Ohio Nurse Practice Act: 1 Hour Category A

To find the NPA, go to the state of Ohio Board of Nursing web page to access the most recent copy: www.nursing.ohio.gov/laws-rules/.

In Ohio, RNs are expected to provide nursing care in a manner defined by the Board of Nursing, as stipulated within the NPA. What is expected, at a minimum, is composed of the following (ORC, 4723.01) (B)-(D)): maintenance of current knowledge in the areas of duties, responsibilities, and accountabilities required for safe nursing practice and the ability to demonstrate both competence and accountability in all areas of practice. Consistent performance in all aspects of nursing care. More detail is available at codes.ohio.gov/ohio-revised-code/section-4723.01. Duties that RNs are expected to complete within a "timely manner" include the following (ORC, 4723.01) (B)-(D)):

• Implementation of any order for a client unless the RN believes or should have reason to believe the order is: inaccurate, not properly authorized, not current or valid, harmful or potentially harmful to the client, and contraindicated by other documented information.
• Clarify any order for a client when the RN believes or should have reason to believe the order is: inaccurate, not properly authorized, not current or valid, harmful or potentially harmful to the client, and contraindicated by other documented information.

When providing direction to an LPN, it is up to the RN to first assess:

• The condition of the client, including their stability
• The type of nursing care required by the client
• The complexity and frequency of any nursing care needed
• The training, skill, and ability of that LPN about their ability to perform specific needed functions or procedures
• The availability and accessibility of resources needed to safely perform the specified function or procedure

The practice of an LPN means providing care to individuals and groups, requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences. The LPN practices under the direction of an RN, physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor. In Ohio, an LPN is expected to function within the limits of practice set by the Ohio Revised Code as well as by any rules by the Board of Nursing, applicable laws, rules, and professional standards (ORC, 4723.01 (B) – (D)).

It is an expectation that current knowledge of duties, responsibilities, and accountabilities necessary for safe nursing practice be maintained and that an LPN can demonstrate competence and accountability in the care they deliver. LPNs are also expected to have the skills necessary to recognize, refer, seek consultation, or implement interventions that may be needed to manage complications that may arise. More detail is available at codes.ohio.gov/ohio-revised-code/section-4723.01.

In the state of Ohio, it is expected that an LPN will promptly implement any order or direction for a client unless the LPN believes or should believe the order is: inaccurate, not properly authorized, not current, valid, or contraindicated by other documented information.

An LPN must obtain clarification for any order or direction for a client when the LPN believes or should have reason to believe the order or direction is: inaccurate, not properly authorized, not current, valid, or contraindicated by other documented information. Clarification for an order or direction requires a timely consultation with an appropriate licensed practitioner.

Advanced practice registered nurses' scope of practice is in Chapter 4723-8 (OAC 4723). These standards apply to the following titles: CRNA, CNS, CNM, CNP, and APRN.

Before beginning practice, a standard care arrangement shall be entered into with each physician or podiatrist with whom the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist collaborates (ORC 4723.431). The requirements for a standard care arrangement are at codes.ohio.gov/ohio-revised-code/section-4723.431 (ORC 4723.431 (B))

An APRN may prescribe any drug or therapeutic device in any form or route of administration if:

1. The ability to prescribe the drug or therapeutic device is within the scope of the practice in the nurse's specialty area
2. The prescription is consistent with the terms of a standard care arrangement
3. The prescription would not exceed the prescriptive authority of the collaborating physician
4. The individual drug or subtype or therapeutic device is not one excluded by the formulary
5. The prescription meets the requirements of state and federal law
6. A valid prescriber-client relationship exists. This relationship may include but is not limited to:
   1. Obtaining a thorough, relevant history of the client
   2. Conducting a physical or mental examination of the client
   3. Rendering a diagnosis
   4. Prescribing medication, ruling out the existence of any recognized contraindications
   5. Consulting with the collaborating physician when necessary
   6. Documenting these steps in the client's medical records

An advanced practice registered nurse may delegate medication administration to an unlicensed person. Before delegating this authority, the APRN with prescriptive authority must assess the client, determine that the drug is appropriate for the client, and determine that the person to whom the authority will be delegated has met the conditions (ORC 4723.489). An APRN with prescriptive authority has many requirements and limitations. These include:

• Limitation on prescribing Schedule II controlled substances (ORC 4725.48)
• Limitations on prescribing controlled substances
• Limitation on the delegation to administer medication (ORC 4723.489)
• An exclusionary formulary species
• Authority may not exceed the prescriptive authority of the collaborating physician or podiatrist.

