ARC 5481C

ARC 5481C

NURSING BOARD[655]

Adopted and Filed

Rule making related to nursing practice for registered nurses/licensed practical nurses

The Board of Nursing hereby rescinds Chapter 6, "Nursing Practice for Registered Nurses/Licensed Practical Nurses," Iowa Administrative Code, and adopts a new Chapter 6 with the same title.

Legal Authority for Rule Making

This rule making is adopted under the authority provided in Iowa Code chapter 152.

State or Federal Law Implemented

This rule making implements, in whole or in part, Iowa Code chapter 152.

Purpose and Summary

Chapter 6 governs the minimum standards of practice for registered nurses (RNs) and licensed practical nurses (LPNs). The chapter had not been reviewed in its totality for many years. Accordingly, the chapter was reviewed as a whole and is being rescinded and replaced with a new Chapter 6 in order to make changes to both phrasing and organization in an effort to bring the chapter in line with modern practices and terminology.

Public Comment and Changes to Rule Making

Notice of Intended Action for this rule making was published in the Iowa Administrative Bulletin on September 9, 2020, as ARC 5172C. A public hearing was held on September 29, 2020, at 9 a.m. at the Board's Office, Suite B, 400 S.W. Eighth Street, Des Moines, Iowa.

The Board received a number of comments on this rule making through email and one at the hearing. Two comments suggested revisions to allow nurses to delegate tasks to unlicensed assistive personnel so long as, in the professional judgment of the delegating nurse, the task poses minimal risk to the patient, even if the patient may not be in stable condition. The Board agreed with this comment and revised paragraphs 6.2(7)"e" and 6.3(9)"e" to add the phrase "in the professional judgment of the delegating nurse." Two comments asserted that the rule for delegating to emergency medical services (EMS) personnel was unclear and may require nurses to check the credentials of every EMS personnel prior to delegating tasks. The Board agreed this was not the intention of the rule and revised subrule 6.2(8) to clarify the standards for delegating to EMS personnel. Several comments requested clarity on the role of LPNs in certain non-acute care settings, particularly regarding performing the initial assessment. The Board agreed to rephrase the rule and revised subparagraphs 6.3(11)"a"(1), 6.3(11)"a"(2), and 6.3(11)"d"(1) to confirm that the RN must always perform the initial assessment and the LPN is responsible for requesting RN consultation as needed.

The Board received one comment requesting that these rules include guidance on treating patients with medical cannabis. The Board declined, finding that the request is premature and that the rules already require all nurses to be trained, competent, and educated in a task prior to performing it. This would apply with equal force to nurses assisting in the medical cannabidiol (CBD) program. One comment requested that the Board utilize an older version of the definition of "ARNP." The Board declined, because both Chapter 7 and this chapter use the definition of "ARNP" contained in the Iowa Code. Two comments requested that physician assistants be added to the list of providers who can supervise LPNs in certain acute and non-acute care settings. The Board declined, finding that the LPN supervision rules have long been in place and the Board has never had any complaints that excluding physician assistants caused practice problems.

One comment requested that a physician be present at the rules stakeholder meeting held prior to instituting this rule-making action, specifically requesting that physicians be present for all Board rules meetings relating to ARNPs. The Board notes that this chapter does not relate to ARNPs, nor do ARNPs or nurses participate in Board of Medicine rules stakeholder meetings. This chapter was proposed in the Notice of Intended Action after a stakeholder meeting that included the professional association, as well as nurses from nearly every practice setting, in accordance with all requirements.

One comment requested the Board to specifically define "significant change" in patient condition. The Board declined, because what is "significant" could vary dramatically depending on the patient, the setting, the ailment, etc.

