One RN, Thirty-Four Residents, and an Aide Who Wants to Help
At 16:40 on the 3-to-11 shift in a 96-bed nursing facility in Bowling Green, the only RN on the unit is responsible for 34 residents, one LPN, and three nurse aides. Two residents need IV antibiotics hung, a new admission with a Stage 3 sacral pressure injury is waiting in the lobby, and a Medicare observation assessment is due by 20:00. A CNA with six years of experience who completed the facility's in-house "medication assistant" course last spring offers to change the sacral dressing and to give the 17:00 oral metoprolol to the resident in room 214 "so you can catch up." A second aide asks whether she may take vital signs and a fingerstick glucose on a stable resident with well-controlled diabetes. The day-shift charge nurse left a note reading: "LPN can do anything you can - just sign off afterward." The facility's delegation policy was last revised 18 months ago and has never been reviewed by the director of nursing.
1. Sort each request - the sacral dressing, the metoprolol, the vital signs and glucose, and the day-shift note - into "may be delegated or assigned," "may be delegated only under conditions," or "may not be delegated," and explain the legal basis for each conclusion.
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Start with the statutory frame. Under KRS Chapter 314 the practice of nursing includes assessment, planning, intervention, and evaluation, and the RN who accepts the assignment is accountable for the nursing process. Board delegation rules and advisory opinions supply the operative test: a task may be delegated only when it does not require nursing judgment, the patient is stable and the outcome predictable, the delegate has documented training and demonstrated competence, and the RN provides direction, supervision, and evaluation.
Vital signs and fingerstick glucose on a stable resident - delegable. Both are standardized, objective, and do not require interpretation at the point of collection. The RN must first set parameters (for example, report a glucose below 70 or a systolic below 100) and must interpret what comes back.
Stage 3 sacral dressing - not delegable today. This is a new admission. Wound assessment, staging, recognition of infection, and care planning are RN acts. Once the RN has assessed the wound and established a routine, uncomplicated dressing change, a trained aide may perform the mechanics under continuing RN assessment - but not before the initial assessment exists.
Metoprolol - not delegable. Administering medication is a nursing act, and this drug requires pulse and blood pressure assessment before it is given. A facility's internal "medication assistant" course creates no legal authority. Only a specific statutory or regulatory pathway for medication aides in that setting could, and even then the pre-administration assessment stays with the nurse.
Day-shift note - disregard. An LPN is licensed and does not need the RN to "sign off" on everything she does; the RN also cannot retroactively blanket-approve care she did not supervise.
2. Identify the criteria the RN must apply before any delegation, and explain where accountability rests if the delegate performs the task incorrectly.
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The working framework is the five rights of delegation: right task, right circumstance, right person, right direction and communication, right supervision and evaluation.
Applying them: right task asks whether the act is a nursing act at all or a standardized skill; right circumstance asks about patient stability, predictability, and the risk of a poor outcome in this specific resident tonight; right person requires verified training and demonstrated competency, not tenure or self-confidence; right direction requires clear, written or verbal instructions with limits and reporting parameters; right supervision requires that the RN be physically available and that the outcome be evaluated.
Accountability is shared but not transferable. The delegate is accountable for performing the task competently and for reporting changes. The RN is accountable for the delegation decision itself, for adequate supervision, and for follow-up. If the aide takes a glucose reading of 58 and the RN never looks at it, the RN owns that failure. If the aide performs a delegated dressing change incorrectly, the RN must intervene, assess the patient, notify the provider, document the event and the patient's condition, and report through the chain of command. "The aide did it" is not a defense, and the RN cannot delegate the nursing process - assessment, diagnosis, planning, and evaluation - to anyone, licensed or unlicensed. Documentation should reflect what was delegated, to whom, the instructions given, and the evaluation afterward.
3. What should the RN do about the day-shift note and about the outdated delegation policy?
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The note reflects a real and common misunderstanding: that an LPN's work must be individually approved by an RN. That is not how licensure works. An LPN holds an independent license and practices within LPN scope under the direction of an RN or physician; she does not need case-by-case sign-off. Conversely, the RN cannot use a signature to convert an out-of-scope act into an in-scope one, and cannot "cover" care delivered before the RN arrived.
Practically: do not act on the note. Speak directly with the LPN to confirm that both of you understand where LPN scope ends and RN assessment begins, particularly for the new admission and for any resident whose condition is changing. If the LPN believes the note authorizes her to perform RN-level assessment or IV push medications outside her scope, escalate immediately to the house supervisor and the director of nursing.
On the policy: an 18-month-old delegation policy never reviewed by the DON is a systems risk. Request in writing that the DON and the education department review it against current Board rules and advisory opinions, and ask that it specify which tasks are delegable, what competency validation is required, and how delegation is documented. Until it is revised, the RN's own licensure - not the policy - governs the decision. Put the request in writing so there is a record that the concern was raised.