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Nursing Delegation and Medication Administration in Assisted Living

Mitty, Ethel EdD, RN; Resnick, Barbara PhD, CRNP, FAAN, FAANP; Allen, Josh RN; Bakerjian, Debra PhD, APRN; Hertz, Judith PhD, RN; Gardner, Wendi BSN, RN-BC, CALN; Rapp, Mary Pat PhD, RN; Reinhard, Susan PhD, RN, FAAN; Young, Heather PhD, RN, FAAN; Mezey, Mathy EdD, RN, FAAN

Nursing Administration Quarterly: April-June 2010 - Volume 34 - Issue 2 - p 162–171
doi: 10.1097/NAQ.0b013e3181d9183f

Assisted living (AL) residences are residential long-term care settings that provide housing, 24-hour oversight, personal care services, health-related services, or a combination of these on an as-needed basis. Most residents require some assistance with activities of daily living and instrumental activities of daily living, such as medication management. A resident plan of care (ie, service agreement) is developed to address the health and psychosocial needs of the resident. The amount and type of care provided, and the individual who provides that care, vary on the basis of state regulations and what services are provided within the facility. Some states require that an RN hold a leadership position to oversee medication management and other aspects of care within the facility. A licensed practical nurse/licensed vocational nurse can supervise the day-to-day direct care within the facility. The majority of direct care in AL settings is provided by direct care workers (DCWs), including certified nursing assistants or unlicensed providers. The scope of practice of a DCW varies by state and the legal structure within that state. In some states, the DCW is exempt from the nurse practice act, and in some states, the DCW may practice within a specific scope such as being a medication aide. In most states, however, the DCW scope of practice is conscribed, in part, by the delegation of responsibilities (such as medication administration) by a supervising RN. The issue of RN delegation has become the subject of ongoing discussion for AL residents, facilities, and regulators and for the nursing profession. The purpose of this article is to review delegation in AL and to provide recommendations for future practice and research in this area.

College of Nursing, New York University, New York (Drs Mitty, AALNA, HIGN and Mezey, HIGN); Sonya Ziporkin Gershowitz Chair in Gerontology, University of Maryland School of Nursing, Baltimore (Dr Resnick, AALNA, GAPNA); Advanced Healthcare Studies LLC, Wildomar, California (Mr Allen, AALNA); Department of Social and Behavioral Sciences School of Nursing, University of California, San Francisco (Dr Bakerjian, GAPNA); Merrill Gardens LLC, Seattle, Washington (Ms Gardner, NADONA/LTC); National Gerontological Nurses Association, Pensacola, Florida (Dr Hertz, NGNA); Public Policy Institute, Center to Champion Nursing in America, Washington (Dr Reinhard, AARP); Gerontological Advanced Practice Nurses Association, Pensacola, Florida (Dr Rapp, GAPNA) and Betty Irene Moore School of Nursing, UC Davis Health System, Sacramento, California (Dr Young).

Corresponding Author: Ethel Mitty, EdD, RN, College of Nursing, New York University, 726 Broadway, 10th Floor, New York, NY 10003 (

Abbreviations for Coalition of Geriatric Nursing Organizations' authors: AALNA, American Assisted Living Nurses Association; AALTCN, American Association for Long Term Care Nursing; GAPNA, Gerontological Advanced Practice Nurses Association; HIGN, Hartford Institute for Geriatric Nursing; NADONA/LTC, National Association Directors of Nursing Administration in Long Term Care.

The authors thank Charlotte Eliopolous, MPH, PhD, RN (President: AALTCN), for her thoughtful reading of the manuscript.

© 2010 Lippincott Williams & Wilkins, Inc.