Multiple comments related to the "proximate area" requirement for LPNs in acute and certain non-acute care settings. The chapter updates the definition of "proximate area" from a skills-based standard to a settings-based standard to allow facilities to easily determine which settings require a provider to be in the proximate area of an LPN. The Board believes that this change will provide greater clarity and no further changes are needed. One comment requested that "receiving" and "implementing" be placed in the same subrule when discussing the nursing process. The Board declined, because the rule is structured to match the flow of the nursing process, which involves receiving orders, seeking additional guidance or asking questions if necessary, and then proceeding with implementation.

One comment requested that nurses not be required to show competence prior to using new equipment. The Board declined, because patient safety demands that nurses be trained and competent prior to using new technology on a patient. One comment requested that "supervision" be specifically defined to include being "on-call." The Board's definition of "supervision" allows for direct and indirect supervision, and the Board believes the definition allows for a nurse to exercise judgment in what the appropriate level of supervision is, based on each setting and patient's circumstances. One comment questioned whether the phrase "evidence-based practices" is vague. The Board notes that the phrase is taught in nursing schools, nurses understand what it means, and the purpose is to ensure nurses have sound justifications for their actions. Finally, one comment requested the rules expressly prohibit unlicensed assistive personnel from functioning as RNs. The Board declined, because Iowa Code section 147.86 already makes it a misdemeanor to practice nursing without a license and any similar rule would be duplicative.

Adoption of Rule Making

This rule making was adopted by the Board on January 20, 2021.

Fiscal Impact

This rule making has no fiscal impact to the State of Iowa.

Jobs Impact

After analysis and review of this rule making, no impact on jobs has been found.

Waivers

Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the Board for a waiver of the discretionary provisions, if any, pursuant to 655—Chapter 15.

Review by Administrative Rules Review Committee

The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making at its regular monthly meeting or at a special meeting. The Committee's meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).

Effective Date

This rule making will become effective on March 31, 2021.

The following rule-making action is adopted:

Rescind 655—Chapter 6 and adopt the following new chapter in lieu thereof:

CHAPTER 6

NURSING PRACTICE FOR REGISTERED NURSES/LICENSED PRACTICAL NURSES

655—6.1(152) Definitions.

"Advanced registered nurse practitioner" or "ARNP" means a person who is currently licensed as a registered nurse under Iowa Code chapter 152 or 152E who is licensed by the board as an advanced registered nurse practitioner.

"Board" as used in this chapter means the Iowa board of nursing.

"Competence" means having sufficient knowledge, judgment, and skill to perform a specific function.

"Expanded intravenous therapy certification course" means the Iowa board of nursing course required for licensed practical nurses to perform procedures related to the expanded scope of practice of intravenous therapy.

"Initial assessment" means the systematic collection of data to determine the patient's health status and plan of care, and to identify any actual or potential health problems, which is performed upon the patient's first arrival or admission to a unit or facility or upon any significant changes in the patient's status.

"Midline catheter" means a long peripheral catheter in which the distal end resides in the mid to upper arm, but the tip terminates no further than the axilla.

"Nursing diagnosis" means a judgment made by a registered nurse, following a nursing assessment of an individual or group about actual or potential responses to health problems, which forms the basis for determining effective nursing interventions.

"Nursing facility" means an institution as defined in Iowa Code chapter 135C. This term does not include acute care settings.

"Nursing process" means ongoing assessment, nursing diagnosis, planning, intervention, and evaluation.

"Peripheral intravenous catheter" means a catheter three inches or less in length.

"Peripherally inserted central catheter" means a soft flexible central venous catheter inserted into an extremity and advanced until the tip is positioned in the vena cava.

"Proximate area" means sufficiently close in time and space, within the same building, to provide timely in-person assistance.

"Supervision" means directly or indirectly observing a function or activity and taking reasonable steps to ensure the nursing care being provided is adequate and delivered appropriately.

"Unlicensed assistive personnel" is an individual who is trained to function in an assistive role to the registered nurse and licensed practical nurse in the provision of nursing care activities as delegated by the registered nurse or licensed practical nurse.

655—6.2(152) Standards of nursing practice for registered nurses.

