List of Delegating Nurses in Maryland: Duties, Supervision, and Limits

A delegating nurse in Maryland must meet a specific set of requirements before handing any nursing task to an unlicensed person, a certified nursing assistant, or a medication technician: confirm the task is one that does not require nursing judgment, assess the patient first, verify or provide the delegatee’s competency for that particular task, supervise the work at the frequency the patient’s condition demands, and document what happened. The rules sit primarily in COMAR Title 10, Subtitle 27, Chapter 11, and the delegating nurse remains accountable for the outcome no matter who performs the task.1Code of Maryland Regulations. COMAR 10.27.11 – Delegation of Nursing Functions

Who Can Delegate and to Whom

Both registered nurses and licensed practical nurses can delegate under Maryland law, though the RN carries broader authority and is the only license type that can serve as a case manager delegating medication administration in approved settings. The regulations recognize three categories of people who may receive a delegated task:

  • Unlicensed individuals who hold no nursing license or certification under Title 8 of the Health Occupations Article.
  • Certified nursing assistants certified by the Board of Nursing.
  • Medication technicians who have completed a Board-approved 20-hour medication administration course and hold Board certification.

Accountability travels with the delegation, not the delegatee. If the person performing the task makes an error, the Board looks first at the nurse who made the decision to delegate.

Tasks You Cannot Delegate

Maryland treats anything that requires nursing knowledge, judgment, and skill as non-delegable. COMAR 10.27.11.05 identifies six categories that stay with the licensed nurse:

  • Nursing assessments, including admission, shift, transfer, and discharge assessments.
  • Developing a nursing diagnosis from assessment findings.
  • Setting patient care goals.
  • Writing the nursing care plan.
  • Evaluating the patient’s progress toward those goals.
  • Any other task that requires nursing judgment.

The regulation also flatly prohibits delegating a task that would force the unlicensed person, CNA, or medication technician to exercise nursing judgment, except in a genuine emergency.2Code of Maryland Regulations. COMAR 10.27.11.03 – Criteria for Delegation Tasks that look routine on their face can require real-time judgment depending on how the patient is presenting, and that judgment stays with the nurse.

What the Nurse Must Do Before Delegating

Three threshold tests come first. The task has to be within the nurse’s own area of responsibility. The nurse has to conclude, based on the specific patient and the specific delegatee, that the task can be performed safely without risk to the patient. And it has to be the kind of task a reasonable and prudent nurse would consider within the scope of sound nursing judgment to hand off.2Code of Maryland Regulations. COMAR 10.27.11.03 – Criteria for Delegation

Once those tests are met, the nurse must:

  • Assess the patient’s nursing care needs before any delegation occurs.
  • Either instruct the delegatee on the specific task or verify that the person already has the competency to perform it.
  • Supervise the delegated task under the standards in COMAR 10.27.11.04.
  • Evaluate how the task was performed after the fact.
  • Make sure accurate documentation appears in the nursing record.

Competency verification is task-specific and person-specific. A CNA competent at wound dressing changes is not automatically competent to perform blood glucose monitoring. The nurse verifies competency for the exact task being handed off to the exact person doing it.

Case Manager Delegation

When an RN takes on the case manager role, the criteria tighten. The RN can delegate only after thoroughly assessing and documenting that the patient’s health care needs are chronic, stable, uncomplicated, routine, and predictable; that the environment supports safe delegation; and that the patient cannot perform their own care.2Code of Maryland Regulations. COMAR 10.27.11.03 – Criteria for Delegation All three conditions must be met and documented. A patient whose condition fluctuates does not qualify.

Supervision and On-Site Visits

Maryland does not set one supervision standard for every task. The delegating nurse sets the level based on patient stability, the delegatee’s training and familiarity with the setting, the nature of the task, and the delegatee’s demonstrated ability to perform it safely.3Code of Maryland Regulations. COMAR 10.27.11.04 – Supervision One rule is absolute: the delegating nurse must be readily available whenever a task is delegated, meaning reachable and able to intervene.

The visit schedule turns on patient stability. For patients who meet the stable, chronic, and predictable criteria under the case manager framework, the RN must make an on-site supervisory visit at least every 45 days. At each visit the RN evaluates the patient’s health status, reviews the tasks being delegated, checks whether care goals are being met, reassesses the delegatee’s competence, and evaluates the care environment.