The exclusionary formulary is on the Board website at www.nursing.ohio.gov/practice-resources/prescribing-resources/ (ORC 4723.431 (E) and ORC 4723.27). The Ohio Automated RX Reporting System is a resource available to APRNs by the State of Ohio Board of Pharmacy. The Morphine equivalent daily dose (MED) helps calculate a client's opioid intake. The MED converts various opioid analgesics to a morphine equivalent dose using accepted conversion tables provided by the state board of pharmacy. The calculator can be found at www.ohiopmp.gov/MED_Calculator.aspx.

Any LPN may perform some IV therapy procedures on any client without receiving authorization to perform IV therapy from the board of nursing if both of the following apply.

The LPN acts under the direction of an RN or a licensed physician, dentist, optometrist, or podiatrist. The RN or a licensed physician, dentist, optometrist, or podiatrist is on the premises where the procedure is to be performed or accessible by some form of telecommunication.

The LPN demonstrates the knowledge, skills, and abilities to perform the procedure safely.

The IV therapy procedures that any LPN may perform are limited to the following:

• Verification of the type of peripheral IV solution being administered
• Examination of a peripheral infusion site and the extremity for infiltration
• Regulation of a peripheral IV infusion according to the prescribed flow rate
• Discontinuation of a peripheral IV device at the appropriate time
• Performance of routine dressing changes at the insertion site of a peripheral venous or arterial infusion, peripherally inserted central catheter infusion, or central venous pressure subclavian infusion

LPNs licensed in Ohio may be eligible for IV therapy privileges if they complete a Board-approved course of study on the safe performance of IV therapy. There are special requirements for LPNs to perform IV therapy procedures (ORC 4723.18). An RN shall be readily available at the IV therapy site when an authorized LPN has been delegated an IV therapy procedure. Before the LPN initiates the IV therapy, the RN shall personally perform an on-site assessment of the adult client to receive the IV therapy. An LPN shall not initiate or maintain any of the following:

• Blood or blood components
• Solutions for total parenteral nutrition
• Any cancer therapeutic medication including, but not limited to, cancer chemotherapy or an antineoplastic agent
• Solutions are administered through any central venous line or arterial line, or any other line that does not terminate in a peripheral vein; except that an LPN authorized by the board to perform IV therapy may maintain the solutions specified that are being administered through a central venous line or peripherally inserted central catheter
• Any investigational or experimental medication

An LPN shall not initiate IV therapy in any vein, except that an IV-authorized LPN may initiate IV therapy in a vein of the hand, forearm, or antecubital fossa. An LPN cannot perform any of the following procedures:

• Discontinuing a central venous, arterial, or any other line that does not terminate in a peripheral vein
• Initiating or discontinuing a peripherally inserted central catheter
• Mixing, preparing, or reconstituting any medication for IV except that an IV authorized LPN may prepare or reconstitute an antibiotic additive
• Administering medication via the IV route, including all the following activities:
  • Adding medication to an IV solution or an existing infusion except that an IV authorized LPN may initiate an IV infusion containing one or more of the following elements: Dextrose 5%, normal saline, lactated ringers, sodium chloride 45%, sodium chloride 0.2% and sterile water
  • Hang subsequent containers of the IV solutions, vitamins, or electrolytes, if an RN initiated the infusion of that same IV solution
  • Initiate or maintain an IV piggyback infusion containing an antibiotic additive
  • Inject medication via a direct IV route, except that an IV authorized LPN heparin or normal saline to flush an intermittent infusion device or heparin lock
  • Change tubing on any line including, but not limited to, an arterial line or a central venous line, except that an IV authorized LPN may change tubing on an IV line that terminates in a peripheral vein
  • Program or set any function of a client-controlled infusion pump

At the direction of a physician or an RN, an authorized LPN may perform the following activities to perform dialysis:

• The routine administration and regulation of saline solution to maintain an established fluid plan
• The administration of a heparin dose IV
• The administration of a heparin dose peripherally via a fistula needle
• The loading and activation of a constant infusion pump or the intermittent injection of a dose of medication for dialysis are administered via the hemodialysis blood circuit and through the client's venous access point

It is an assigned duty for the board to investigate evidence showing a violation has occurred (ORC 4723.28). The process and activities that may result in disciplinary action are listed at codes.ohio.gov/ohio-revised-code/section-4723.28 (ORC 4723.28).

