Code of Colorado Regulations
700 - Department of Regulatory Agencies
716 - Division of Professions and Occupations - State Board of Nursing
3 CCR 716-1 - NURSING RULES AND REGULATIONS
Section 3 CCR 716-1.13 - RULES AND REGULATIONS REGARDING THE DELEGATION OF NURSING OR CERTIFIED MIDWIFE TASKS
Universal Citation: 3 CO Code Regs 716-1 ยง 13
Current through Register Vol. 47, No. 17, September 10, 2024
A. STATEMENT AND BASIS OF PURPOSE
The Rules contained in this Rule 1.13 are adopted pursuant to authority granted the Board by sections 12-20-204(1) and 12-255-107(1)(j), C.R.S., and specifically pursuant to authority granted in section 12-255-131(6), C.R.S. The purpose of these Rules is to specify procedures and criteria regarding the delegation of nursing or certified midwife tasks.
The practical nurse ("PN"), professional nurse ("RN"), advanced practice registered nurse ("APRN"), certified midwife ("CM") are responsible for and accountable to each consumer of nursing care for the quality of nursing or midwifery care he or she provides either directly or through the delegated care provided by others.
B. DEFINITIONS:
For the purposes of Rule 1.13, the following terms have the indicated meaning;
1. "Board" means
the State Board of Nursing.
2.
"Client" means the recipient of nursing or midwifery care.
3. "Competence" is the Certified Nurse Aide's
(CNA) ability to perform those tasks included in the expanded scope of practice
as set forth in Section (I)(3) of Rule 1.10, with reasonable skill and safety
to a client, as deemed by the RN or APRN.
4. "Continued Competence" is the CNA's
ability to perform those tasks included in the expanded scope of practice as
set forth in Section (I)(3) of Rule 1.10, with reasonable skill and safety to a
client, as deemed by the RN, or APRN's direct observation of the CNA's clinical
performance of the task to occur not less than annually after initially being
deemed competent.
5. "Deemed
Competent" is the RN or APRN's determination that the CNA is competent to
perform the task with reasonable skill and safety to a client.
6. "Delegatee" means an individual receiving
the Delegation who acts in a complementary role to the PN, RN, APRN, or CM who
has been trained appropriately for the task delegated, and whom the PN, RN,
APRN, or CM authorizes to perform a task that the individual is not otherwise
authorized to perform.
7.
"Delegation" means the assignment to a competent individual the authority to
perform in a selected situation a selected nursing or selected certified
midwife task included in the practice of practical nursing as defined in
section 12-255-104(10),
C.R.S., or in the practice of professional nursing as defined in section
12-255-104(8),
C.R.S.; or the practice of a certified midwife as defined in section
12-255-104 (7.5), C.R.S.
8. "Delegator" means the PN, RN, APRN, or CM
making the Delegation; the Delegator must hold a current, active license and if
appropriate advanced practice registration and prescriptive
authority.
9. "Developmental
Disabilities Nurse (DDN) Setting" means a practice setting for a RN or APRN,
employed by or contracted by community center boards, the community board's
provider organizations or other agencies providing services through the
Colorado Division of Developmental Disabilities.
10. Individualized Healthcare Plan ("IHP")
means a plan for a specific Client that is developed by a RN or APRN employed
or contracted by the Client's School, Licensed Child Care Facility, or DDN
Setting in conjunction with the Client and parent or guardian and, if
applicable, based on the Client's Licensed Health Care Provider's orders for
the administration of Medications and/or treatments for the Client.
11. "Licensed Child Care Facility" means any
facility licensed as a family child care home or child care center as defined
in section
26-6-102, C.R.S.
12. "Licensed Health Care Provider" means an
individual who is licensed or otherwise authorized by the state pursuant to
this Title 12, or Article
3.5 of Title
25, C.R.S., to provide health care
services.
13. "Medication" means
any prescription or nonprescription drug as defined in section
12-280-103, C.R.S.
14. "Practitioner" means a person authorized
by law to prescribe treatment, Medication or medical devices and acting within
the scope of such authority.
15.
"School" means any institution of primary or secondary education, including
preschool and kindergarten.
16.
"Supervision" means the provision of guidance and review by a PN, RN, APRN, or
CM for the accomplishment of a nursing task or activity, with initial direction
of the task, periodic inspection of the actual act of accomplishing the task or
activity, and evaluation of the outcome.
