2.5 Legal, Ethical, and Abuse Reporting
Key Takeaways
- Abuse types tested on the NC CNA exam are physical, emotional/verbal, sexual, financial, and neglect (active or passive); self-neglect is also recognized under NC adult-protection law.
- North Carolina General Statute 108A-102 makes any person with reasonable cause to believe that a disabled adult is in need of protective services a mandatory reporter to the county Department of Social Services (DSS).
- Good-faith reporters are protected from civil and criminal liability under NC law - retaliation against a reporter is itself a violation.
- HIPAA protects identifiable health information; CNAs may only share resident information with team members who need it for care, and never on social media, in public areas, or with the resident's family without consent.
- Common advance directives in NC include the Living Will, the Health Care Power of Attorney, and the MOST (Medical Orders for Scope of Treatment) form - a portable physician order honored across NC settings; a DNR is a specific MOST/physician order, not a personal preference.
2.5 Legal, Ethical, and Abuse Reporting
Quick Answer: In North Carolina, anyone with reasonable cause to believe a disabled adult is being abused, neglected, or exploited must report to the county Department of Social Services under NCGS 108A-102. Reporters acting in good faith are protected from liability. CNAs also follow HIPAA, respect advance directives like the Living Will, Health Care Power of Attorney, and MOST form, and act inside the CNA Code of Ethics - even when no one is watching.
Why This Matters for the Exam
More than one in ten NC CNA scenario items involve a possible abuse, neglect, or confidentiality situation. The right answer is almost always to report immediately - to the charge nurse and, when warranted, to DSS - and to stop participating in the suspect behavior.
Types of Abuse and Neglect
| Type | What It Looks Like | Indicators |
|---|---|---|
| Physical abuse | Hitting, slapping, pinching, rough handling, force-feeding, improper restraint | Bruises in unusual patterns (rings around wrists, paired bruises, fingertip marks), unexplained fractures, fear of certain staff |
| Emotional / verbal abuse | Yelling, threats, intimidation, humiliation, ignoring, name-calling, isolating | Withdrawal, fearfulness, sudden behavior change, refusal to talk in front of caregiver |
| Sexual abuse | Any non-consensual sexual contact; sexual contact with a resident who cannot consent | Bruising or injury to inner thighs/genitals, torn or bloody undergarments, sudden fear of bathing |
| Financial abuse / exploitation | Stealing money, cashing checks, taking property, manipulating signatures, gifts pressured from a resident | Missing valuables, unpaid bills despite funds, sudden changes to will or POA |
| Active neglect | Intentional failure to provide care - food, fluids, hygiene, meds, supervision | Dehydration, weight loss, pressure injuries, soiled clothing or linens, untreated infections |
| Passive neglect | Failure to provide care due to inability, lack of knowledge, or short staffing | Same indicators as active neglect |
| Self-neglect | Adult unable or unwilling to provide their own basic care | Poor hygiene, malnutrition, untreated medical conditions, hoarding, unsafe living conditions |
Common Indicators - High-Yield for the Exam
The exam expects you to recognize these as red flags that trigger a report:
- Bruising in the shape of a hand, belt buckle, or fingertips
- Bruises or pressure injuries in unusual locations (inner arms, inner thighs, behind ears)
- The resident flinches when a particular staff member approaches
- Inconsistencies between the injury and the story
- Sudden weight loss, dehydration, or untreated pressure injuries
- Soiled clothing or wet bedding that was not addressed
- Personal items missing from the room
- The resident is afraid to speak in front of a caregiver or family member
- A staff member is alone with a resident for unexplained long periods, or is secretive
NC Mandatory Reporting - NCGS 108A-102
North Carolina General Statute 108A-102 (Article 6 of Chapter 108A) requires:
Any person having reasonable cause to believe that a disabled adult is in need of protective services shall report such information to the director of the department of social services in the county where the disabled adult resides or is present.
Key points:
- Any person - the duty is universal in NC. It applies to CNAs, nurses, doctors, family, neighbors, and strangers.
- Reasonable cause - you do not need proof. You need a reasonable, good-faith belief.
- Report to county DSS in the county where the disabled adult lives or is present.
- The standard is the disabled adult's need for protective services, which includes abuse, neglect, exploitation, and self-neglect.
