Medication Administration in Nursing Homes: RN Delegation to Unlicensed Assistive Personnel ‘Amy Vogelsmeier, PhD, RN, GCNS-BC Medication administration in nursing homes is a complex process that requires careful oversight by registered nurses (RNs) to minimize risks of errors and adverse effects. However, the declining number of RNs in nursing homes requires RNs to delegate some aspects of medication administration to other nursing statf members, including unlicensed assistive person- nel (UAP}, Delegating medication administration allows RNs to focus on al aspects of the medication use process, including communicating with physicians about residents’ conditions and medication therapy needs as well as assessing and evaluating residents’ responses to medication therapy. With a carefully supervised delegation process, UAP should be able to administer ‘medications safely, and RNs can oversee the complex needs of frail, vulnerable nursing home residents. eS Learning Objectives + Describe medication administeation in the nursing home, Recall steps of the delegation process. + Identify che zole of unlicensed assistive personnel in medica- tion administration, + Discuss how a registered nurse can appropriately delegate medication administration. Je more than 1.6 million residents in our nation’s nurs- I ing homes are primarily elderly, have muleiple chronic conditions take multiple medications, and ave physically dependens for much of their care needs (Agency for Healthcare Research & Quality, 2001). Many residents rely on registered nurses (RNS) to oversee their care and co minimize theie risk of harm, Studies by Hora, Buerhaus, Betstzom, and Smout (2005) and Weech-Maldonado, Meret-Hanke, Neff, and Mor (2004) un erscote the importance of RNs to nursing home safecy; howeves, in times of nursing shortage and fiscal constraint, nursing homes have limited numbers of RNs to oversee resident care (Ranez et al., 2004; Seblega et al., 2010). Thus, nursing homes must rely 0 RN delegation to ensure safe, appropriate cate In nursing homes, RNs frequently delegate medication administration to unlicensed assistive personnel (VAP), such as medication sides and medication technicians (Budden, 2011a, 201 1b). Despice some evidence that UAP can administer medi- cations safely (Arizona State Board of Nursing, 2008; Scot- Cawiezell et al., 2007), about one-third of the states do not Volume 2/lsue 3 October 2011 allow delegation of medication administration to UAP (Budden, 20118), “The purposes of this article are to provide an overview of ‘medication errors in nursing homes, an understanding of the challenges nursing homes face in ensuring safe medication pro- cesses, and the role delegation can play in safe medication admin= istration. The focus of this article is primarily on RN delegation because in many states licensed practical and vocational nurses (LPNsIVNs) are not legally permitted co delegate to UAP, or the scope of practice for LPNs/VNs lacks definition, Even ia states ‘where LPNs/VNs ate legally permitted to delegate some tasks, ‘questions exist about whether chey can safely delegate che task of medication administration in nursing homes Medication Errors it The National Coordinatin Reporting and Prevention (NCCMERP, 2011) defines madica- sion error as any preventable medication-related event that may ‘cause of lead co patient harm, Medication errors can take place ac any point from prescribing a drug co monicoring its effects (Ofcen believed to be the fault of individuals, medication errors ion Esror ‘most commonly result from faulty systems and processes, includ ing nurse staffing, physician-nurse communication, medication procurement ftom offsite pharmacies, nd medication packaging (Pepper & Towsley, 2007). Frail nursing home residents ate at particular risk for harm from medication errors that can lead to adverse drug events (ADEs; Gurwitz et al., 2005; Instieute of Medicine [TOM], 2007). Gurwitz and colleagues (2005) project that more th 800,000 ADEs occur annually in nursing homes because of medi= wwwjournalofaursingregulation.com 49s in the Nursing Home Medication Use Process Medication Registered Nurse (RN) Responsibilities Use Process, Prescribing Communicating with physicians about residents’ medical condition and medi cation therapy needs Ensuring accurate transcription and doc- lumentation of multiple medication or ders and managing complicated medica- ‘tion orders through complex medication order processes: ‘Communicating with off-site pharmacies ‘and ensuring accurate and timsly deliv- ery of medications Ensuring safe administration of volumes of medications withit straints Assessing and evaluating residents’ r sponses to medication therapy and ‘monitoring residents for adverse drug events Transcribing Dispensing ‘Administering Monitoring