Legal and Ethical Behavior

Scope of Practice — Staying In Your Lane

Scope of practice is the list of tasks you are legally permitted to perform as a CNA. In Massachusetts, a CNA performs basic, delegated tasks under the supervision of a licensed nurse (RN or LPN). Delegation is when a nurse assigns a specific task to a CNA who is trained and competent for it. You may perform a task only when it is within CNA scope AND the nurse has delegated it.

Tasks that are outside CNA scope (never do these):

• Giving or applying medications (oral, topical, eye, or insulin).
• Inserting or removing catheters, IVs, or feeding tubes.
• Performing sterile dressing changes.
• Assessing, diagnosing, or creating the care plan.
• Taking verbal orders from a physician.

Tasks within CNA scope when delegated include bathing, feeding, vital signs, repositioning, ambulation, range-of-motion, and reporting observations. On the exam, when a task is above your scope, the correct answer is almost always "report to the nurse" or "the nurse must do it."

Why it matters: working beyond your scope can cause resident harm, end your certification, and create personal legal liability. "I was told to" is not a defense — you may refuse an improper delegation.

The CNA Code of Ethics

A code of ethics is the set of moral standards that guide professional conduct. Core duties:

• Beneficence — act in the resident's best interest.
• Nonmaleficence — do no harm.
• Confidentiality — protect resident information.
• Honesty — chart only what truly happened; never falsify records.
• Accountability — own your actions and report your own errors.

Ethical practice also means never accepting tips, gifts, money, or being named in a resident's will. Borrowing from or accepting gifts from a resident is financial exploitation and is reportable abuse.

Confidentiality and HIPAA

HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. It is the federal law that requires you to keep Protected Health Information (PHI) private. PHI includes a resident's name, diagnosis, condition, and any identifying detail.

HIPAA rules for a CNA:

• Share resident information only with the care team on a need-to-know basis.
• Never discuss residents in hallways, elevators, the break room, or at home.
• Never post about residents on social media, even without a name — describing a resident's situation can identify them.
• Do not let visitors or other residents see charts or screens.

Violating HIPAA can bring termination and federal penalties, and may also be an abuse-related finding on the MA NAR.

Common Legal Terms (Know the Definitions)

Standard of care is what a reasonably careful CNA would do in the same situation. The repositioning standard for an immobile resident is at least every 2 hours; failing to do so when it causes harm is negligence — and may also be neglect, which is reportable.

Advance Directives: MOLST vs. Healthcare Proxy

Massachusetts uses two documents the exam loves to contrast.

MOLST stands for Medical Orders for Life-Sustaining Treatment. It is a portable physician (or nurse-practitioner) order that states a seriously ill resident's actual wishes about CPR, ventilation, intubation, dialysis, antibiotics, and artificial nutrition. Because it is a signed medical order, it is binding the moment it is signed and must be honored by every healthcare worker. A valid DNR (Do Not Resuscitate) order or MOLST means you do NOT start CPR. Note: Massachusetts is transitioning MOLST to the national POLST form in Spring 2027; until then, the MOLST stays valid.

A Healthcare Proxy, governed by MGL Chapter 201D, is different. It is a legal document in which a competent adult (18+) names a Health Care Agent to make decisions if the resident later loses capacity. The proxy names who decides; the MOLST states what was decided. The proxy only takes effect when the resident is found unable to make decisions.

Step-by-step at end of life: if you find an unresponsive resident, call for help and stay with them, but do not begin CPR if a valid DNR/MOLST is in the care plan. The nurse directs all further care.

Incident Reports and Honest Documentation

When an unexpected event happens — a fall, a medication error you witness, a skin tear, a resident-to-resident altercation, or an injury of unknown origin — Massachusetts facilities require an incident (occurrence) report. The exam tests how a CNA completes one correctly:

• Report the event to the charge nurse immediately and check the resident for injury first.
• Write only objective, factual information: the time, what you observed, the position you found the resident in, and the resident's own words in quotation marks.
• Do not record opinions, blame, or guesses about cause ("the resident fell because the aide was late").
• Do not chart that an incident report was filed in the resident's medical record — the report is a separate internal risk-management document.

Falsifying a record, backdating an entry, or charting care that was not given is fraud and an ethics violation that can end your certification. If you make an error in charting, draw a single line through it, write "error," and initial — never erase, white-out, or scribble over it.

Accountability, Whistleblowing, and Personal Liability

Accountability means owning your actions and reporting your own mistakes, even when it is uncomfortable. If you give the wrong tray to a resident on a thickened-liquid diet or notice you forgot to lock a wheelchair before a transfer, you tell the nurse at once so the resident can be protected. Hiding an error to avoid blame puts the resident at risk and compounds the violation.

Massachusetts law also protects employees who report unsafe conditions or suspected abuse in good faith from retaliation. You cannot be fired or disciplined for making an honest report through the proper channels. At the same time, a CNA can be held personally liable for harm caused by working outside scope, ignoring the care plan, or acting carelessly — "the facility is responsible" and "my supervisor told me to" are not legal shields when a resident is injured by your own negligent act.

Common Exam Traps

• Performing a task because someone told you to, even though it is above CNA scope.
• Confusing MOLST (the orders) with the Healthcare Proxy (the decision-maker).
• Starting CPR on a resident with a valid DNR/MOLST.
• Thinking confidentiality allows "venting" about residents at home or online.
• Mixing up assault (threat) and battery (actual unwanted contact).