- For long-term care facilities, NC also requires reports to NC DHSR Health Care Personnel Investigations Section for staff-related allegations and to the NC Long-Term Care Ombudsman for resident-rights issues.
- Inside the facility, the CNA first notifies the charge nurse and administrator unless they are the suspected wrongdoer; the facility must then report externally on a defined timeline (often within 2-24 hours depending on severity).
Reporter Protections
NC law gives immunity from civil and criminal liability to any person who makes a report in good faith, even if the investigation does not substantiate the allegation. Retaliation against a reporter is itself a violation.
A CNA who fails to report suspected abuse can face certificate revocation, civil penalties, and criminal charges, and can be placed on the Nurse Aide Registry abuse listing - which permanently bars employment in long-term care.
What to Include in a Report
- The resident's name and location
- Who is suspected (if known)
- What was seen, heard, or said - in objective language and quotes
- Date, time, and where it occurred
- Names of anyone else present
- Any injuries observed
- Actions already taken
Do not confront the suspected abuser, interview the resident in depth, take photos of injuries on a personal phone, or post about the incident.
Confidentiality and HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) protects Protected Health Information (PHI) - any information that could identify the resident together with a health detail.
CNAs follow HIPAA by:
- Discussing residents only with team members who need the information for care.
- Never discussing residents in elevators, cafeterias, parking lots, or on social media.
- Never posting photos, videos, names, or descriptions of residents online.
- Logging off the EHR and locking paper charts when stepping away.
- Refusing to confirm or deny that a person is even a resident to outside callers without verified identity and authorization.
- Sharing information with family only when the resident has consented or designated that person.
A HIPAA breach can result in fines, termination, and certificate action. Many facilities also impose immediate dismissal for social media posts about residents - even "positive" ones.
Advance Directives in North Carolina
An advance directive is a legal document in which a competent adult states future health-care preferences or names a decision-maker. NC recognizes three main forms:
| Document | What It Does |
|---|---|
| Living Will (Declaration of a Desire for a Natural Death) | Directs what life-prolonging treatment a person wants withheld or withdrawn when they have a terminal/irreversible condition |
| Health Care Power of Attorney (HCPOA) | Names a health-care agent to make decisions when the patient cannot |
| MOST - Medical Orders for Scope of Treatment | A bright-pink physician's order form that travels with the resident across NC settings and specifies CPR status, level of intervention, antibiotics, and tube feedings |
A Do Not Resuscitate (DNR) order is a specific physician order - typically captured on the MOST form in NC or on a stand-alone DNR document - directing that no CPR or advanced resuscitation be started when the resident has no pulse and no respirations.
CNA Responsibilities Around Advance Directives
- The CNA does not create, witness, or interpret advance directives.
- The CNA must know which residents have a DNR/MOST and where the document is filed.
- If a resident with a DNR/MOST is found unresponsive and pulseless, the CNA does not start CPR; the CNA calls the nurse and provides comfort care.
- If there is no DNR order in the chart and the resident is found unresponsive and pulseless, the CNA starts CPR and calls for help.
- A resident can change or revoke an advance directive at any time while competent; report any such request to the nurse and social worker.
The CNA Code of Ethics - Daily Practice
Ethical CNAs:
- Tell the truth, even when it is uncomfortable.
- Respect every resident's dignity, choices, beliefs, and culture.
- Stay inside their scope of practice.
- Maintain confidentiality at all times.
- Refuse gifts of money or valuables from residents and families.
- Do not witness legal documents (wills, POAs) for residents.
- Report mistakes - their own and others' - promptly.
- Continue learning and renew certification on schedule.
- Treat every resident the same regardless of background, ability to pay, behavior, or diagnosis.
Internal Links
- See Section 2.4 Residents' Rights for the rights that abuse, neglect, and HIPAA breaches violate.
- See Section 2.3 Documentation and Reporting for how to document an incident objectively.
- See Section 2.1 Scope of Practice for why a CNA never accepts a verbal DNR order over the phone.
A CNA in a Greensboro, NC nursing facility sees a coworker slap a confused resident on the arm during a transfer. Under NCGS 108A-102 and facility policy, what should the CNA do FIRST?
A CNA in a NC long-term care facility finds Mr. Alvarez unresponsive in bed without a pulse and not breathing. The CNA recalls that Mr. Alvarez has a current MOST form on file with a "Do Not Attempt Resuscitation" order. What should the CNA do?