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PROPOSED RULEMAKING

STATE BOARD OF NURSING

[49 PA. CODE CH. 21]

Nursing Functions

[27 Pa.B. 2950]

   The State Board of Nursing (Board) proposes to amend §§ 21.11, 21.12--21.17 and 21.145 pertaining to functions of the licensed registered nurse (RN) and functions of the licensed practical nurse (LPN) to read as set forth in Annex A.

   The proposed rulemaking has two purposes. First, the proposal would require that nurses when accepting medical orders exercise responsibility to assure the correctness of the order and employ standard procedures to document the order. Second, the proposal would implement the Board's review of certain regulations in conformance with Executive Order 1996-1, which directs State agencies to eliminate unnecessary or burdensome regulations.

   With respect to medical orders, the Board proposes to revise § 21.11 (relating to general functions) pertaining to registered nurses (RNs) and § 21.145 (relating to functions of the LPN) pertaining to licensed practical nurses (LPNs) to establish a single practice standard. The proposal was generated by a request from the Pennsylvania Health Care Association which suggested that the Board consider removing language in § 21.145 which prohibits an LPN from accepting an oral order except in urgent circumstances.

   Although concurring in the need for regulatory relief with regard to the language of § 21.145, the Board also believes that safe nursing practice would benefit from standards and guidelines for both the RN and the LPN. The proposal would amend § 21.11 by inserting a new subsection (a)(8) governing the acceptance of orders and would revise § 21.145. The scope of practice of nursing includes the execution of medical regimens as prescribed by a licensed physician or dentist. In doing so, the nurse accepts an order from a physician in written or oral form. In accepting an order, nurses have the responsibility to question an order where circumstances indicate the order is either unclear or contraindicated for the patient. The Board proposes to add this professional standard in its regulations. Further, the Board proposes to establish uniform procedures for the acceptance of an oral order by either the RN or the LPN. A cross reference to the LPN would be made to § 21.14 (relating to administration of drugs) with regard to administration of drugs.

   In proposing these changes, the Board recognizes that health care facility regulations of the Department of Health contain similar uniform regulations concerning the acceptance of oral orders. See 28 Pa. Code §§ 107.62 and 201.3. Easing the restrictions on LPNs in this regard is in accordance with the education requirements of an LPN and will improve patient care by increasing communication between the prescribing or ordering practitioner and the nurse.

   The Board also proposes additional changes to § 21.11. The Board proposes to add language to subsection (a)(1), (2), (4) and (5) and to add a new subsection (a)(7) to incorporate into the functions of the RN general health care services in addition to nursing care and the RN's participation in multidisciplinary teams of professionals who collaborate to identify health care needs and plan for the delivery of health care services. The new subsection (a)(8) governs the acceptance of oral and written orders by a registered nurse.

   The Board proposes to amend subsection (b) to clarify the Board's intention to make the RN accountable for the delivery of nursing care in a safe manner. Existing subsection (b) makes the RN accountable for the quality of the care delivered. The Board deems this language ambiguous inasmuch as quality may be affected by factors beyond the nurse's control or ability to control. The Board believes that the manner of delivery of care is properly within the professional responsibility of the RN.

   Existing subsection (c) was intended to cover circumstances in which the RN practices in a specialized practice. The Board determined that by revising subsection (c) the appropriate standard could be established which could apply to all areas of practice and functions. In so doing, §§ 21.12, 21.13, 21.15 and 21.16 could be deleted since the requisite criteria for performance of a function or practice, preparation skill and knowledge, remain a constant standard, embodied in § 21.11(c). By restructuring the regulations in this fashion, the Board anticipates that it will protect the public from incompetent practice while avoiding the need to increase the volume of regulations. A new subsection (d) would list functions and cross reference to subsection (c).

   Technical amendments are proposed to § 21.17 pertaining to the administration of anesthesia to reflect the correct name of the National accrediting body for nurse anesthetists and to include dentists as part of the collaborating team.

Fiscal Impact and Paperwork Requirements

   The proposed amendments will have no fiscal impact and will not impose additional paperwork on the private sector, the general public and the Commonwealth and its political subdivisions.

Statutory Authority

   The Board has authority to promulgate these proposed amendments under section 2.1(k) of the Professional Nursing Law (63 P. S. § 212.1(k)) and section 17.6 of the Practical Nurse Law (63 P. S. § 667.6). These provisions authorize the Board to establish rules and regulations for the administration of the law.

Regulatory Review

   Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on June 6, 1997, the Board submitted a copy of these proposed amendments to the Independent Regulatory Review Commission (IRRC) and to the Chairperson of the House Committee on Professional Licensure and to the Senate Committee on Consumer Protection and Professional Licensure. In addition to submitting the proposed amendments, the Board has provided the Committee and IRRC with a copy of a detailed Regulatory Analysis Form. A copy of this material is available to the public upon request.

