2.3 Nursing Delegation in Texas (Rules 224 & 225)
Key Takeaways
- In Texas, only the Registered Nurse (RN) possesses the legal authority to delegate nursing tasks to Unlicensed Assistive Personnel (UAP); LVNs can assign and supervise within job descriptions but cannot legally delegate.
- 22 TAC Chapter 224 governs RN delegation in acute care environments and unstable client situations, whereas 22 TAC Chapter 225 governs delegation in independent living, community, and stable/predictable settings.
- Core nursing functions can NEVER be delegated under any Texas rule: comprehensive assessment, nursing diagnosis, care plan formulation, clinical judgment, evaluation of patient response, and health counseling requiring professional interpretation.
- Under 22 TAC §217.11(3)(B) the registered nurse holds the delegation function: an LVN may be assigned work but does not delegate nursing tasks to unlicensed personnel, and an APRN delegates on the same terms as any other RN.
Nursing Delegation in Texas (Rules 224 & 225)
In modern healthcare delivery, Registered Nurses frequently collaborate with Unlicensed Assistive Personnel (UAP), such as certified nurse aides, patient care technicians, medical assistants, and community direct support staff. In Texas, nursing delegation is defined as authorizing an unlicensed person to provide aspects of nursing care on behalf of the nurse while the nurse retains accountability for the outcome.
The Texas Board of Nursing maintains two comprehensive, distinct administrative chapters governing RN delegation:
- 22 TAC Chapter 224: Delegation in Acute Care Environments or for clients with Unstable / Unpredictable conditions.
- 22 TAC Chapter 225: Delegation in Independent Living Environments (community settings, schools, group homes, private residences) for clients with Stable and Predictable conditions.
[!IMPORTANT] Only RNs Possess Legal Delegation Authority: Under Texas law, only Registered Nurses (RNs) possess the legal authority to delegate nursing tasks to UAPs. Licensed Vocational Nurses (LVNs) supervise and assign tasks to UAPs within defined institutional job descriptions, but an LVN cannot legally delegate professional nursing tasks because delegation requires comprehensive nursing assessment and clinical judgment.
1. The Five Rights of Delegation in Texas
Every delegation decision made by a Texas RN must satisfy the Five Rights of Delegation established under 22 TAC §224.5 and §225.5:
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| THE FIVE RIGHTS OF NURSING DELEGATION |
| |
| 1. RIGHT TASK --> Is the task appropriate to delegate under |
| Rule 224 or Rule 225 criteria? |
| 2. RIGHT CIRCUMSTANCE --> Is the patient's condition stable, setting |
| appropriate, and resources adequate? |
| 3. RIGHT PERSON --> Has the specific UAP demonstrated documented |
| competency for this precise skill? |
| 4. RIGHT DIRECTION --> Are instructions clear, concise, and specific |
| with explicit limits and reporting thresholds?|
| 5. RIGHT SUPERVISION --> Does the RN provide appropriate monitoring, |
| timely intervention, and outcome evaluation? |
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2. Tasks That Can NEVER Be Delegated Under Any Texas Rule
The Board strictly prohibits the delegation of core professional nursing acts. These functions demand specialized knowledge, synthesis of clinical data, and independent professional discretion:
| Non-Delegable Nursing Function | Regulatory Rationale & Legal Limitation |
|---|---|
| Comprehensive Nursing Assessment | Only the RN can evaluate baseline physiology, subtle clinical deterioration, or complex psychosocial responses. |
| Formulation of Nursing Diagnoses | Clinical judgment required to identify pathophysiological patterns cannot be transferred to unlicensed staff. |
| Development of Nursing Care Plan | Establishing therapeutic goals, clinical priorities, and care interventions is exclusively an RN responsibility. |
| Clinical Judgment & Decision Making | Determining whether a clinical finding requires immediate medical escalation requires professional licensure. |
| Evaluation of Patient Responses | Assessing whether an intervention was therapeutically successful or harmful must be conducted by the RN. |
| Health Teaching & Patient Counseling | While a UAP can reinforce routine factual instructions, initial health education and counseling require professional nursing assessment. |
3. Which Licence Level May Delegate — 22 TAC §217.11(3)(B)
Before reaching the setting-specific frameworks, settle the threshold question the Board asks first. 22 TAC §217.11(3)(B) places the delegation function with the registered nurse: it is the RN who determines whether a nursing task may be delegated, to whom, and under what supervision, and who remains accountable for that decision under §217.11(1)(U).