cx consider this aumber to be an underesti- cextors, Exp imate (JOM, 2007) Pepper and Towsley (2007) zepore the most com ing home medication errors are prescribing errors, including. wrong dose and inappropriate medication use, and medication administration errors, including omitted doses and wrong time, Excluding wrong-time errors, Barker, Flynn, Pepper, Bates, & Mikeal (2002) found more than 10% of doses administered to ‘nursing home residents wete in ersor. Monitoring errors ate be~ lieved to be common in nursing homes, but they have not been well studied. Medication administration errors may relate in ‘part to the large number of medications nussing home residents receive. On average, residents receive seven to eight medica~ ‘ions daly, and about one-third receive nine or more medications (Doshi, Shaffer, & Briesacher, 2005). Moreover, large numbers of medications are often administered multiple times per day, adding complexity to the medication administration process Medication Administration in Nursing Homes Medication administravion in nursing homes is often consid However, in re cxed a simple task of "passing medications ity medication adminiseration is a complex process requiring many interactions of specific decisions and actions (Kaushal et al., 2001), Perhaps the complexity of medication administration can best be understood within nodes (or stages) ofthe medication tase process. These five nodes include prescribing, transcribing, 50 Journal of Nursing Regulation dispensing, administering, and monitoring (NCCMERP, 2000; United States Pharmacopeia [USP], 2004). Prescribing iavolves evaluating the patient co establish medication need and selecting the right medication to manage the condition, taking into consideration possible interactions and allergies. Tramtribing involves documenting the physician's medication order and transmitting the order to the phacmacy. Dispensing involves reviewing the ordet and confirming the tran- scription accuracy, contacting the prescriber regarding discrepan- cies, preparing the medication, and dispensing the medication tothe health cae site, Administering involves reviewing the order and confirming transcription accuracy, checkin, cations, such as allergies and interactions; assessing the patient; and administering the medication. Monitoring involves assessing the patient's response to the medication and documenting the results (USP, 2004), Traditionally, physicians are responsible for prescribing medications, pharmacists for dispensing and moni- ‘oting medications, and nusses for administering medications Despite the traditional view thar the nurse's primary re- sponsibility is co administer medications, the nature and com- plexity of nursing home care require licensed nurses, particularly RNs, co be involved in the encize medication use process. First, physicians are often not on site and must rely on communication, from nurses about residents’ medical condition and medication therapy needs (Vogelsmeier, Scote-Cawiezell, & Zellmer, 2007). Second, multiple medication orders and complicated medica tion ordering processes require careful communication to off site pharmacies (Vogelsmeier et al., 2007). Third, che aursing staf is responsible o ensute the appropriate and timely delivery cof medications from offsite pharmacies to the nursing home (Vogelsmeier et al., 2007), Fourth, nursing staff must ensure residents receive multiple medications wichin tight regulatory ‘ime consteaints (Vogelsmeies ex al, 2007); the average medica ‘ion pass involves 73 medications and takes an average of 113 ‘minutes (Score-Cawiezell et al., 2007), Fifth, pharmacists spend limived time in nursing homes monitoring medication effects, ‘making nurses esponsible for assessing and evaluating complex residents for therapeutic and adverse responses (Vogelsmeier et al,, 2007). (See Table 1.) While chese nursing home realities support che need for RNs to be involved in all aspects of the medication use process, the number of nutsing home RNs has declined over the yeas, resulting i fewer and fewer RNs to oversee and manage care (Seblega eral, 2010), RNs now account for less than 14% of the purses in nursing homes (Ranez et al,,2004). Thus, the role ofthe RN must be maximized through appropriace and safe delegation, RN Delegation RN delegacion must he grounded in the fundamental principle to protect the healt, saety, and welfare ofthe public. In an effort, to support the practice of RN delegation while upholding thecenet of patient safety, the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) joined to define delegation, According to the NCSBN and ANA, delegation is defined as an RN and in some states LPNsiVNs (Corazzini ec al., 2011) having che authority co ditect another individual to perform nursing tasks and activities