6.2(1) A registered nurse shall recognize and understand the legal boundaries for practicing nursing within the scope of nursing practice. The scope of practice of the registered nurse is determined by the nurse's education, experience, and competency and the rules governing nursing. The scope of practice of the registered nurse shall not include those practices requiring the knowledge and education of an advanced registered nurse practitioner.

6.2(2) The registered nurse shall demonstrate professionalism and accountability by:

a. Demonstrating honesty and integrity in nursing practice.

b. Basing nursing decisions on nursing knowledge, judgment, skills, the needs of patients, and evidence-based practices.

c. Maintaining competence through ongoing learning, application of knowledge, and applying evidence-based practices.

d. Reporting instances of unsafe nursing practices by self or others to the appropriate supervisor.

e. Being accountable for judgments, individual nursing actions, competence, decisions, and behavior in the practice of nursing.

f. Assuming responsibility for the nurse's own decisions and actions.

g. Wearing identification which clearly identifies the nurse as a registered nurse when providing direct patient care unless wearing identification creates a safety or health risk for either the nurse or the patient.

6.2(3) The registered nurse shall utilize the nursing process by:

a. Conducting a thorough nursing assessment based on the patient's needs and the practice setting.

b. Applying nursing knowledge based on the biological, psychological, and sociocultural aspects of the patient's condition.

c. Detecting inaccurate or missing patient information.

d. Receiving a physician's, ARNP's, or other health care provider's orders and seeking clarification of orders when needed.

e. Formulating independent nursing decisions and nursing diagnoses by using critical thinking, objective findings, and clinical judgment.

f. Planning nursing care and nursing interventions by establishing measurable and achievable outcomes, consistent with the patient's overall health care plan.

g. Obtaining education and ensuring competence when encountering new equipment, technology, medication, procedures or any other unfamiliar care situations.

h. Implementing treatment and therapy as identified by the patient's overall health care plan.

i. Monitoring patients and attending to patients' health care needs.

j. Identifying changes in the patient's health status, as indicated by pertinent signs and symptoms, and comprehending the clinical implications of those changes.

k. Evaluating continuously the patient's response to nursing care and other therapies, including:

(1)Patient's response to interventions.

(2)Need for alternative interventions.

(3)Need to communicate and consult with other health team members.

(4)Need to revise the plan of care.

l. Documenting nursing care accurately, thoroughly, and in a timely manner.

m. Communicating and consulting with other health team members regarding the following:

(1)Patient concerns and special needs.

(2)Patient status and progress.

(3)Patient response or lack of response to interventions.

(4)Significant changes in patient condition.

(5)Interventions which are not implemented, based on the registered nurse's professional judgment, and providing:

1.A timely notification to the physician, ARNP, or other health care provider who prescribed the intervention that the order was not executed and reason(s) for not executing the order;

2.Documentation in the medical record that the physician, ARNP, or other health care provider was notified and reason(s) for not implementing the order; and

3.If appropriate, a timely notification to other persons who, based on the patient's circumstances, should be notified of any orders which were not implemented.

n. Revising plan of care as needed.

o. Providing a safe environment for the patient.

p. Providing comprehensive health care education to the patient and others, according to nursing standards and evidence-based practices.

6.2(4) The registered nurse shall act as an advocate for the patient(s) by:

a. Respecting the patient's rights, confidentiality, concerns, decisions, and dignity.

b. Identifying patient needs.

c. Attending to patient concerns or requests.

d. Promoting a safe environment for the patient, others, and self.

e. Maintaining appropriate professional boundaries.

