by statute to prescribe, appropriate storage of medications, administration procedures including the use of pharmacy or pharmaceutical company labeled medications and documentation.

9.6	Nothing in this Section 8 shall be construed to prohibit a professional nurse from delegating a specific nursing task to a specific delegatee for a specific child in the child care facility setting, as otherwise provided for and governed by the provisions of this Chapter XIII.

10.	Exclusions from this Rule

	10.1	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.

	10.2	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.

	10.3		The professional nurse who teaches the Child Care Medication Administration course required by the Colorado Department of Human Services shall not be considered to be delegating as defined by this Chapter XIII.

	10.4		Any child care provider as defined in 26-6-102(1.7) C.R.S. acting in compliance with 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 of the client to whom medications are administered;

				C.	Administer only routine medications as defined in 26-6-102(1.8) C.R.S. 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.