Role, Responsibilities & Scope of Practice

The Core of the Role: Observe, Record, Report

The single most-tested idea on the Massachusetts exam is that the CNA is the eyes and ears of the nurse. Your defining duty is to observe, record, and report (ORR): notice changes in a resident's condition, document objective facts, and report anything abnormal to the licensed nurse promptly.

• Observe — use sight, hearing, smell, and touch (e.g., a reddened heel, a new cough, confusion, refusal to eat).
• Record — chart objective data (what you measured or saw) and the resident's exact words for subjective data.
• Report — tell the charge nurse immediately for any change; do not wait for the next shift.

A CNA never diagnoses, interprets, or decides treatment. If a resident's blood pressure is unusually high, you report the number — you do not call it "hypertension" or adjust care yourself.

Delegation: Working Under the Nurse

CNAs practice under delegated authority from a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Delegation means the nurse remains responsible for the outcome; the CNA performs the task as trained. You may perform a delegated task only when it is within your training and the resident is stable.

Within the CNA scope (typical):

1. Activities of daily living — bathing, dressing, grooming, toileting, feeding.
2. Measuring and recording vital signs (temperature, pulse, respirations, blood pressure).
3. Repositioning, transfers, ambulation, and range-of-motion assistance.
4. Measuring intake and output, applying standard precautions, and reporting observations.

Outside the CNA scope (never do):

• Administering or adjusting medications (including over-the-counter).
• Assessing, diagnosing, or creating/changing the care plan.
• Sterile/invasive procedures (e.g., inserting catheters, sterile dressing changes, IV care).
• Taking a verbal or telephone order from a physician.

Chain of Command & Following Orders

Massachusetts facilities run on a chain of command: CNA → charge nurse → nurse manager/Director of Nursing → physician/medical director. When a problem arises, the CNA reports up the chain — starting with the charge nurse — rather than acting independently.

CNAs must also follow valid clinician orders. The MOLST (Medical Orders for Life-Sustaining Treatment) is a Massachusetts medical-order form signed by a physician, nurse practitioner, or physician assistant. It directs care such as CPR, intubation, artificial nutrition, and hospitalization. The MOLST has the force of a physician order, so a CNA must follow it — it is not merely a preference document. (A Healthcare Proxy under MGL Ch. 201D names a substitute decision-maker; it is different from the MOLST.)

Mandatory Abuse Reporting (MA-Specific)

Massachusetts CNAs are mandatory reporters under MGL Chapter 19A, Section 15. If you have reasonable cause to believe an elder (age 60+) is suffering abuse, neglect, or financial exploitation, you must:

1. Immediately make a verbal report to Elder Protective Services (EPS): (800) 922-2275.
2. File a written report within 48 hours.
3. Report facility abuse to the MA DPH hotline (800) 462-5540 and notify your supervisor.

Failure to report can bring a fine up to $1,000. Good-faith reporters are protected from liability. You report suspicion — you never wait for proof or investigate yourself.

Documentation: Objective vs. Subjective Data

Accurate charting is part of scope and is heavily tested. You must distinguish two kinds of data:

• Objective data — what you can measure or observe directly (e.g., "Blood pressure 150/90," "ate 50% of breakfast," "2 cm reddened area on left heel").
• Subjective data — what the resident tells you, charted in their own words (e.g., resident states, "My hip hurts when I stand").

Chart facts, not opinions or labels. Write "resident shouted and pushed the tray away," not "resident was rude." Document care after it is given, never before, and never chart for another person. A worked example: a CNA who finds a resident on the floor records the time found, position, what the resident said, and that the nurse was notified — then stops; the CNA does not chart "the resident fell," because no one witnessed the fall.

Worked Example: A Change in Condition

Scenario: midway through your shift a usually alert resident becomes drowsy and slurs words. The correct sequence is: (1) observe the specific changes, (2) stay with the resident and ensure safety, (3) report to the charge nurse immediately with objective facts, and (4) document the observation and that you notified the nurse. You do not decide it is a stroke, give anything by mouth, or wait until your break — interpreting and treating are outside scope, and delay risks the resident's safety.

Resident Rights, Refusals & Common Traps

Under OBRA 1987 and 105 CMR 155.000, residents have rights including dignity, privacy, confidentiality, and the right to refuse any care. When a resident refuses, the correct CNA action is to respect the refusal, offer an alternative, document it factually, and notify the charge nurse — never force care, which is a form of abuse and can lead to removal from the registry.

Watch these exam traps:

• Forcing a refused bath "because the care plan says so" — wrong; honor the refusal and report.
• Documenting opinions ("resident was rude") instead of facts — chart objective, factual language.
• "Helping" by giving a medication or interpreting a symptom — both exceed scope.
• Reporting abuse only "if you're sure" — you must report reasonable suspicion right away.