   If IRRC has objections to any portion of the proposed amendments, it will notify the Board within 30 days of the close of the public comment period. The notification shall specify the regulatory review criteria which have not been met by that portion. The Regulatory Review Act specifies detailed procedures for review, prior to final publication of the amendments, by the Board, the General Assembly and the Governor of objections raised.

Public Comment

   Interested persons are invited to submit written comments, suggestions or objections regarding the proposed amendments to Herbert Abramson, Board Counsel, State Board of Nursing, P. O. Box 2649, Harrisburg, PA 17105-2649, within 30 days of publication of these proposed amendments in the Pennsylvania Bulletin. Please reference (16A-514) Nursing Functions, when submitting comments.

M. CHRISTINE ALICHNIE, Ph.D., R.N.   
Chairperson

   Fiscal Note: 16A-514.  No fiscal impact; (8) recommends adoption.

Annex A

TITLE 49.  PROFESSIONAL AND VOCATIONAL STANDARDS

PART I.  DEPARTMENT OF STATE

Subpart A.  PROFESSIONAL AND OCCUPATIONAL AFFAIRS

CHAPTER 21.  STATE BOARD OF NURSING

RESPONSIBILITIES OF THE REGISTERED NURSE

§ 21.11.  General functions.

   (a)  The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals [or], families or groups for whom the nurse is responsible. In carrying out this responsibility, the nurse performs [all of] the following general functions:

   (1)  Collects complete and ongoing data to determine nursing and health care needs.

   (2)  Analyzes the health status of the individuals [and], families and groups and compares the data with the norm when possible in determining nursing care needs and the delivery of health care services.

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   (4)  Carries out nursing care actions which promote, maintain [and], restore or support the well-being of individuals, families or groups across their life span.

   (5)  Involves individuals [and their], families or groups in their health promotion, maintenance [and] or restoration.

   (6)  Evaluates the effectiveness of [the quality of] nursing care [provided].

   (7)  Participates with the multidisciplinary team in identification of health care needs and coordination of health care services. A multidisciplinary team is a team composed of professionals from a variety of disciplines who are consultants in the health management of the individual, family or group for whom the nurse is responsible.

   (8)  Accepts oral or written orders for medical regimens as prescribed by a licensed physician or dentist.

   (i)  The registered nurse shall question any order which the registered nurse perceives to be unclear, unsafe or contraindicated for the patient/client. If an order appears to be unclear, unsafe or contraindicated for the patient/client, the registered nurse shall take action in accordance with standards of practice.

   (ii)  An oral order to execute a medical regimen accepted by the registered nurse shall be immediately transcribed in the proper place on the medical record of the patient/client. The transcription shall include the prescriber's name, date and time of acceptance of the oral order for a medical regimen and the full signature of the registered nurse accepting the oral order for a medical regimen.

   (b)  The registered nurse is [fully] responsible for all actions as a licensed nurse and is accountable to patients/clients for the [quality of care delivered] delivery of safe care.

   (c)  The registered nurse may not engage in [areas] any area of [highly specialized] practice without [adequate knowledge of and skills in the practice areas involved] the necessary preparation, experience and knowledge to properly implement the practice.

   (d)  [The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations as the criteria for assuring safe and effective practice.] The registered nurse performs functions including venipuncture, intravenous fluids, resuscitation and airway maintenance, monitoring and defibrillating and immunizations in accordance with subsection (c).

   (e)  The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations.

§ 21.12.  [Venipuncture; intravenous fluids] (Reserved).

   [Performing of venipuncture and administering and withdrawing intravenous fluids are functions regulated by this section, and these functions may not be performed unless:

   (1)  The procedure has been ordered in writing for the patient by a licensed doctor of the healing arts.

   (2)  The registered nurse who performs venipuncture has had instruction and supervised practice in performing venipuncture.

   (3)  The registered nurse who administers parenteral fluids, drugs or blood has had instruction and supervised practice in administering parenteral fluids, blood or medications into the vein.

   (4)  A list of medications which may be administered by the registered nurse is established and maintained by a committee of physicians, pharmacists and nurses from the employing agency or the agency within whose jurisdiction the procedure is being performed if no employing agency is involved.

   (5)  The intravenous fluid or medication to be administered is the fluid or medication specified in the written order.

   (6)  The blood is identified as the blood ordered for the patient.

   (7)  An accurate record is made concerning the following:

   (i)  The time in the injection.

   (ii)  The medication or fluid injected.

   (iii)  The amount of medication or fluid injected.

   (iv)  Reactions to the fluid.]

§ 21.13.  [Resuscitation and respiration] (Reserved).