C. CRITERIA FOR DELEGATION
1. Any nursing or Certified Midwife task
delegated by the PN, RN, APRN, or CM shall be:
a. Within the scope of practice and the area
of responsibility of the Delegator;
b. Within the knowledge, skills, ability and
scope of practice of the Delegator;
c. Of a routine, repetitive nature and shall
not require the Delegatee to exercise nursing or midwifery judgment or
intervention;
d. A task that a
reasonable and prudent nurse or certified midwife would find to be within
generally accepted nursing or midwifery practice;
e. An act consistent with the health and
safety of the Client; and f. Limited to a specific Delegatee, for a specific
Client, and within a specific time frame, except for Delegation in Schools or
Delegation in a Licensed Child Care Facility as described in Section (F) of
Rule 1.13.
2. The
Delegatee shall not further delegate to another individual the tasks delegated
by the PN, RN, APRN, or CM.
3. The
delegated task may not be expanded without the express permission of the
Delegator.
4. The Delegator shall
assure that the Delegatee can and will perform the task with the degree of care
and skill that would be expected of the PN, RN, APRN, or CM.
5. The delegation of a nursing- or Certified
Midwife task shall not limit the practice of nursing or of certified midwife as
defined in sections
12-255-104 (7.5), (9) or (10),
C.R.S., by any certified midwife or nurse including, but not limited to,
advanced practice registered nurses.
D. RESPONSIBILITY OF THE DELEGATOR
1. The decision to delegate
shall be based on the Delegator's assessments of the following:
a. The Client's nursing or midwifery care
needs, including, but not limited to, complexity and frequency of the nursing
or midwifery 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 after training has been provided;
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 availability 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 or midwifery care needs; and
e. The availability of adequate Supervision
of the Delegatee.
2. The
Delegator shall:
a. Explain the Delegation to
the Delegatee 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 or Certified Midwife task, or verify the
Delegatee's competence to perform the delegated nursing or Certified Midwife
task;
c. Provide instruction on how
to intervene in any foreseeable risks that may be associated with the delegated
task;
d. Provide appropriate and
adequate Supervision to the Delegatee to the degree determined by the
Delegator, based on an evaluation of all factors indicated in Section (D)(1) in
Rule 1.13; and
e. If the delegated
task is to be performed more than once, develop and employ a system for ongoing
monitoring of the Delegatee.
3. The Delegator, on an ongoing basis, shall
evaluate the following:
a. The degree to which
nursing or midwifery care needs of the Client are being met;
b. The performance by the Delegatee of the
delegated task;
c. The need for
further training and/or instruction; and
d. The need to continue or withdraw the
Delegation.
4.
Documentation of the Delegation by the Delegator in the Client record shall
adhere to generally accepted standards and shall minimally include, but not be
limited to, the following:
a. Assessment of
the Client;
b. Identification of
the task delegated, the Delegatee, the Delegator, time delegated, and time
frame for which the Delegation is effective;
c. Direction for documentation by the
Delegatee that the task or procedure was performed and the Client's response,
if appropriate; and
d. Periodic
evaluation of the Client's response to the performed delegated task.
E. STANDARDS FOR THE ACCOUNTABILITY OF THE DELEGATOR
1.
The Delegator shall adhere to the provisions of the Nurse and Nurse Aide
Practice Act and the rules and regulations of the Board.
2. The Delegator is accountable for the
decision to delegate and the assessments indicated in Section (D)(1) of Rule
1.13.
3. The Delegator is
accountable for monitoring, outcome evaluation, and follow-up of each
Delegation.
4. The Delegator is
accountable for the act of delegating and supervising.
F. DELEGATION OF THE ADMINISTRATION OF MEDICATIONS IN SCHOOLS AND LICENSED CHILD CARE FACILITIES
1. A RN or APRN employed or contracted by a
School or Licensed Child Care Facility may delegate the administration of
prescription and non-prescription medication with an order from an appropriate
health care provider to a specific Delegatee(s) who has successfully completed
appropriate training for the population of a School or Licensed Child Care
Facility, within a specific time frame not to exceed one school year.
2. A RN or APRN employed by or contracted by
a School, school district or Licensed Child Care Facility may delegate the
administration of prescribed emergency medications to one or more specific
Delegatee(s) who have successfully completed appropriate training. The
professional nurse must provide to the Delegatee a specific written protocol
for each specific Client as determined in the IHP.
3. A professional nurse shall not delegate to
a delegatee the administration of any medication that requires nursing
assessment, judgment, or evaluation before, during or immediately after
administration.
4. Nothing in this
Section (F) of Rule 1.13 shall be construed to prohibit a professional nurse or
advanced practice registered nurse from delegating a specific nursing task to a
specific Delegatee for a specific Client in the School or Licensed Child Care
Facility setting, as otherwise provided for and governed by the provisions of
Rule 1.13.
