Form 8589 | Universal Rehabilitation Services

Nursing Special Needs: RN Delegation and Care Instructions for Assistive Personnel

Based on assessment and care plan

For:

Date:

Unlicensed Assistive Personnel (UAP), are described by the Texas Board of Nursing (TX BON) as assistive personnel without licensure.

Certified Nurse Assistants (CNAs) and Certified Medication Aides (CMAs) are not licensed, and are unlicensed assistive personnel.

Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) hold licensure.

Medications including OTCs and Vitamins

Administered:

Each Medication will be:

Self

self-administered by the individual himself/herself;

HMA

administered as a Health Maintenance Activity directed by the client's responsible adult (CRA);

Delegated

administered as a Delegated task trained and monitored by an RN;

not delegated per Human Resources Code, Title 11, Chapter 161, Subchapter D; or

nursing only, may only be given by a licensed nurse.

Self-Administration of Medication. Individual knows how to safely take each medication (what, why) dose, route and time of each medication.

Administration of Medication to an individual by a paid unlicensed person(s) to ensure that medications are received safely.

Health Maintenance Activity (HMA). Specific activities identified in TX BON §225.4(8)(A-D).

Delegation of Medication Administration. Authorization of an unlicensed person to provide nursing services.

Not Delegated. Delegation not required for oral, topical and metered dose inhalers.

Nursing Only: Task may only be performed by an RN or an LVN.

Administered

Medication

Dose

Frequency

Route

Purpose

Side Effects

Comments

HMAs exempt from delegation

May be performed by Assistive Personnel only as individually trained and directed by:

CRA Name

CRA Telephone No.

Back-up Telephone No.

as described

not applicable

Description of HMAs

RN Delegated Tasks

May be performed by Assistive Personnel only as individually authorized and directed by RN for this specific individual.

RN Telephone No.

RN After Hours or No Answer Telephone No.

Tasks:

as described

not applicable

Vital signs:

call if outside ranges listed

not applicable

Blood Pressure:

Heart Rate:

Weight:

Breaths:

Blood Sugar:

Nursing Tasks

May only be performed by a licensed nurse.

Nurse Telephone No.

After Hours or no answer Telephone No.

Initial dose of new medications:

Required

not applicable

Additional tasks:

as described

not applicable

Additional Special Needs Training

Texture:

Describe:

Example:

Liquids:

Describe:

Example:

Nutritional needs:

Describe:

Example:

Adaptive Aids and instructions for safe use

Health Care Follow-Up

Staff must contact nurse regarding each health appointment. Written documentation of all orders and labs must be submitted to nurse. Doctor's office may fax information to fax no. Medication Side Effects

Nurse Monitoring

Determine, in consultation with the individual or CRA, the level of supervision and frequency of supervisory visits, taking into account: the stability of the individual's status; the training, experience and capability of the assistive personnel to whom the nursing task is delegated; the nature of the nursing task being delegated; the proximity and availability of the RN to the unlicensed person when the task will be performed; and the level of participation of the individual or CRA. §225.9(a)(3)(A-E)

RN follow-up to monitor competency of assistive personnel

Not applicable, no tasks are delegated

Once additionally within the first then:

Other (med minders, insulin):

Additional monitoring of assistive personnel by a licensed (RN or LVN) nurse

Not applicable, no tasks are delegated

Once additionally within the first then:

Once additionally within the year

Notes:

Participants in Special Needs Planning

Individual

I have participated in decisions about the overall management of my health care (§225.1(2)) and:

can make all of my own decisions, and am able to direct own health care.:

would like assistance from to act as my Client Responsible Adult (CRA),

Printed Name

Date

Signature

Client Responsible Adult (CRA)

No CRA available

will be participating in decisions only, not directing care. No HMAs will be performed.

agree to train assistive personnel in the proper performance of tasks identified as HMAs, be present when the task is performed or if not present will have observed the unlicensed person perform the task and will be immediately accessible in person or by phone to the assistive personnel when the task is performed. [§225.8(2)(D)(ii)(I-II)].

Printed Name

Date

Signature

Provider Advocate Client Responsible Adult (PAC) as CRA

Attached

Not Necessary

A PAC will act as the CRA. In this situation the individual cannot make decisions regarding health care and does not have a single identified adult that is willing and able to participate in decisions about the overall management of the individual's health care. (§225.1(a)(2)]

Registered Nurse (RN)

I have developed this plan and retain accountability for delegated tasks. Each assistive personnel's competency will be verified before allowing delegated tasks to be performed without direct nursing supervision. An RN will be immediately accessible by phone to the assistive personnel when the task is performed.

Printed Name

Date

Signature

Delegation: Nursing Special Needs Delegation and Training

Plan Dated:

Individual Date of Training.

Delegated Tasks

Description/Key Teachings

RN Verification Of Competency And Observation Of Return Demonstration (Initial Each Key Teaching):

Additional Tasks

Assistive Personnel

I understand above, was provided a copy of this information and agree to communicate changes, questions and concerns.

Printed Name

Date

Signature

RN

I have developed this plan and retain accountability for delegated tasks. Each assistive personnel's competency must be verified before allowing delegated tasks to be performed without direct nursing supervision. An RN will be immediately accessible by phone to the assistive personnel when the task is performed.

Printed Name

Date

Signature