- An LVN does not delegate. The LVN practises a directed scope under NPA §301.353 and may be assigned work, but the authority to transfer a nursing task to unlicensed personnel is not part of that scope (Section 2.7).
- An APRN delegates as an RN does — advanced practice recognition does not enlarge what may be delegated or to whom (Section 2.8).
- The licensure level of the delegator is the first thing to check in any delegation item. If the stem says an LVN delegated to a UAP, the analysis usually ends there.
4. Chapter 224 vs. Chapter 225: The Two Delegation Frameworks
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| RULE 224 (ACUTE) VS. RULE 225 (COMMUNITY) DELEGATION |
| |
| [RULE 224: ACUTE CARE / UNSTABLE] [RULE 225: COMMUNITY / STABLE] |
| - Inpatient hospitals, ER, ICU, - Schools, group homes, assisted |
| ambulatory surgery, urgent care living, private residences |
| - High acuity / fluctuating status - Stable, predictable conditions |
| - Strict task prohibitions - Non-invasive & routine tasks |
| - NO MEDICATION ADMINISTRATION - ALLOWS ORAL/TOPICAL/SUB-Q |
| (except topical barrier creams) MEDICATIONS UNDER STRICT RULES |
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22 TAC Chapter 224: Acute Care & Unstable Settings
Chapter 224 applies to all acute healthcare facilities (hospitals, surgery centers, inpatient psychiatric centers) and any setting where a patient's clinical condition is fluctuating or unstable.
What Can Be Delegated Under Rule 224:
- Routine activities of daily living (bathing, feeding, ambulation of stable clients, turning and repositioning).
- Non-invasive data collection (routine vital signs, height, weight, intake and output).
- Clean, non-sterile dressing changes on superficial, intact skin.
- Applying clean, non-medicated barrier creams for skin protection.
Prohibited Delegations Under Rule 224 (§224.8(c)):
- Administration of any medications (oral, IV, IM, SubQ, rectal, inhalational, or via tube) — with the sole exception of over-the-counter topical barrier creams applied to intact skin for moisture prevention.
- Intravenous procedures: Inserting IV lines, administering IV piggybacks/pushes, or accessing central venous lines.
- Sterile procedures: Inserting indwelling urinary catheters, sterile wound packing, or tracheostomy suctioning.
- Controlled Substances: Handling or administering Schedule II-V controlled substances.
22 TAC Chapter 225: Independent Living & Stable Community Settings
Chapter 225 applies to community environments where individuals reside and receive supportive care (public/private schools, group foster homes, assisted living facilities, adult day programs, private homes). The client must have a stable and predictable condition.
Delegation of Medication Administration Under Rule 225 (§225.10):
Unlike Rule 224, Chapter 225 allows an RN to delegate the administration of certain routine medications to a trained UAP if specific mandatory criteria are satisfied:
- Stable & Predictable Status: The client's clinical condition is stable, predictable, and requires no ongoing clinical calculation or dosage titration.
- Approved Routes: Oral, topical, eye drops, ear drops, nasal sprays, rectal suppositories, and pre-calculated subcutaneous insulin (using fixed-dose insulin pens or pre-filled syringes).
- UAP Training & Competency Verification: The RN personally trains the UAP, observes return demonstrations, and documents written competency.