5. The administration of
stock Epinephrine and/or Naloxone by designated personnel is not a delegated
nursing function and is described in Section (H)(4) of Rule 1.13.
G. DELEGATION OF INSULIN AND GLUCAGON ADMINISTRATION IN THE SCHOOL SETTING, LICENSED CHILD CARE FACILITY OR DDN SETTING
1. The administration of
insulin or glucagon is a nursing task that may be delegated in accordance with
the requirements of Rule 1.13. The selection of the type of insulin and dosage
levels shall not be delegated.
2.
An IHP shall be developed for any Client receiving insulin in the School,
Licensed Child Care Facility or DDN Setting. 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:
(1)
Carbohydrate counting
(2) Glucose
testing
(3) Activation or
suspension of an insulin pump
(4)
Usage of insulin pens
(5) Medical
orders
(6) Emergency protocols
related to glucagon administration
3. Insulin administration by the Delegatee
shall only occur when the Delegatee has followed the guidelines of the IHP.
a. Dosages of insulin may be administered by
the Delegatee as designated in the IHP.
b. Non-routine, correction dosages of insulin
may be given by the Delegatee only after:
(1)
Following the guidelines of the IHP; and
(2) Consulting with the Delegator, as
designated in the IHP, and verifying and confirming the type and dosage of
insulin being administered.
c. Under Section (G)(3) of Rule 1.13, insulin
administration by the Delegatee is limited to a specific Delegatee, for a
specific Client and for a specific time.
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 other administration
route.
5. When the Client is not
capable of self-administration, routine daily meal boluses of insulin, based on
carbohydrate counts and blood glucose levels, may be administered via the
insulin pump by the Delegatee as designated in the IHP.
H. EXCLUSIONS FROM THE RULE 1.13
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.
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.
3. The professional nurse who
teaches the Medication Administration Instructional Program as approved by the
Colorado Department of Human Services shall not be considered to be delegating
as defined by Rule 1.13.
4. The
professional nurse or advanced practice registered nurse who teaches stock
epinephrine auto-injection and/or stock Naloxone administration to designated
school staff that act in an emergency situation to assist a Client shall not be
construed to be delegating as defined by Rule 1.13.
5. The issuance by an advanced practice
registered nurse with prescriptive authority of standing orders and protocols
for the use of epinephrine auto-injectors for emergency use to designated
school staff shall not be construed to be delegating as defined by Rule
1.13.
6. Any child care provider as
defined in section
26-6-102(6),
C.R.S., acting in compliance with Section
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 or guardian of the client to whom
medications are administered;
c.
Administer only routine medications 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.
7. School personnel that volunteer
to administer or assist in the administration of medical marijuana in
non-smokeable form to any student with a valid recommendation for medical
marijuana pursuant to section
22-1-119.3, C.R.S.
I. CNA EXPANDED SCOPE OF PRACTICE / NOT CONSIDERED DELEGATION OF NURSING TASKS
1. The following tasks included in the CNA's
expanded scope of practice as set forth in section
12-255-206(1)(a), (b), and
(c), C.R.S., are not considered delegated
nursing tasks provided that a RN or APRN has deemed the CNA competent to
perform such tasks:
a. Digital stimulation,
insertion of a suppository, or the use of an enema, or any other medically
acceptable procedure to stimulate a bowel movement for clients/patients with
stable health conditions and are not considered high risk;
b. Gastrostomy-tube and jejunostomy-tube
feedings for clients/patients with stable health conditions and are not
considered high risk; and
c.
Placement in a client's mouth of presorted medication that has been boxed or
packaged by a PN, RN, or APRN, or a Pharmacist for clients/patients with stable
health conditions and are not considered high risk.
(1) The CNA may only perform this task if the
boxed or packaged medication has been stored in a secure manner and showing no
sign of tampering.
(2) The CNA will
report any medication not placed in the client's mouth in a timely manner but
not more than two hours after the medication was due.
(3) In the case of liquid medication that has
been sorted by the minor's parent or guardian, such medication must be in its
original sealed container and a standard measuring device must be
used.
(4) The first dose of an
antibiotic sorted by a minor's parent or guardian must be under the observation
of a professional nurse, physician, podiatrist, or dentist who is present in
the same patient care area.
(5)
Administration of oxygen as authorized by a health care provider.
(6) Changing ostomy bags.
