1.1 The CNA Role in Indiana Long-Term Care: Scope of Practice, Interdisciplinary Team, and Chain of Command

The CNA Role in Indiana Long-Term Care

Quick Answer: In an Indiana licensed health facility, a Certified Nurse Aide (CNA) provides hands-on personal care and basic nursing skills under the delegation and supervision of a licensed nurse (RN or LPN). The CNA is part of an interdisciplinary team, reports through a defined chain of command, and may only perform tasks allowed by 410 IAC 16.2 Standard 14 and within the scope of their training. CNAs do not take physician orders and do not independently create the care plan.

Scope of Practice in Indiana

Indiana regulates nurse aides under 410 IAC 16.2, the state's administrative code governing long-term care facilities. Under this rule, a CNA's permitted duties fall into four categories:

1. Personal care skills — bathing, grooming, dressing, toileting, oral care, and perineal care
2. Basic nursing skills — vital signs, height/weight, intake and output, positioning and transfers, and observation/reporting
3. Restorative care — range of motion, ambulation assistance, and use of assistive devices as assigned
4. Communication and documentation — charting, end-of-shift report (SBAR), and reporting changes to the licensed nurse

A CNA in Indiana never works independently. Every task is delegated by a licensed nurse who is responsible for assessing the resident, determining that the task is appropriate to delegate, and verifying the CNA has been trained and is competent to perform it. The licensed nurse remains accountable for the outcome of delegated care.

The Interdisciplinary Team

Indiana LTC facilities operate as interdisciplinary teams. Each member has a defined scope, and the CNA is the member who spends the most direct hands-on time with the resident:

The CNA is often called the "eyes and ears" of the team because of continuous resident contact. The CNA is frequently the first to notice a change in skin, appetite, mood, mobility, bowel/bladder pattern, or mental status — and is responsible for reporting those changes to the licensed nurse promptly.

The Chain of Command

Indiana facilities must maintain a clearly defined reporting structure. The standard chain of command in an Indiana LTC facility is:

1. CNA — provides care, observes, reports
2. LPN / Staff Nurse — receives reports, delegates tasks, gives medications and treatments
3. RN Charge Nurse — clinical assessment, care plan updates, acute-change response
4. Director of Nursing (DON) — overall nursing leadership, staffing, regulatory compliance
5. Administrator — facility operations, survey response, staffing budgets
6. Indiana Department of Health (IDOH) — state survey, complaints, adverse-event reporting

A CNA does not accept verbal or telephone orders from a physician — that is a licensed nurse function. If a physician or family member gives a CNA a direct instruction about a resident's care, the CNA's correct response is to relay the request to the licensed nurse immediately.

Delegation and the Five Rights

Indiana uses the delegation principles anchored in the National Council of State Boards of Nursing (NCSBN) "Five Rights of Delegation":

• Right task — the task is within the CNA's permitted scope (410 IAC 16.2 Standard 14)
• Right circumstance — resident condition is stable and the setting is appropriate
• Right person — the CNA has been trained and demonstrated competency for the task
• Right direction/communication — the nurse gives clear, specific instructions
• Right supervision/evaluation — the nurse monitors and evaluates the outcome

If a task is outside Standard 14 — for example, a nurse instructs a CNA to give an injection — the CNA must refuse and report up the chain. Performing a prohibited task can result in registry sanctions against both the CNA and the delegating nurse.

Documentation and Reporting

Indiana CNAs document care in the medical record in an accurate, timely, and objective manner. The CNA's documentation becomes part of the legal record reviewed by IDOH surveyors and can be subpoenaed. Key principles:

• Chart what you observe, not what you assume (objective over subjective)
• Chart in real time, not from memory at end of shift
• Correct errors with a single line through, initial, date, and time — never obliterate or use white-out
• Report acute changes verbally first, then document the report and the response
• Use approved abbreviations per facility policy

Under the federal OBRA 1987 mandate that Indiana enforces through 410 IAC 16.2, every resident must have a comprehensive care plan within 7 days of completion of the comprehensive assessment. The CNA contributes observations to the care plan but does not author it independently — the RN coordinates care planning with the interdisciplinary team.

Professional Boundaries

Indiana CNAs must maintain professional boundaries with residents and families. This includes not accepting gifts, loans, or bequests from residents; not sharing personal contact information; and not performing care outside the facility or outside scheduled hours for pay. Crossing a boundary is reportable to the licensed nurse and can lead to a substantiated finding on the Indiana Nurse Aide Registry (see Section 1.3).