6.2(5) The registered nurse shall apply the delegation process when delegating to another registered nurse or licensed practical nurse by:

a. Delegating only those nursing tasks that fall within the delegatee's scope of practice, education, experience, and competence. The initial assessment and ongoing application of the nursing process shall only be provided by the registered nurse.

b. Matching the patient's needs and circumstances with the delegatee's qualifications, resources, and appropriate supervision.

c. Communicating directions and expectations for completion of the delegated activity and receiving confirmation of understanding of the communication from the delegatee.

d. Supervising the delegatee by monitoring performance, progress and outcomes and ensuring appropriate documentation is complete.

e. Evaluating patient outcomes as a result of the delegation process.

f. Intervening when problems are identified, revising plan of care when needed, and reassessing the appropriateness of the delegation.

g. Retaining accountability for properly implementing the delegation process.

h. Promoting a safe and therapeutic environment by:

(1)Providing appropriate monitoring and surveillance of the care environment.

(2)Identifying unsafe care situations.

(3)Correcting problems or referring problems to appropriate management level when needed.

6.2(6) The registered nurse shall not delegate the following intravenous therapy procedures to a licensed practical nurse:

a. Initiation and discontinuation of a midline catheter or a peripherally inserted central catheter (PICC).

b. Administration of medication by bolus or IV push except maintenance doses of analgesics via a patient-controlled analgesia pump set at a lock-out interval.

c. Administration of blood and blood products, vasodilators, vasopressors, oxytoxics, chemotherapy, colloid therapy, total parenteral nutrition, anticoagulants, antiarrhythmics, thrombolytics, and solutions with a total osmolarity of 600 or greater.

d. Provision of intravenous therapy to a patient under the age of 12 or any patient weighing less than 80 pounds, with the exception of those activities authorized in the limited scope of practice found in subrule 6.3(5).

e. Provision of intravenous therapy in any other setting except a licensed hospital, a nursing facility and a certified end-stage renal dialysis unit, with the exception of those activities authorized in the limited scope of practice found in subrule 6.3(5).

6.2(7) The registered nurse shall apply the delegation process when delegating to an unlicensed assistive personnel (UAP) by:

a. Ensuring the UAP has the appropriate education and training and has demonstrated competency to perform the delegated task.

b. Ensuring the task does not require assessment, interpretation, and independent nursing judgment or nursing decision during the performance or completion of the task.

c. Ensuring the task does not exceed the scope of practice of a licensed practical nurse.

d. Ensuring the task is consistent with the UAP's scope of employment and can be safely performed according to clear and specific directions.

e. Verifying that, in the professional judgment of the delegating nurse, the task poses minimal risk to the patient.

f. Communicating directions and expectations for completion of the delegated activity and receiving confirmation of understanding of the communication from the UAP.

g. Supervising the UAP and evaluating the patient outcomes of the delegated task.

6.2(8) Subrule 6.2(7) does not apply to delegations to certified emergency medical care personnel who are employed by or assigned to a hospital or other entity in which health care is ordinarily provided, so long as:

a. The nurse has observed the patient;

b. The delegated task is a nonlifesaving procedure; and

c. The task is within the delegatee's job description.

6.2(9) Additional acts which may be performed by, and specific nursing practices for, registered nurses:

a. A registered nurse shall be permitted to practice as a diagnostic radiographer while under the supervision of a licensed practitioner provided that appropriate training standards for use of radiation-emitting equipment are met as outlined in 641—Chapter 42.

b. A registered nurse may staff an authorized ambulance, rescue, or first response service provided the registered nurse can document equivalency through education and additional skills training essential in the delivery of out-of-hospital emergency care. The equivalency shall be accepted when documentation has been reviewed and approved at the local level by the medical director of the ambulance, rescue, or first response service and the Iowa department of public health bureau of emergency and trauma services in accordance with the form adopted by the Iowa department of public health. An exception to this subrule is the registered nurse who accompanies and is responsible for a transfer patient.

c. A registered nurse, while circulating in the operating room, shall provide supervision only to persons in the same operating room.

This rule is intended to implement Iowa Code section 147A.12 and chapters 136C and 152.

655—6.3(152) Standards of nursing practice for licensed practical nurses.

6.3(1) The licensed practical nurse shall recognize and understand the legal boundaries for practicing nursing within the scope of nursing practice. The scope of practice of the licensed practical nurse is determined by the nurse's education, experience, and competency and the rules governing nursing.