they would otherwise not be assigned (NCSBN, 2005). Delegation, how- ‘ever, is much more complex than it seems by mere definition; i cequites a critical understanding of the steps in the delegs~ tion process and appropriate clinical training to delegate safely (NCSBN, 1995), (See Table 2.) Delegation requites ‘organizational accountability to ensure safe care is delivered (NCSBN, 1995, 2005). A nurse is responsible for carefully con sidering the competencies of staff members, the condition of the patient, and the degtee of supervision tequited for sae care. The nurse also must ensure adequate two-way communication wich staff members when delegating caze, Moreover, the nurse must monitor organizational systems to ensure that safe, appropriste delegation can be carried out, Organizations and nurse leaders, lividual nurse accountability and on the other hand, must ensure that adequate systems are in place co support safe delegation, including adequate staff resources, clear documentation of staff competencies, and organizational standards developed with purse input to define safe delegation ss Both individuals and organizations must adhere co the delegation principles, including the five rights of delegs ion. (See Table 3.) Unlicensed Assistive Personnel States that allow UAP to administer medications have education al programs to establish competencies; however, these programs ‘vary widely, In a review of medication-aide teaining programs across the United States, Budden (201 1a) found variation in ap- plicanc requirements, training, testing, and continuing education hours. For example, some training programs require applicanes be cercfied nursing assistants; others do not, Mast requice some form of work experience in long-term cae. Didactic and clinical training hours averaged 73.97; however, didactic training varied from 4 ¢0 150 houts, and clinical taining vatied from 0 co 40 hours. The majoricy of programs require written examination acer teaining, and neatly one-thitd have a skills-demonsteation component. Continuing education requirements vary from no continuing education to formal receaining every 2 years Similar eo variability in training programs, roles and responsibilities vary among the UAP who administer medic: tions in cheir workplace. Budden (20116) conducted a survey lof medication aides (n = 3,455) co identify relevant workplace ‘issues, such as work role and supervision. Medication administra- tion responsibilities ranged from administering topical and oral ulin medications to regulating LV. Quids and programming pumps, Medication aides often administered medications, in~ Volume 2/lsue 3 October 2011 TABLE 2 Steps ir the Delegation Process “Assessment and planning ‘Assess and plan the delegation activity based on the patient's need and available resources, including appropriate staff members. Communicate directions to the delegated staf. Include patient requirements and characteristics as well as clear expectations regarding what to do, what to report, and when t0-ask for assistance. Communication Surveillance and supervision Provide surveillance and supervision of the delegation, including the level of ‘supervision needed and the implamentation of the supervision, Include follow-up to problems or a changing situation. Evaluate and provide feedback to consider the effectiveness of the delegation, including any need to agjust the plan of care. National Council of State Boars of Nursing, 2005 Evaluation and feedback cluding as needed (pen) medications, without prior assessment or follow-up monitoring by a licensed nurse. Many medication aides also received medication orders from prescribers and tran- scribed che medication orders into the secord, Supervision and nursing oversight were often limited. Many medication aides had no supervision at all or no contact with a supervisor during atypical shift. These issues identified by Budden reflect the realities in many nursing homes today. ‘State Board of Nursing (BON; 2008) sought to develop a comprehensive standardized starewice medication- The Avizo technician pilot program that supports safe delegation within nursing homes. The program included course contene based on the complex sealities of medication administration in nussing homes. For example, the 100-hour curriculum included content ‘on administering large quantities of medications; working within ‘ime constraints; crushing medications appropriately; calculat- ing complicated dosage calculations; and working with vati- ‘ous dispensing methods, administration methods, and resident medication administration challenges such as resident refusals. Protocols further delineated the conditions under which delega- tion could and could nor safely occur Ina study by Scott-Cawiezell etal. (2007), no differences ‘were found in