In response to the COVID-19 pandemic, the Ohio Revised Code was updated to allow for synchronous or asynchronous technology to provide services within the professional's scope of practice (ORC 472309). Telehealth services are defined as the use of technology by the healthcare professional to provide services to a client at a site other than the provider's location. The standard of care for such services must be equal to the standard of care for in-person services. When a client consents to receive telehealth services, the health care provider is not liable for damages under any claims made that the services provided do not meet the same standard of care that would apply if the service was provided in person.

An initial in-person visit is required when prescribing a schedule II-controlled substance; however, this requirement is waived if the client receives palliative or hospice care. The requirement is also waived for a client who meets any of the following: medication-assisted treatment or any other medication for opioid-use disorder, who is a client with a mental health condition, or who, as determined by the clinical judgment of a health care professional, is in an emergency (ORC 4723.09).

Telehealth services may be denied, and the health care professional may require the client to attend in-person visits only. If the client is present in another state, Ohio allows the healthcare provider to complete the visit if permitted by the laws of the state in which the client is located.

During morning rounds, Jane RN assessed her clients, including stability, nursing care needed, complexity and frequency of care, and availability of unit stock. It is a busy day, and one of the staff is an LPN from another unit. Jane does not know the training, skills, or ability of the LPN. Jane would like to delegate some IV responsibilities to this LPN.

Intervention/Strategies:

Jane RN called the unit's nurse manager the LPN came from to identify IV training. The nurse manager is not available. She speaks with the charge nurse, who says the LPN is authorized to do IV therapy. The charge nurse does not have the documentation but has observed the LPN performing IV therapy. Jane decided not to delegate any IV therapy to the LPN from another unit except for discontinuation of peripheral lines, which any LPN can do.

Discussion of outcomes:

Jane was busy and could have used the LPN to do IV therapy, but Jane delegated other tasks to the LPN. Jane could have taken the charge nurse's confirmation that the LPN is authorized for IV therapy; however, Jane does not know the charge nurse and would be more comfortable discussing the situation with the nurse manager who has access to the LPN's competency file. Jane felt she did not have any more time to commit to identifying the LPN's authorization for IV therapy.

Strengths and weaknesses of the approach used in the case:

Another 15 minutes of questioning could have identified a supervisor or manager who could confirm the LPN's authorization for IV therapy. Jane did not want to spend any more time on the issue. Had Jane taken the extra time, she could have delegated IV responsibilities that amounted to more than 15 minutes. Delegating the search for authorization for IV therapy to the supervisor or her nurse manager would have been a better use of time. Jane is responsible for knowing the training, skill, and ability of that LPN about their ability to perform specific needed functions or procedures, time was short, and resources limited. Jane made a safe decision. Jane also knew that resources were available, but accessibility to resources is limited for someone who has not oriented to the unit.

When a nurse seeks initial licensure or renewal of license from a state, they agree to practice their profession in such a manner as to meet or exceed the level of care that they have set. In Ohio, the NPA recognizes the many functions and levels a professional nurse might practice. Recognition of professional nursing practice as a specific and special means for providing nursing care indicates an understanding of what nurses are and what nurses do.

• Ohio Board of Nursing (2016). Administrative rule update. Momentum. 2016; 14(1). Visit Source.
• Ohio Revised Code. Chapter 4723. Nurses. Visit Source. (2022).
• Ohio Revised Code. Chapter 4743. Standards for telehealth services. (2022). Visit Source.
• Ohio Board of Nursing. (2022) New APRN law: Delegation of authority to administration of drugs. Momentum.2022; 4(13). Visit Source.