Washington Nurse Delegation and Medication Administration Rules: AFH and ALF Compliance Guide

Nurse delegation is a critical regulatory mechanism in Washington State that allows registered nurses (RNs) to delegate specific nursing tasks to trained caregivers in community-based settings such as Adult Family Homes (AFHs) and Assisted Living Facilities (ALFs). Because many residents require medication support and chronic condition management, understanding nurse delegation rules is essential for compliance with both the Washington Administrative Code (WAC) and Department of Social and Health Services (DSHS) regulations.

Improper delegation, inadequate documentation, or unauthorized medication administration can result in citations, license action, and liability exposure. This guide explains Washington’s nurse delegation framework, caregiver training requirements, medication administration standards, documentation expectations, and enforcement risks.

Regulatory Framework

Washington nurse delegation and medication administration are governed by:

• Chapter 18.79 RCW – Nursing Care

• WAC 246-840 – Nursing Commission Rules

• WAC 388-76 – Adult Family Home Licensing Requirements

• WAC 388-78A – Assisted Living Facility Licensing Requirements

• DSHS policy and interpretive guidelines

The Washington State Nursing Care Quality Assurance Commission regulates nurse delegation authority, while DSHS regulates facility compliance.

What Is Nurse Delegation in Washington?

Nurse delegation allows a registered nurse (RN) to transfer the performance of certain nursing tasks to a trained caregiver in a community setting, while retaining overall responsibility and accountability.

Delegation is not a blanket authorization. It is:

• Resident-specific

• Task-specific

• Time-limited

• Documented

• Supervised

The RN remains accountable for the decision to delegate and must determine that delegation is appropriate and safe.

Settings Where Nurse Delegation Applies

Nurse delegation commonly occurs in:

• Adult Family Homes

• Assisted Living Facilities

• Supported living programs

• Community residential settings

Delegation allows residents to remain in less restrictive environments while receiving necessary care.

Tasks That May Be Delegated

Under Washington law, RNs may delegate certain nursing tasks, including:

• Oral medication administration

• Topical medication application

• Eye and ear drops

• Insulin injections

• Blood glucose monitoring

• Certain wound care tasks

• Oxygen administration (in limited circumstances)

Each task must be evaluated individually for appropriateness.

Delegation is not automatic. The RN must assess the resident’s condition and caregiver competence.

Tasks That Cannot Be Delegated

Certain tasks are prohibited from delegation, including:

• Initial nursing assessment

• Nursing judgment and care planning

• Complex wound care requiring advanced clinical decision-making

• Intravenous medication administration

• Central line care

• Tasks requiring ongoing nursing assessment

The RN must determine that the task does not require nursing judgment during execution.

RN Responsibilities in Delegation

The delegating registered nurse must:

1. Assess the resident’s condition

2. Determine task suitability for delegation

3. Evaluate caregiver competence

4. Provide task-specific training

5. Document delegation authorization

6. Develop written delegation instructions

7. Provide ongoing supervision

8. Reassess the resident periodically

9. Rescind delegation if conditions change

The RN cannot delegate without conducting a thorough assessment.

Caregiver Requirements for Delegation

Caregivers receiving delegated tasks must:

• Complete basic training required by DSHS

• Complete nurse delegation training course

• Demonstrate competency

• Follow written delegation instructions

• Notify the RN of condition changes

• Maintain accurate documentation

Competency must be demonstrated before task performance begins.

Nurse Delegation Process

The delegation process typically follows these steps:

1. Initial RN Assessment
   The RN evaluates the resident’s stability and appropriateness for delegation.

2. Caregiver Training
   The RN trains the caregiver on the specific task.

3. Competency Demonstration
   The caregiver demonstrates proficiency.

4. Written Delegation Authorization
   Documentation must specify:

   • Resident name

   • Task delegated

   • Frequency

   • RN signature

   • Start date

5. Ongoing Supervision
   The RN provides follow-up and periodic reassessment.

Delegation must be renewed or reassessed as required by rule.

Medication Administration vs Medication Assistance

Washington distinguishes between:

Medication Assistance

Caregivers may assist residents with self-administration by:

• Opening medication containers

• Reminding residents

• Handing medications to residents

• Observing ingestion

No delegation is required if the resident self-administers.