6.3(2) The licensed practical nurse shall demonstrate professionalism and accountability by:

a. Demonstrating honesty and integrity in nursing practice.

b. Basing nursing decisions on nursing knowledge and skills, the needs of patients, and licensed practical nursing standards.

c. Maintaining competence through ongoing learning and application of knowledge in practical nursing practice.

d. Reporting instances of unsafe nursing practices by self or others to the appropriate supervisor.

e. Being accountable for judgments, individual nursing actions, competence, decisions, and behavior in the course of practical nursing practice.

f. Assuming responsibility for the nurse's own decisions and actions.

g. Wearing identification which clearly identifies the nurse as a licensed practical nurse when providing direct patient care unless wearing identification creates a safety or health risk for either the nurse or the patient.

6.3(3) The licensed practical nurse, practicing under the supervision of a registered nurse, advanced registered nurse practitioner (ARNP), or licensed physician, consistent with the accepted and prevailing practices and practice setting, may participate in the nursing process by:

a. Participating in nursing care, health maintenance, patient teaching, evaluation and collaborative planning and rehabilitation to the extent of the licensed practical nurse's education, experience, and competency.

b. Conducting a thorough, ongoing nursing assessment based on the patient's needs after the initial assessment is completed by the registered nurse.

c. Assisting the supervising registered nurse, ARNP, or physician in planning for patient care by identifying patient needs and goals.

d. Demonstrating attentiveness and providing patient surveillance and monitoring.

e. Seeking clarification of orders when needed.

f. Obtaining education and ensuring competence when encountering new equipment, technology, medication, procedures or any other unfamiliar care situations.

g. Implementing treatment and therapy as identified by the patient's overall health care plan.

h. Documenting nursing care accurately, thoroughly, and in a timely manner.

i. Evaluating continuously the patient's response to nursing care and other therapies, including:

(1)Patient's response to interventions.

(2)Need for alternative interventions.

(3)Need to communicate and consult with other health team members.

(4)Need to revise the plan of care.

j. Collaborating and communicating relevant and timely patient information with patients and other health team members to ensure quality and continuity of care, including:

(1)Patient concerns and special needs.

(2)Patient status and progress.

(3)Patient response or lack of response to interventions.

(4)Significant changes in patient condition.

(5)Interventions which are not implemented, based on the licensed practical nurse's professional judgment, and providing:

1.A timely notification to the physician, ARNP, registered nurse, or other health care provider who prescribed the intervention that the order was not executed and reason(s) for not executing the order;

2.Documentation in the medical record that the physician, ARNP, registered nurse, or other health care provider was notified and reason(s) for not implementing the order; and

3.If appropriate, a timely notification to other persons who, based on the patient's circumstances, should be notified of any orders which were not implemented.

k. Providing a safe environment for the patient.

l. Participating in the health care education of the patient and others, according to nursing standards and evidence-based practices.

6.3(4) A licensed practical nurse shall not perform any activity requiring the knowledge and education of a registered nurse, including but not limited to:

a. Initiating a procedure or therapy that requires the knowledge and education level of a registered nurse.

b. Performing an assessment of a procedure or therapy that requires the knowledge and education level of a registered nurse.

c. Initiating or administering blood components.

d. Initiating or administering medications requiring the knowledge and education level of a registered nurse.

6.3(5) A licensed practical nurse, under the supervision of a registered nurse, may engage in the limited scope of practice of intravenous therapy. The licensed practical nurse shall be educated and have documentation of competency in the limited scope of practice of intravenous therapy. Limited scope of practice of intravenous therapy may include:

a. Addition of intravenous solutions without adding medications to established peripheral intravenous sites.

b. Monitoring and regulating the rate of nonmedicated intravenous solutions to established peripheral intravenous sites.

c. Administration of maintenance doses of analgesics via the patient-controlled analgesia pump set at a lock-out interval to established peripheral intravenous sites.

d. Discontinuation of peripheral intravenous therapy.

e. Administration of a prefilled heparin or saline syringe flush, prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse, to an established peripheral lock, in a licensed hospital, a nursing facility or a certified end-stage renal dialysis unit.