medication error rates when observing RNs, LPNs! VNs, and UAP. In fact, when wrong-time: RNs had slightly higher medication-error rates. The authors 1s were excluded, think the higher error rate is elated to the number of incertup- wwe journalofaursingregulationcom 51TABLES Five Rights of Delegation ‘= Right task Task that is delegable for a specific patient resident ‘+ Right circumstances: Appropriate patient setting, avail able resources, and other relevant factors ‘* Right person: Right person delegating the right task to ‘the right person to be performed on the right person + Right direction/communication: Clear, concise descrip- tion of the task, including its objective, limits, and ex: pectations ‘+ Right supervision: Appropriate monitoring, evaluation, intervention, and feedback ‘atonal Council of State Boards of Nursing, 2006. sions and distract Wns many RNs encounter during medication administration RN and UAP Partnering for Safe Medication If medication administration is done by UAP, safe systems must be in place to support this role in practice. Ensuring a compe- cent UAP staff requites the involvement of regulators, nurs~ ing home administeators/nurse leaders, and individual licensed nurses (NCSBN, 1995, 2005). Regulatory involvement includes ensuring that statewide training programs establish UAP competencies and define and ‘each safe and unsafe medication administration activities. For example, the Arizona State BON’s training program not only defines safe parameters for administering medications, i also defines activities that are unsafe for UAP, including adminis- cering first doses, inhalane medications, injectable medications, and pin medications; regulating LV. fluids; and programming insulin pumps (Randolph & Scoct-Cawiezell, 2010) [Nursing home administeatocs and nurse leaders must en sure thei UAP meet the state's compecence requirements and must have documentation on site for reference by stall RNs. Moreover, nursing home leaders must make sure job descrip ‘ions and role responsibilities clearly match the competencies as established through statewide training, When job descr sibilities are clearly defined wichin an organiza tion, all staff RNs, LPNs/VNs, and UAP will know what can and cannot be safely delegated With standards in place, RNe have a responsibility to make sure UAP are competent to administer medications, tak~ ing into account the complexities of individual resident needs ac the time of delegation, Working wichin defined limits and carefully considering individual resident needs can guide the safe adminiscration of medications by UAP. UAP can then focus on the tasks they are competent to perform, thus freeing RNs tobe involved in all aspects of the medication use process. 52 Journal of Nursing Regulation Because all aspects of the medication use process are sub- ject to medication error (NCCMERP, 2000; Pepper & Towsley, 2007), RNs play a critical role in minimizing errors. RNs must be able to focus on medication assessment, monitoring, and evaluation to ensure residents are meeting theit therapeutic goals, while UAP focus on administering routine medications accurately and on time. Conclusion Medication administration in nursing homes is a complex process that requires a collaborative effort between RNs and UAP to ‘ensure safe medication administration. Delegating medication administration allows RNs to focus on all aspects of the medi- ‘ation use process, including communicating with physicians about residents’ conditions and medication therapy needs as ‘well as assessing and evaluating residents’ cesponses to medica tion therapy. Theough a carefully supervised delegation process, UAP can administer medications safely, and RNs can oversee the complex needs of feu, vulnerable nussing home residents, References Agency for Healthcare Research & Quality (2001), AHRQ Rewarch Re ior. The Charasteristi of Long-Term Care Use. AHRQ Publication No, 00-0049, January 2001. Reckvlle, MO: Author. Recieved from wow abe govirevearhitcuters! Acizona Stace Board of Nussing. (2008), Repott co he legislarare: Ati ‘ona medication technician pilot project. Retiewed from ware hn, gow Documents misc FINALS 20REPORT 5207020 ‘THES 20LEGISLATURE pf Barker, K.N., Flynn, E.A., Pepper G. A, Bates, DW. ae Mikes, R 1. (2002). Medication exes observed in 36 health caze facilities Archive of Internal Medici, 162116), 1897-190. Budden, J. (20113). The safety and cegulation of medication aides Jur sul of Nessng Regulation, 22), 1-6, Budden, J. (201 1b). The fse national survey of medication aides Joa tual of Nersing Repelation, 203), 4-12 Corarrni, KIN, Anderson, R. A, Mueller, C, McConnell, ES, ao, L.R., Thorpe, JM, etal. 2011). Regulation of LPN sin longetcrm cate Journal of Naring Realatin, ‘Lande Doshi, J. A, Shafer, T & Bresacher, B (2005). National estimates of ‘medication we in mscting homes: Findings from the 1997 Medi cate current beneficiary survey and the 1996 Medicare expenditure Survey Jour ofthe American Geriatric Sais, 53, 438-843, Gurwiee, JH, Feld, TS, Judge, J, Rochos, P, Hazel, LR, Cado= et,C., ea. (2005). The incidence of adverse deug events i ew Inege academic long-rezm cae facilities, The American Journal of Medcne,118(3), 251-258, Hor, S., Buethaus, B, Besttom, N., Sout, R. J. (2005), RN staff ing time sud outcomes of lag, ican Journal of Nusng, 105, 38-0. Inseirue of Medicine. (2007), Preening medication eros, Wasi 'DC: National Academies Press using borne tesidents, AmeKaushal, R, Bates, D. W, Landsigan, C, McKenna, K.J., Clapp, M 'D., Fedetico, R, etal. 2001). Medication errors asd adverse deug events in pediatric inpatienes. Journal ofthe American Medical Aso= dation, 285(16), 2114~2120. National Coordinating Council for Medication Error Reporting and Prevention (2011). Abnut medication errs, Retrieved from ‘woo. nccmetp otp/medErterCatIndex hte Nasional Coordinating Council for Medication Error Reporting and Prevention. (2000). Aiming a administering: Pactice recommen ations to prevent exror USP Quality Review, 71, 1-2 National Council of State Boseds of Nursing. (1995). Concepes and de- isiog-making process. Retrieved from www ncsba o¢g/323 hem National Council of Sate Bosrds of Nursing. (2005), Joint statement ‘on delegation, American Nurses Awociation/National Council of State Boards of Nursing. Recieved from warw.nesbn orgioine satement pa Pepper, G. A. Towsley, GL. (2007). Medication ero in aursing Thomes: Incidence and redaction srstgies Journal of Pharmaceutical Financ, Econom, & Policy, 161), 5133. Randolph, P.K.,& Scort-Cawiezell, J (2010). Developing statewide ‘medication technician plot program in nursing homes Journal of Gorontsloical Navsing, 36.9), 3A. Rants, M.J, Hicks, I., Grando, V, Petros, G. F, Madsen, R. Wr, ‘Mebs, D-., etal (2004). Nussing home qualiy, cost, stalling fad staff mine The Gerntlegi, 44, 24-58 Scot-Cawiezell J. Peppes,G., Madsen, R, Peuosk, G. Vopelsmeies, ‘A. &Zellinee,D. (2007), Nussing home ettor and level of salt credeneals, Clinical Nuring Research, 15(1), 72-19. Seblega, B.K., Zhang, N.J., Unruh, L ¥, Breen, GM, Pack, 8.6. & ‘Wan, TH, (2010), Changes in nursing home staffing levels, 1997 02007. Miz Care Resarh Review, 67(2), 232-246, United States Pharmacopei. (2004). The medication use proces. Re- ‘tieved from werwusp.otg/peHTEN patient Sufeeyimedication- UseProcess pat Vogelsmeie, A. Scott-Cawiezll, J, & Zeller, D. (2007), Batirs to safe medication administration inthe nursing home. Jounal of Ge ological Nursing. 3318), 5-12 \Weech-Maldonado, R., Meret-Hanke, I, Neff, M.C., & Mor, ¥, (2008), Nuss stalling patterns and quality of cae in autsing homes, Health Care Management Review, 28, 107-116 Amy Vogelsmeier, PhD, RN, GCNS-BG, is an assistant profesor and John A, Hartford Claire M. Fagin Fellow at Sinclaie School of Nursing, University of Missouri in Columbia, Volume 2/lssue 3 October 2011 ‘wws.journslofaursingregulation com 3Medication Administration in Nursing Homes: RN Delegation to Unlicensed Assistive Personnel Learning Objectives + Describe medication administea- tion in the nursing home. ‘© Recall steps of the delegation pro- + Identity the role of unlicensed as- sistive personnel in medication administration «Discuss how a registered nurse can appropriately delegate m cation administration. : RN Delegation to Unlicensed Assistive Personnel Ifyou reside in the United States and wish to obtain 1.4 contact hours of continuing education {CE} credit, please review these instructions. Instructions Go online to take the posttest and ‘earn CE credit Members - www.nesbninteractive. ‘org (no charge) Nonmembers - www.learningext. com ($15 processing fee) It you cannot take the posttest ‘online, complete the print form and mail it to the address (nonmembers ‘must include a check for $15, payable to NCSBN) included at bottom of form. Provider accreditation The NCSBN is accredited as 2 provider of CE by the Alabama State Board of Nursing. ‘The information in this CE does not imply endorsement of any product, service, or company referred to in this activity. Contact hours: 1.4 Posttest passing score is 75%. Expiration: October 2014 54 Journal of Nursing Regulation Posttest 2 = 2 circle the correct answer What is the average number of ‘medications a nursing home resident receives daily? 2t04 5t08 percentage of nursing home residents thats wrengist wx 5% t 10% 12%. ‘ ‘The stages ofthe medication use Process include: moniterng a checking b counting t reporting a Which statement about responsibilities 4 inthe medication use process in nursing homes is correct? a Unlicensed assistive personnel (UAP) are 5 responsible fr ensuring timely e administration, 4 ‘The physician communicates directly withthe pharmacy. 