For patients who do not meet those stability criteria, the on-site visit must happen at least every two weeks, and at each visit the RN must decide whether the tasks can still be safely delegated given the patient’s current status. That is the regulation’s built-in mechanism for catching a patient whose condition has changed enough that delegation is no longer appropriate.

Medication Administration

Medication administration has its own layer of rules because the risks are higher. Four medication tasks cannot be delegated at all, with limited exceptions for certified personnel in specific settings:

  • Calculating any medication dose.
  • Administering medications by injection.
  • Administering medications through a tube inserted in a body cavity.
  • Administering medication intravenously.

Where medication administration can be delegated, it happens only in designated settings: supervised group living facilities, schools, correctional institutions, hospice care, and adult medical day care centers. The delegatee must be on-site in the care unit on a continuing basis to monitor effects, watch for adverse reactions, and report changes to the delegating nurse.4Maryland Division of State Documents. COMAR 10.27.11.05 – Nursing Functions

Medications that can be delegated to a certified medicine aide or medication technician in those approved settings include oral medications, topical medications (advanced wound care excluded), eye, ear, and nose drops, suppositories, metered-dose inhalers, nebulizer treatments, and subcutaneous injections where the nurse has calculated the dose. The nurse must provide specific instruction and direction beforehand even for these.

Extra Requirements for Assisted Living Delegating Nurses

Assisted living programs impose additional requirements on top of the general framework. A delegating nurse in an assisted living program must be a registered nurse who has completed the Board of Nursing’s approved training program for RNs serving as delegating nurses and case managers in assisted living.5Library of Maryland Regulations. COMAR 10.07.14.21 – Delegating Nurse

The delegating nurse must be on-site to observe each resident at least every 45 calendar days and must be available on call at all times, or must have a qualified alternate delegating nurse available. Responsibilities include managing resident care, issuing nursing orders, reviewing the assisted living manager’s resident assessments, and making delegation decisions. If the assisted living manager fails to carry out nursing orders and does not identify care alternatives, the delegating nurse must notify the resident’s health care provider, the Department, and the resident or their representative.

What Happens When Delegation Goes Wrong

The Maryland Board of Nursing has broad disciplinary authority over improper delegation. Under the Health Occupations Article, the Board can reprimand a nurse, impose probation, suspend the license, or revoke it, and can deny or condition a license on application.6Maryland General Assembly. Maryland Health Occupations Code 8-316 – Denials, Reprimands, Probations, Suspensions, and Revocations Several statutory grounds map directly onto delegation failures:

  • Exceeding scope of practice, which covers delegating a non-delegable task such as a nursing assessment.
  • Falling below generally accepted professional standards, which covers a delegation decision no reasonable nurse would make.
  • Gross negligence, the most serious clinical ground, which can apply when a delegation directly causes serious harm because the nurse skipped the assessment, competency verification, or supervision.
  • Violating any provision of Title 8, a catch-all that reaches any breach of COMAR 10.27.11.

The severity of the sanction generally tracks the severity of the outcome and the nurse’s decision-making. A nurse who delegates a routine task to a CNA who needed slightly more supervision faces a different conversation than a nurse who hands off medication administration to an unqualified person in an unapproved setting. Before the Board acts, the nurse is entitled to written notice by certified mail at least 30 days before a hearing and can be represented by counsel.

Board discipline is not the only exposure. When improper delegation causes injury, the nurse can be sued for negligence, and Maryland’s delegation regulations effectively supply the standard of care the nurse’s conduct will be measured against. A civil verdict and Board discipline can arise from the same incident; winning one does not resolve the other.

How Following the Rules Protects You

The framework that creates accountability also creates a defense. The regulation frames the standard as what a reasonable and prudent nurse would consider within the scope of sound nursing judgment.2Code of Maryland Regulations. COMAR 10.27.11.03 – Criteria for Delegation A nurse who assessed the patient, verified the delegatee’s competency for the specific task, gave clear instructions, supervised at the required frequency, and documented the process has a record that shows each regulatory requirement was met.

The regulation’s emphasis on professional judgment leaves room for defensible decisions even when outcomes are imperfect. A bad outcome, by itself, does not prove improper delegation. What matters is whether the nurse’s decision-making process was sound at the time. A nurse who documents the patient assessment, the rationale for delegating, and the supervision plan is in a far stronger position than one who delegated informally and kept no record. Discretion has to be exercised, though, not assumed: a nurse who never assessed the patient’s stability before delegating cannot invoke professional judgment as a shield afterward.