   [External cardiac resuscitation and artificial respiration, mouth-to-mouth, are procedures regulated by this section, and these functions may not be performed unless both of the following provisions are met:

   (1)  External cardiac resuscitation and artificial respiration, mouth-to-mouth, shall only be performed by a nurse on an individual when respiration or pulse, or both, cease unexpectedly.

   (2)  A nurse may not perform external cardiac resuscitation and artificial respiration, mouth-to-mouth, unless the nurse has had instruction and supervised practice in performing the procedures.]

§ 21.14.  Administration of drugs.

   (a)  Administering to a patient a drug ordered for that patient by a licensed doctor of the healing arts in the dosage prescribed is a procedure regulated by this section, and the function may not be performed by a person other than a licensed registered nurse[,] and licensed practical nurse except that a licensed registered nurse, responsible for administering a drug, may supervise a nursing student in an approved program and a graduate nurse.

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§ 21.15.  [Monitoring, defibrillating and resuscitating] (Reserved).

   [The use of monitoring, defibrillating or resuscitating equipment, or a combination of the three, hereinafter called ''therapy,'' is a proper function of a registered nurse and is a function regulated by this section; the function may not be performed unless all of the following provisions are met:

   (1)  The employer, through written policy, has agreed that the registered nurse may administer the therapy.

   (2)  A committee of licensed physicians and nurses within the employing agency has established written criteria prescribing when the therapy shall be administered by a registered nurse either in the presence or absence of the attending physician.

   (3)  The techniques for administering the therapy have been established by a committee of licensed physicians and registered nurses within the employing agency.

   (4)  The registered nurse has had instruction and supervised practice in administering the therapy.

   (5)  The registered nurse has demonstrated competency in administering the therapy to the satisfaction of the employer.

   (6)  The registered nurse shall have employed the prescribed techniques in administering the therapy in accordance with the established criteria.]

§ 21.16.  [Immunizations] (Reserved).

   [(a)  Immunization and skin testing is a proper function of a registered nurse and is a function regulated by this section, and the function may not be performed unless all of the following conditions are met:

   (1)  A written order has been issued by a licensed physician. The order may be a standing order applicable to individuals or groups.

   (2)  The policies and procedures under which the registered nurse may administer immunizing agents and do skin testing have been established by a committee representing the nurses, the physicians, and the administration of the agency or institution. These written policies and procedures shall be available to the nurse. The committee shall also perform the following functions:

   (i)  Identify the immunizing and skin testing agents which the nurse may administer.

   (ii)  Determine contraindications for the administration of specific immunizing and skin testing agents.

   (iii)  Outline medical principles governing the treatment of possible anaphylactic reactions.

   (iv)  Establish instruction and supervised practice required to insure competency in administering immunizing and skin testing agents.

   (b)  Following skin testing, the size of the induration or its absence may be observed and recorded by the properly instructed registered nurse.]

§ 21.17.  Anesthesia.

   The administration of anesthesia is a proper function of a registered nurse and is a function regulated by this section; this function may not be performed unless:

   (1)  The registered nurse has successfully completed the education program of a school for nurse anesthetists accredited by the Council on Accreditation of [Education Programs of] Nurse Anesthesia Educational Program of the American Association of Nurse Anesthetists.

*      *      *      *      *

   (b)  For purposes of this section, ''cooperation'' means a process in which the nurse anesthetist and the surgeon or dentist work together with each contributing an area of expertise, at their individual and respective levels of education and training.

FUNCTIONS OF THE LICENSED PRACTICAL NURSE

§ 21.145.  Functions of the LPN.

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   (b)  The LPN administers medication and carries out the therapeutic treatment prescribed or ordered for the patient/client. The LPN [shall] may accept [only] oral or written prescriptions or orders [from the responsible practitioner] as directed by the licensed physician or dentist for medication and therapeutic treatment [unless the urgency of the medical circumstances requires immediate medication or therapeutic treatment]. The LPN shall question any order which is not clear, perceived as unsafe or contraindicated for the patient/client. If an order appears to be unclear, unsafe or contraindicated for the patient/client, the LPN shall take action in accordance with standards of practice. The LPN may not accept an oral prescription or order [under this subsection] which is not within the scope of functions permitted by this [subsection] section or which the LPN does not understand. An oral prescription or order accepted by the LPN [under this subsection] shall be immediately transcribed by the LPN in the proper place on the medical record of the patient/client. The transcription shall include the [name of the physician giving the order,] the prescriber's name, date and time of acceptance of the oral prescription or order and the full signature of the LPN accepting the oral prescription or order. [The countersignature of the physician shall be obtained in accordance with applicable regulations of the Department of Health governing the licensed facility.]

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[Pa.B. Doc. No. 97-979. Filed for public inspection June 20, 1997, 9:00 a.m.]



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