Medication Administration

When caregivers directly administer medication (e.g., insulin injection), nurse delegation is required.

Administration involves:

• Measuring dosage

• Physically administering medication

• Making no independent clinical decisions

Unauthorized medication administration is a serious violation.

Insulin and Blood Glucose Monitoring

Washington permits delegation of:

• Insulin injections

• Blood glucose monitoring

Conditions include:

• Resident must be stable

• RN must assess and approve delegation

• Caregiver must demonstrate competency

• Clear written instructions must exist

Delegation of insulin is common in AFHs.

Documentation Requirements

Proper documentation is essential for compliance.

Facilities must maintain:

• RN delegation assessment form

• Written delegation authorization

• Caregiver competency verification

• Training records

• Medication administration record (MAR)

• Ongoing RN supervision documentation

Records must be readily available during DSHS inspections.

Incomplete delegation documentation is a frequent deficiency.

RN Supervision Requirements

The RN must provide ongoing oversight, including:

• Periodic in-person or remote evaluation

• Review of medication logs

• Reassessment of resident condition

• Monitoring caregiver performance

If the resident’s condition changes significantly, delegation must be reassessed.

Delegation may be revoked at any time.

Medication Administration Records (MAR)

Facilities must maintain accurate MAR documentation, including:

• Resident name

• Medication name

• Dosage

• Route

• Time administered

• Staff initials/signature

• Refusals

• Omitted doses

• PRN documentation

Errors, blank entries, or pre-signing are compliance violations.

Nurse Delegation Timeframes

Delegation authorization is not indefinite. It must be:

• Reviewed periodically

• Renewed per regulatory timeframes

• Updated when care needs change

Facilities should track delegation expiration dates to prevent lapses.

DSHS Survey Focus Areas

During inspection, DSHS surveyors evaluate:

• RN delegation files

• Training documentation

• MAR accuracy

• Caregiver interviews

• RN supervision records

• Insulin delegation compliance

• Wound care delegation documentation

Surveyors compare documentation to observed practice.

Common Nurse Delegation Deficiencies

Common citations include:

• Missing RN assessment

• Expired delegation authorization

• Caregiver performing non-delegated tasks

• Insufficient RN supervision

• Incomplete MAR entries

• Delegation of prohibited tasks

• Lack of competency documentation

Proactive auditing reduces survey risk.

Liability Considerations

Improper delegation exposes:

• The RN to professional discipline

• The facility to DSHS enforcement

• Caregivers to employment consequences

• The facility to civil liability

Strict adherence to delegation rules protects all parties.

Best Practices for Compliance

To maintain compliance:

1. Maintain a nurse delegation tracking log

2. Conduct quarterly MAR audits

3. Verify delegation renewal dates

4. Provide refresher training

5. Ensure written instructions are clear and updated

6. Audit insulin documentation weekly

7. Maintain communication between RN and administrator

Structured systems prevent compliance failures.

Frequently Asked Questions

Can LPNs delegate in Washington?
Delegation authority is limited to registered nurses.

Can insulin always be delegated?
Only if the resident is stable and the RN approves.

Is nurse delegation permanent?
No. It must be reassessed periodically.

Can a caregiver refuse delegated tasks?
Yes. Caregivers are not obligated to accept delegation.

Conclusion

Washington nurse delegation and medication administration rules allow residents in Adult Family Homes and Assisted Living Facilities to receive necessary care while remaining in community settings. However, delegation is tightly regulated and requires careful RN oversight, caregiver training, documentation, and ongoing supervision.

Facilities that implement structured delegation tracking, documentation audits, and regular RN communication significantly reduce regulatory and liability risks.

Nurse delegation is a powerful tool when used properly. It must be executed with precision, doc:umentation integrity, and strict adherence to Washington law.

URL:

Washington Nursing Commission – WAC 246-840
https://apps.leg.wa.gov/WAC/default.aspx?cite=246-840

Washington Adult Family Home Rules – WAC 388-76
https://apps.leg.wa.gov/WAC/default.aspx?cite=388-76

Washington Assisted Living Rules – WAC 388-78A
https://apps.leg.wa.gov/WAC/default.aspx?cite=388-78A

Washington State DSHS Residential Care Services
https://www.dshs.wa.gov/altsa