6.3(6) In a certified end-stage renal dialysis unit, nursing tasks which may be delegated by a registered nurse to a licensed practical nurse, for the sole purpose of hemodialysis treatment, include:

a. Initiation and discontinuation of the hemodialysis treatment utilizing any of the following established vascular accesses: central line catheter, arteriovenous fistula, and graft.

b. Administration, during hemodialysis treatment, of local anesthetic prior to cannulation of the vascular access site.

c. Administration of prescribed dosages of heparin solution or saline solution utilized in the initiation and discontinuation of hemodialysis.

d. Administration, during hemodialysis treatment via the extracorporeal circuit, of the routine intravenous medications erythropoietin, Vitamin D Analog, intravenous antibiotic solutions prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse, and iron, excluding any iron preparation that requires a test dose. The registered nurse shall administer the first dose of erythropoietin, Vitamin D Analog, antibiotics, and iron.

6.3(7) The licensed practical nurse shall act as an advocate for the patient by:

a. Always practicing under the supervision of a registered nurse, ARNP, or physician.

b. Respecting the patient's rights, confidentiality, concerns, decisions, and dignity.

c. Identifying patient needs.

d. Attending to patient concerns or requests.

e. Promoting a safe environment for the patient, others, and self.

f. Maintaining appropriate professional boundaries.

6.3(8) The licensed practical nurse shall apply the delegation process when delegating to another licensed practical nurse by:

a. Delegating only those nursing tasks that fall within the scope of practice of a licensed practical nurse.

b. Delegating only those nursing tasks that fall within the delegatee's scope of practice, education, experience, and competence.

c. Matching the patient's needs and circumstances with the delegatee's qualifications, resources, and appropriate supervision.

d. Communicating directions and expectations for completion of the delegated activity and receiving confirmation of the communication from the delegatee.

e. Supervising the delegatee by monitoring performance, progress and outcomes and ensuring appropriate documentation is complete.

f. Evaluating patient outcomes as a result of the delegation process.

g. Intervening when problems are identified, revising plan of care when needed, and reassessing the appropriateness of the delegation.

h. Retaining accountability for properly implementing the delegation process.

i. Promoting a safe and therapeutic environment by:

(1)Providing appropriate monitoring and surveillance of the care environment;

(2)Identifying unsafe care situations; and

(3)Correcting problems or referring problems to appropriate management level when needed.

6.3(9) The licensed practical nurse shall apply the delegation process when delegating to an unlicensed assistive personnel (UAP) by:

a. Delegating only those nursing tasks that fall within the scope of practice of a licensed practical nurse.

b. Ensuring the UAP has the appropriate education and training and has demonstrated competency to perform the delegated task.

c. Ensuring the task does not require assessment, interpretation, and independent nursing judgment or nursing decision during the performance or completion of the task.

d. Ensuring the task is consistent with the UAP's scope of employment and can be safely performed according to clear and specific directions.

e. Verifying that, in the professional judgment of the delegating nurse, the task poses minimal risk to the patient.

f. Communicating directions and expectations for completion of the delegated activity and receiving confirmation of the communication from the UAP.

g. Supervising the UAP and evaluating the patient outcomes of the delegated task.

6.3(10) The licensed practical nurse may provide nursing care in an acute care setting so long as a registered nurse, ARNP, or physician is present in the proximate area. Acute care settings requiring a registered nurse, ARNP, or physician to be in the proximate area include but are not limited to:

a. Units where care of the unstable, critically ill, or critically injured individual is provided.

b. General medical-surgical units.

c. Emergency departments.

d. Operating rooms. (A licensed practical nurse may assist with circulating duties when supervised by a registered nurse circulating in the same room.)

e. Postanesthesia recovery units.

f. Hemodialysis units.

g. Labor and delivery/birthing units.

h. Mental health units.

i. Diagnostic testing centers.

j. Surgery centers.

k. Outpatient procedure centers.

