1.3 Scope, Delegation, and Reporting
Key Takeaways
- Missouri defines a CNA as a trained, tested employee who provides or assists with direct resident health care under licensed-nurse supervision.
- The Missouri-safe CNA pattern is assist, observe, measure, record, and report; assessment, diagnosis, care-plan changes, and independent treatment belong to licensed staff.
- When a task is unclear, untrained, unsafe, or outside the care plan, the CNA stops and asks the nurse before doing it.
- Missouri long-term care employees and other caregivers have immediate reporting duties for suspected abuse or neglect, and the Adult Abuse and Neglect Hotline is 1-800-392-0210.
Scope Starts With Supervision
Section 198.082, RSMo, defines a certified nursing assistant as an employee who has completed the required training, passed the certification exam, and is assigned to provide or assist in direct resident health care services under the supervision of a nurse licensed under Missouri's nursing practice law. The 19 CSR 30-84.010 training rule uses the same practical boundary: Missouri trains CNAs to perform uncomplicated nursing procedures and assist LPNs or RNs in direct resident care.
For the exam, translate that legal language into a bedside rule: the CNA assists, observes, measures, records, and reports under supervision. The CNA does not assess independently, diagnose, prescribe, insert catheters, give medications as a basic CNA, change oxygen settings independently, perform sterile treatments, or revise the care plan. A Missouri CNA who later becomes a Certified Medication Technician has a separate credential and set of rules; do not import CMT authority into basic CNA questions.
CNA Versus Licensed Nurse Decisions
| Situation | Missouri-safe CNA action | Why it matters |
|---|---|---|
| Resident says chest hurts | Stay with the resident, call the nurse immediately, observe breathing and color | The CNA reports urgent symptoms but does not diagnose or treat chest pain |
| New red area on heel | Relieve pressure if safe, keep the resident protected, report promptly | Skin assessment and treatment decisions belong to the nurse |
| Family asks, "Is Mom getting worse?" | Refer medical interpretation to the nurse, share only appropriate observations through the care team | Diagnosis and prognosis are outside CNA scope and may involve protected health information |
| Nurse delegates a transfer not on the care plan | Clarify before doing it, especially if equipment or assistance is missing | Delegation must be safe, trained, and consistent with the resident's current plan |
| Resident refuses a bath | Respect the refusal, explain briefly, offer an alternative if appropriate, report | Residents have rights; forcing care is unsafe and may be abuse |
Missouri test items often hide the scope issue inside a familiar care task. A candidate may know how to help with toileting but still fail the question by ignoring a new symptom, a refusal, or a change in condition. The first decision is not, "Can I physically do this?" It is, "Has this been delegated, am I trained and found proficient, is it in the care plan, and does the resident remain safe?"
Delegation and Reporting in Daily Work
Delegation is not a license to improvise. The nurse keeps responsibility for assessment, clinical judgment, and care planning; the CNA carries out assigned tasks and reports facts that may require nursing action. Good reporting is objective, timely, and routed to the right person. "The resident is infected" is a diagnosis. "The left heel is newly red, warm, and painful when touched" is a CNA observation the nurse can act on.
A useful format is situation, background, action, response: what changed, what you observed, what you did within the care plan, and who was notified.
Report Immediately, Then Document as Required
| Trigger | First action | Documentation trap |
|---|---|---|
| Fall or suspected injury | Stay with the resident, call for the nurse, do not move unless directed or necessary for safety | Do not chart "no injury" before the nurse evaluates |
| New confusion, weakness, or shortness of breath | Notify the nurse promptly and keep the resident safe | Do not wait until end-of-shift charting for an urgent change |
| Abnormal vital sign | Recheck if appropriate and report according to facility policy | Do not erase or invent a better number |
| Suspected abuse, neglect, or exploitation | Protect immediate safety and report through required channels | Do not investigate privately or confront the alleged abuser alone |
| Task outside training | Stop and ask the nurse or supervisor | Do not do it because another aide says it is easy |
| Resident refusal | Respect the refusal and report it | Do not chart the care as completed |
Confidentiality still applies: report to the nurse, chart in the proper record, and avoid hallway, family, online, or visible-note disclosures.
Missouri Abuse Reporting and Resident Rights
Section 198.070, RSMo, requires long-term care facility employees and other listed caregivers to immediately report suspected abuse or neglect of a facility resident to the department when they have reasonable cause to believe abuse or neglect occurred. The same statute describes report contents, protects confidentiality, prohibits retaliation, and makes knowing failure to report within a reasonable time a class A misdemeanor. For eligible adults outside the facility context, section 192.2405 also lists mandatory reporters and requires immediate reporting to the department when the statutory conditions are met.
DHSS's Stop Adult Abuse page gives the public reporting route: the Adult Abuse and Neglect Hotline is 1-800-392-0210, and online reporting is available. The page also reminds readers that anyone may report suspected abuse, neglect, or exploitation, while certain professionals are mandated reporters. For a CNA exam answer, this means suspicion is enough to report; the aide does not need proof, a confession, or permission from a supervisor before the concern is routed as required.
Resident rights connect directly to reporting. Missouri DHSS lists rights such as freedom from mental and physical abuse, being informed of medical condition, choosing a physician, participating in care planning, refusing treatment, voicing grievances, being treated with respect and dignity, and receiving treatments in privacy. A CNA protects those rights in small actions: knocking, explaining care, covering the resident, using preferred names, keeping call lights reachable, and reporting retaliation or intimidation.
Missouri Scenario Traps
- A resident says an aide took cash from a drawer. The CNA reports the allegation; the CNA does not decide it is probably a misunderstanding and ignore it.
- A nurse asks a CNA to apply a sterile dressing because the unit is busy. Basic CNA scope does not expand because the unit is short-staffed; the aide should tell the nurse the task is outside training and scope.
- A competent resident refuses a shower before a family visit. The CNA may encourage and offer choices, but forcing care violates resident rights.
- A family member asks whether the resident has dementia. The CNA redirects medical questions to the nurse and reports observations through the care team.
Scope, delegation, and reporting are linked. Staying inside scope does not mean staying passive. The Missouri CNA acts quickly when residents are unsafe, reports facts to licensed staff and mandated channels, and refuses to perform tasks that require nursing judgment.
A Missouri CNA sees a new open area on a resident's coccyx during perineal care. What is the best scope-of-practice response?
Which report best uses objective CNA language?
A Missouri long-term care resident tells a CNA that another employee slapped him. What should the CNA do first after protecting immediate safety?