4.3 The Healthcare Team and Delegation
Key Takeaways
- CNAs work within an interprofessional team and report to the charge nurse in the chain of command
- Delegation follows the Five Rights: Right Task, Right Circumstance, Right Person, Right Direction, Right Supervision
- Only a licensed nurse (RN or LPN) can delegate a nursing task — a CNA cannot delegate to another CNA
- The delegating nurse keeps accountability for the decision; the CNA is responsible for performing the task correctly and reporting back
- CNAs must refuse, politely, any task outside their scope — medication administration, sterile procedures, assessment, and tube feedings are nurse-only
- If a safety concern is not resolved by your supervisor, go up the chain of command and, when needed, contact IDPH
The Interprofessional Team
A CNA is one member of an interprofessional healthcare team, and the INACE expects you to know who does what, who you report to, and which tasks you may legally accept. Knowing the team prevents you from doing a job that belongs to a licensed professional — a leading cause of disciplinary action and exam failure on delegation items.
| Team member | Core role | How the CNA interacts |
|---|---|---|
| Physician (MD/DO) | Diagnoses, writes orders | Orders reach you through the nurse, never directly |
| Registered Nurse (RN) | Assesses, builds the care plan, gives medications | Your primary supervisor; report all changes to the RN |
| Licensed Practical Nurse (LPN) | Skilled nursing under RN direction | May delegate to and supervise you |
| Physical Therapist (PT) | Mobility and strength programs | Reinforce safe transfer and ambulation per the plan |
| Occupational Therapist (OT) | Daily-living skills, adaptive devices | Use OT techniques during ADL care |
| Speech-Language Pathologist (SLP) | Swallowing and communication | Follow diet textures; report any choking or coughing |
| Registered Dietitian | Therapeutic diets | Honor diet orders; chart intake |
| Social Worker | Psychosocial needs, discharge planning | Pass along resident and family concerns |
Chain of Command
The chain of command is the line of authority for reporting and resolving problems. In a typical Illinois long-term-care facility it runs:
- CNA → reports to the
- Charge Nurse (RN or LPN) → who answers to the
- Unit Manager / Nurse Manager (RN) → who reports to the
- Director of Nursing (DON) → who answers to the
- Administrator, with the Medical Director (MD) overseeing clinical care.
Start at the bottom: take a concern to your charge nurse first. If a resident-safety issue is not addressed, you have both the right and the duty to move up the chain — and Illinois law protects you from retaliation for reporting in good faith. Suspected abuse or neglect, or an unresolved safety hazard, can be reported to IDPH directly.
What Delegation Is
Delegation is the process by which a licensed nurse transfers the performance of a selected nursing task to a competent CNA while keeping the authority and accountability for the decision. Two ideas drive every exam question on this topic:
- Only a licensed nurse delegates. A CNA can never delegate a task to another CNA, and a CNA never accepts a delegated nursing task directly from a physician.
- Accountability stays with the nurse; responsibility shifts to the CNA. The nurse is accountable for delegating appropriately; once you accept the task, you are responsible for doing it correctly, safely, and reporting the result back.
The Five Rights of Delegation
| Right | Question it answers | Example |
|---|---|---|
| Right Task | Is this within the CNA scope at all? | Taking vital signs — yes. Giving an injection — no. |
| Right Circumstance | Is the situation stable enough? | A routine bath on a stable resident — yes. An acute change — the nurse steps in. |
| Right Person | Is this specific CNA trained and competent? | A CNA trained on a mechanical lift — yes. One never in-serviced on it — no. |
| Right Direction | Were clear, complete instructions given? | "Weigh Mr. Lee before breakfast and report a gain over 3 pounds." |
| Right Supervision | Is a nurse available to monitor and help? | Charge nurse on the unit and reachable. |
Inside vs. Outside the CNA Scope
In Illinois, certain tasks are always nurse-only and can never be delegated to a CNA, no matter how busy the unit is:
| Within CNA scope | Outside CNA scope (nurse-only) |
|---|---|
| Vital signs, height, weight | Administering any medication, including over-the-counter |
| Bathing, dressing, feeding, toileting | Sterile dressing changes and wound assessment |
| Ambulation, transfers, repositioning | Inserting or removing catheters or tubes |
| Measuring intake and output | Tube feedings and IV care |
| Reporting and recording observations | Performing assessments or care-plan decisions |
Refusing a Task Professionally
You must decline — and the INACE rewards declining — when a task is outside your scope, you were never trained on it, no supervision is available, the situation is unsafe, or it violates facility policy. Refuse respectfully and offer a path forward:
- State it plainly: "I'm not able to give medications — that's outside my scope of practice."
- Offer help: "I'll find the nurse so it can be done right away."
- Never simply ignore the request or perform it anyway to avoid conflict — doing the task does not transfer the liability to the nurse.
- If unsafe delegation continues, document it and escalate up the chain of command to the DON.
How Assignment Differs From Delegation
The exam sometimes contrasts assignment with delegation. An assignment is the routine distribution of tasks already squarely within the CNA role — the charge nurse assigning you the residents in rooms 210–218 for morning care. Delegation is the nurse's decision to transfer a specific nursing task and her judgment that you are competent to do it in that situation. Both flow downward from the nurse, and both leave accountability for the decision with the nurse. What never changes is that you may carry out only tasks within the CNA scope of practice, however they reach you.
Resident Rights and the Team
Every interaction with the team is bounded by resident rights under the federal Omnibus Budget Reconciliation Act (OBRA) and the Illinois Nursing Home Care Act. Residents have the right to participate in their own care planning, to refuse care and treatment, to confidentiality, and to be free from abuse and neglect. When a resident refuses a delegated task — a bath, a weight, a meal — you do not force it. You explain, you offer to return later, you respect the refusal, and you report and document it so the nurse can update the plan. Forcing care can constitute battery and abuse.
Reporting Abuse and Neglect Is Mandatory
Illinois CNAs are mandated reporters. If you witness or suspect abuse, neglect, or misappropriation of a resident's property, you must report it immediately — to the charge nurse and DON, and, when the facility does not act or the harm is serious, directly to IDPH and Adult Protective Services. Failure to report is itself a violation that can be entered on the Health Care Worker Registry. This duty overrides any concern about "going over a supervisor's head," and Illinois law protects good-faith reporters from retaliation.
Putting the Team Together: A Worked Scenario
You are bathing Mrs. Lee when you notice a new 2-inch reddened, non-blanching area over her sacrum and she winces when you turn her. Within scope, you finish providing safe care and reposition her off the area. Outside your scope is assessing or treating the wound — that is the nurse's job. So you report immediately using SBAR, chart the objective observation ("2-inch non-blanching red area over sacrum, resident winced on turning, nurse notified at 0915"), and let the RN assess and update the care plan, which the SLP, dietitian, and PT may all feed into.
This single situation touches communication, documentation, scope, and the chain of command — exactly how the INACE bundles concepts into one scenario item.
A busy nurse asks you to give a resident's scheduled oral medication "just this once" so she can attend to another patient. What should you do?
Which of the Five Rights of Delegation asks whether the specific CNA is trained and competent for the task?
A CNA wants to hand off part of her assignment to a coworker because she is overwhelmed. Which statement is correct?