- Supervision & Re-Evaluation: The RN conducts regular clinical audits and reassesses the client's condition and UAP performance at least annually or when any change in medication regimen occurs.
- Prohibited Medications Under Rule 225: Intravenous medications can NEVER be delegated under Rule 225. PRN (as-needed) medications requiring clinical assessment before administration (e.g., PRN narcotic pain meds, PRN cardiac medications) cannot be delegated unless an explicit, unambiguous protocol exists.
5. Legal Division of Accountability: RN vs. UAP
When a task is delegated in Texas, accountability is divided into two distinct legal spheres:
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| DUAL ACCOUNTABILITY SPECTRUM |
| |
| [REGISTERED NURSE (RN) ACCOUNTABILITY] |
| - Assessing patient suitability for delegation |
| - Selecting the appropriate UAP with verified competency |
| - Providing clear, explicit instructions and parameters |
| - Providing adequate supervision and timely intervention |
| - Evaluating clinical outcomes and taking corrective actions |
| |
| [UNLICENSED ASSISTIVE PERSONNEL (UAP) ACCOUNTABILITY] |
| - Correctly and safely performing the physical steps of the task |
| - Following the precise instructions given by the RN |
| - Reporting abnormal findings and completion of task back to the RN |
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[!NOTE] Is the RN Liable for UAP Negligence? An RN is not automatically liable for an unexpected, rogue error committed by a UAP if the RN properly applied the Five Rights of Delegation, verified the UAP's competency, provided clear instructions, and maintained appropriate supervision. However, if the RN delegates an inappropriate task (e.g., delegating IV push morphine to a UAP in an ICU), the RN is directly liable under BON rules for improper delegation.
6. Realistic Clinical Scenario & Legal Analysis
Clinical Scenario
Nurse Thomas, RN, is the charge nurse in an acute medical-surgical unit. The unit is short-staffed with 24 patients, two RNs, and one experienced Patient Care Technician (PCT / UAP) named Jamal. Jamal has worked on the unit for 5 years and regularly draws blood and takes vitals.
Thomas is busy completing a blood transfusion. He hands Jamal a vial of subcutaneous heparin 5,000 units and a tuberculin syringe, saying: 'Jamal, Mr. Davis in Bed 4 needs his DVT prophylaxis right now. You've seen this given hundreds of times. Please inject this subQ in his abdomen and chart that you gave it.' Jamal performs the injection correctly without immediate adverse effects.
Legal Analysis under 22 TAC Chapter 224
- Gross Violation of Rule 224 (§224.8(c)): Thomas committed an illegal delegation. In an acute care facility governed by Chapter 224, medication administration of any kind (oral, injectable, IV) is strictly non-delegable to unlicensed personnel. The fact that Jamal is experienced and performed the injection safely does not eliminate the statutory violation.
- Regulatory Sanction: Both Thomas (RN) and the hospital are subject to severe regulatory scrutiny. Thomas violated 22 TAC §217.11(1)(A) (complying with Board rules), §217.11(1)(T) (safe delegation), and 22 TAC §224.8 (prohibited delegation). This constitutes unprofessional conduct under 22 TAC §217.12 and warrants formal disciplinary sanctions against Thomas's RN license.
Under 22 TAC Chapter 224, which of the following tasks is strictly PROHIBITED from being delegated by a Registered Nurse to an Unlicensed Assistive Personnel (UAP) in an acute care hospital setting?
A Registered Nurse working in a public school district is developing an individualized health plan for a student with Type 1 Diabetes Mellitus under 22 TAC Chapter 225. Which condition must be met before the RN can legally delegate the administration of subcutaneous insulin via a fixed-dose pen to an unlicensed school staff member?
When a Registered Nurse properly delegates a permissible task to a competent Unlicensed Assistive Personnel (UAP) in accordance with the Five Rights of Delegation, what is the correct legal distribution of accountability if an error occurs?