6.3(11) The licensed practical nurse may provide nursing care in a non-acute care setting. However, a registered nurse, ARNP, or physician must be present in the proximate area if the licensed practical nurse provides nursing care in the following non-acute care settings:

a. Community health settings, except:

(1)The licensed practical nurse shall be permitted to provide supportive and restorative care in the home setting under the supervision of a registered nurse or a physician. However, the initial assessment shall be provided by the registered nurse, and the licensed practical nurse is responsible for requesting nurse consultation as needed.

(2)The licensed practical nurse shall be permitted to provide supportive and restorative care in a camp setting under the supervision of a registered nurse or a physician. However, the initial assessment shall be performed by the registered nurse, and the licensed practical nurse is responsible for requesting registered nurse consultation as needed.

b. Schools, except:

(1)The licensed practical nurse shall be permitted to provide supportive and restorative care to a specific student in the school setting in accordance with the student's health plan when under the supervision of, and as delegated by, the registered nurse employed by the school district.

(2)The licensed practical nurse shall be permitted to provide supportive and restorative care in a Head Start program under the supervision of a registered nurse or a physician if the licensed practical nurse was in this position prior to July 1, 1985.

c. Occupational health settings.

d. Correctional facilities, except:

(1)The licensed practical nurse shall be permitted to provide supportive and restorative care in a county jail facility or municipal holding facility operating pursuant to Iowa Code chapter 356. The supportive and restorative care provided by the licensed practical nurse in such facilities shall be performed under the supervision of a registered nurse. However, the initial assessment shall be performed by the registered nurse, and the licensed practical nurse is responsible for requesting registered nurse consultation as needed. The registered nurse shall be available 24 hours per day by teleconferencing equipment.

(2)Reserved.

e. Community mental health settings.

f. Health care clinics, except:

(1)The licensed practical nurse shall be permitted to conduct height, weight and hemoglobin screening and record responses to health questions asked in a standardized questionnaire under the supervision of a registered nurse in a Women, Infants and Children (WIC) clinic. A registered nurse employed by or under contract to the WIC agency will assess the competency of the licensed practical nurse to perform these functions and will be available for consultation. The licensed practical nurse is responsible for performing under the scope of practice for licensed practical nurses and requesting registered nurse consultation as needed. This exception to the proximate area requirement is limited to WIC clinics and to the services permitted in this subrule.

(2)Reserved.

6.3(12) A licensed practical nurse may be permitted to supervise other licensed practical nurses or unlicensed assistive personnel, pursuant to Iowa Code section 152.1(5)"b," in the following practice settings, in accordance with the following:

a. A licensed practical nurse working under the supervision of a registered nurse may be permitted to supervise in an intermediate care facility for persons with an intellectual disability or in a residential health care setting.

b. A licensed practical nurse working under the supervision of a registered nurse who is in the proximate area may direct the activities of other licensed practical nurses and unlicensed assistive personnel in an acute care setting in giving care to individuals assigned to the licensed practical nurse.

c. A licensed practical nurse working under the supervision of a registered nurse may supervise in a nursing facility if the licensed practical nurse completes the National Healthcare Institute's Supervisory Course for Iowa's Licensed Practical Nurses within 90 days of employment in a supervisory role. Documentation of the completion of the course shall be maintained by the licensed practical nurse. A licensed practical nurse shall be entitled to supervise without completing the course if the licensed practical nurse was performing in a supervisory role on or before October 6, 1982. A licensed practical nurse who is currently enrolled as a full-time student in a registered nurse program and is scheduled to graduate within one year is not required to complete the course. If the licensed practical nurse does not obtain a registered nurse license within one year, the licensed practical nurse must take the course to continue supervisory duties.