2 ‘The on-site pharmacist is responsible for veritying dosages. ‘The registered nurse (RN) must evaluate residents responses to medication e thorapy. a The modication pass in the 13 nursing home invelves how many medications? a 8 52 w b a ‘cate professionals and the medication use process in nursing homes is correct? Ns are only responsible for 1 administering medications. RNs are invelved in the entice process, Physicians play a more active role in a medication administration, Pharmacists closely evaluate for adverse affects sidonts ANs aecountfor what percentage of nurses in nursing homes? us 35% a Less than 9% Less than 18% ‘What term is defined as “an RN and in some states LPNS [licensed practical nurses] having the authority to direct another individual to perform nursing tasks and activities they would otherwise not be assigned”? Delegation Monitoring Assigning Prescription The step in the del includes follow-up ‘changing situation is: evaluation and feedback. surveillance and supervision, communication. assessment and planning process that blems or a The step in the delegation process that cludes determining the need to adjust ‘the plan of care is: ‘evaluation and feedback. surveillance and supervision. communication. assessment and planning Which “right” of delegation includes available resources? Task Supervision Circumstances Direction Which “tight” of delegation includes objectives, limits, and expectations? Task Supervision Circumstances Direction Which statement about m ‘raining is correct? Application requirements, raining, testing, and continuing education vary widely Application requirements and training vary widely, but testing and continuing ‘education are standardized «, Retraining is required every 2 years 4, Retraining is required every 4 years. According to research, which statement about medication aides’ roles and responsibilities is correct? Medication sides are not permitted to administer topical medications Medication aides do nat administer as-needed medications without prior assessment. Many medication aides have litle to no supervision Most medication aides have contact with 8 supervisor twice a shit.15, Which statement about RNs and medication aides is correct? 1, RNs should focus on transcribing and dispensing, while medication aides should facus on administering rautine medications b, RNs should focus on medication assessment, monitoring, and evaluation, While medication aides should fecus on administering routine medications. ¢. RNs should focus on medication assessment, monitaring, and evaluation, hile medication aides should focus on administering complicated medication regimens 4. RNs should focus on dispensing and calculating, while medication aides should focus on administering orl inteamuseulay, and intravenous drugs. 16, Nutsing home administrators should 1, ensure UAP who administer medications moot the state competency requirements. b. directly supervise UAP who administer medications to reduce errors. €. keep job descriptions and role responsibilities for RNs and UAP who administer medications general n scope, 4, keep off-site documentation ofthe competence of UAP who administer medications 17.Which statement about the regulatory issues related to UAP administering medications is correct? 1, State boards of medicine should assume responsiilty or UAP regulation b. State boards of nursing (BONs} should not ist what drugs UAP cannot administer. «, Each state BON should create a unique training program, 4, State BONs should define what is needed i training programs. Volume 2/lsue 3 October 201 Evaluation Form (required) t01 {low/poer). ++ Describe medication administra ‘tion in the nursing home. 1 2 3 46 ‘+ Recall steps of the delegation pro: 1 2 3 4 ‘= Tdentity the role of unlicensed as. sistive personnel in medication administration 1 2 3 4 ‘= Discuss how a registered nurse ean appropriately delegate medi- cation administration. 1 2 3 6 2. Wore the authors knowledgeable about the subject? 1 2 2 4 5 3. Wore the methods of presentation text, tables, figures, etc) effective? 1 2 8 4 5 4, Was the content relevantto the objectives? 1 20 8 4 5 5, Was the article usefulto you in your work? 1 2 8 4 5 6, ‘enough time allotted fr this 12 8 4 5 Comments: PI se print clearly Name 9 address Street city State Home phone Business phone Fax E-mail Method of payment (check one box) Member {no charge} Zip C1 Nonmembers (must include a check for $15 payable to NCSBN} PLEASE 00 NOT SEND CASH. Mail completed posttest, evaluation form, registr NcsBN clo Beth Rado 111 East Wacker Drive Suite 2300 Chicago, IL 60601-4277 Please allow 4 to 6 weeks for processing. jon form, and payment to: www journalofaursingregulationcom 55