2. The CNA, pursuant to
the definition of nurse aide at section
12-255-104 (8.5), C.R.S., requires
supervision of tasks by an Licensed Health Care Provider acting within the
scope of the license or certificate.
3. A RN or APRN who in good faith determines
that a CNA is competent to perform the tasks listed in Section (I)(1) of Rule
1.13 is not liable for the actions of the CNA in the performance of the tasks.
a. The RN or APRN deeming a CNA competent to
perform tasks listed in Section (I)(1) of Rule 1.13 will have the knowledge,
skills and ability to perform such skills and teach such skills.
b. For the purposes of this Rule, "is not
liable" means the actions of the CNA in the performance of the expanded scope
listed in Section (I)(1) of Rule 1.13 shall not form the basis for discipline
for the RN or APRN pursuant to
12-255-120(1),
C.R.S.
4. A RN or APRN
may determine a CNA is competent to perform the tasks listed in Section (I)(1)
of Rule 1.13 by teaching such task, demonstration of clinical performance of
the task followed by return demonstration of the performance of the task by the
CNA:
a. Teaching of the procedure to perform
the task;
b. RN or APRN
demonstration of the steps to perform the task;
c. Review of risks associated with
performance of the task;
d.
Identification of what to report to the supervising healthcare professional;
and
e. Return demonstration of the
clinical performance of the task.
f. Digital stimulation, insertion of a
suppository, or the use of an enema, or any other medically acceptable
procedure to stimulate a bowel movement for clients/patients with stable health
conditions and are not considered high risk;
(1) The RN will include within the teaching
of this task that it will only be performed for clients/patients with stable
health conditions and are not considered high risk.
g. Gastrostomy-tube and jejunostomy-tube
feedings for clients/patients with stable health conditions and are not
considered high risk;
(1) The RN or APRN will
include within the teaching of this task that it will only be performed for
clients/patients with stable health conditions and are not considered high
risk.
h. Placement in a
client's mouth of presorted medication that has been boxed or packaged by a PN,
RN, APRN, or a Pharmacist for clients/patients with stable health conditions
and are not considered high risk.
(1) The RN
or APRN will include within the teaching of this task that it will only be
performed for clients/patients with stable health conditions and are not
considered high risk.
i.
When the RN or APRN deems the CNA competent to perform a task, a competency
document will be completed. The competency document will be signed, dated and
retained for at least one year by the RN determining competency. The competency
document will be signed, dated and retained permanently by the CNA deemed
competent to perform such tasks.
j.
Within thirty days of being deemed competent to perform the tasks in Section
(I)(1) of Rule 1.13 the CNA will update the expanded scope questions on the
Healthcare Professions Profile (HPPP) indicating the tasks the CNA has been
deemed competent to perform, the name and license number of the RN or APRN that
deemed the CNA competent, along with the date deemed competent.
5. The RN or APRN must deem the
CNA competent to perform the tasks in Section (I)(1) of Rule 1.13 as evidenced
by a competency document as described in Section (I)(4) of Rule 1.13 signed,
dated and retained for at least one year by the RN or APRN determining
competence. The competency document will be signed, dated and retained
permanently by the CNA deemed competent to perform such task. The competency
document will be produced upon Board request.
6. Continued Competence of the CNA to perform
tasks in Section (I)(1) of Rule 1.13
a. Not
less than annually the CNA must demonstrate continued competence under the
direct clinical observation of the RN or APRN to perform the tasks in Section
(I)(1) of Rule 1.13. Upon determination of the continued competence and the CNA
demonstrating continued competence an updated competency document will be
signed, dated and retained for at least one year by the RN or APRN determining
continued competence. The updated competency document will be signed, dated and
retained permanently by the CNA demonstrating continued competence. The
competency document will be provided to the Board upon request.
b. Within thirty days of the completion of
the updated competency document the CNA will update the expanded scope
questions on the HPPP indicating the tasks the CNA has continued competence to
perform, along with the name and license number of the RN or APRN that deemed
continued competence and the date of such completion.
7. Nothing in this Section (I) of Rule 1.13
will be construed to prohibit or impede a facility, agency or employer from
establishing policies and procedures for the tasks set forth in Section (I)(1)
of Rule 1.13, provided these minimum requirements are met.
Adopted: April 28, 2010
Effective: June 30, 2010
Revised: April 22, 2014
Effective: June 14, 2014
Revised: July 21, 2015
Effective: September 14, 2015
Revised: April 26, 2017
Effective: 6/14/2017
Revised: October 27, 2021
Effective: December 30, 2021
Revised: January 24, 2024
Effective: March 16, 2024
Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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