6.3(13) A licensed practical nurse shall be permitted to practice as a diagnostic radiographer while under the supervision of a licensed practitioner provided that appropriate training standards for use of radiation-emitting equipment are met as outlined in 641—Chapter 42.

6.3(14) A licensed practical nurse shall be permitted to perform, in addition to the functions set forth in subrule 6.3(5), procedures related to the expanded scope of practice of intravenous therapy upon completion of the board-approved expanded intravenous therapy certification course and in accordance with the following:

a. To be eligible to enroll in the course, the licensed practical nurse shall:

(1)Hold a current unrestricted Iowa license or an unrestricted license in another state recognized for licensure in this state pursuant to the nurse licensure compact contained in Iowa Code chapter 152E.

(2)Have documentation of 1,040 hours of practice as a licensed practical nurse.

(3)Be practicing in a licensed hospital, a nursing facility or a certified end-stage renal dialysis unit whose policies allow the licensed practical nurse to perform procedures related to the expanded scope of practice of intravenous therapy.

b. The course must be offered by an approved Iowa board of nursing provider of nursing continuing education. Documentation of course completion shall be maintained by the licensed practical nurse and employer.

c. The board-approved course shall incorporate the responsibilities of the licensed practical nurse when providing intravenous therapy via a peripheral intravenous catheter, a midline catheter and a peripherally inserted central catheter (PICC) to children, adults and elderly adults.

d. Upon completion of the course, when providing intravenous therapy, the licensed practical nurse shall be under the supervision of a registered nurse. Procedures which may be performed if delegated by the registered nurse are as follows:

(1)Initiation of a peripheral intravenous catheter for continuous or intermittent therapy using a catheter not to exceed three inches in length.

(2)Administration, via a peripheral intravenous catheter, midline catheter, and a PICC line, of premixed electrolyte solutions or premixed vitamin solutions. The first dose shall be administered by the registered nurse. The solutions must be prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse.

(3)Administration, via a peripheral intravenous catheter, midline catheter, and a PICC line, of solutions containing potassium chloride that do not exceed 40 meq per liter and that do not exceed a dose of 10 meq per hour. The first dose shall be administered by the registered nurse. The solutions must be prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse.

(4)Administration, via a peripheral intravenous catheter, midline catheter, and a PICC line, of intravenous antibiotic solutions prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse. The first dose shall be administered by the registered nurse.

(5)Maintenance of the patency of a peripheral intravenous catheter, midline catheter, and a PICC line with a prefilled heparin or saline syringe flush, prepackaged by the manufacturer or premixed by a registered pharmacist or registered nurse.

(6)Changing the dressing of a midline catheter and a PICC line per sterile technique.

e. Intravenous therapy procedures which shall not be delegated by the registered nurse to the licensed practical nurse are as follows:

(1)Initiation and discontinuation of a midline catheter or a PICC.

(2)Administration of medication by bolus or IV push except maintenance doses of analgesics via a patient-controlled analgesia pump set at a lock-out interval.

(3)Administration of blood and blood products, vasodilators, vasopressors, oxytoxics, chemotherapy, colloid therapy, total parenteral nutrition, anticoagulants, antiarrhythmics, thrombolytics, and solutions with a total osmolarity of 600 or greater.

(4)Provision of intravenous therapy to a patient under the age of 12 or any patient weighing less than 80 pounds, with the exception of those activities authorized in the limited scope of practice found in subrule 6.3(5).

(5)Provision of intravenous therapy in any other setting except a licensed hospital, a nursing facility and a certified end-stage renal dialysis unit, with the exception of those activities authorized in the limited scope of practice found in subrule 6.3(5).

These rules are intended to implement Iowa Code chapter 152.

[Filed 2/4/21, effective 3/31/21]

[Published 2/24/21]

Editor's Note: For replacement pages for IAC, see IAC Supplement 2/24/21.