2.1 Healthcare Team and CNA Scope of Practice
Key Takeaways
- The CNA works under the direct supervision and delegation of a licensed nurse (RN or LPN) and never independently of the chain of command.
- In North Carolina, a CNA I cannot administer medications, perform sterile procedures, insert or remove urinary catheters, manage IVs, or accept verbal physician orders.
- A CNA II in North Carolina is listed on a separate NC Board of Nursing registry and may perform expanded skills (sterile dressings, ostomy care, tracheostomy care, suctioning, urinary catheter care, NG tube feedings) only after delegation by an RN.
- If a CNA is asked to perform a task outside the CNA scope of practice, the correct response is to refuse the task and notify the supervising nurse, not to attempt it.
- The healthcare team is interdisciplinary: RN, LPN, attending physician, PT, OT, ST, RD, social worker, and CNA each have a defined role in resident care planning.
2.1 The Healthcare Team and CNA Scope of Practice
Quick Answer: A North Carolina CNA always works under the supervision of a licensed nurse and may never give medications, do sterile procedures, manage IVs, or accept verbal physician orders. A NC CNA II is a separate listing on the NC Board of Nursing registry and adds advanced skills (sterile dressings, ostomy, tracheostomy, suctioning, urinary catheter care, NG feedings) only when a registered nurse delegates them.
Why This Topic Matters for the Exam
The NC Nurse Aide I written exam tests scope of practice in nearly every section. Questions usually describe a scenario in which the CNA is asked to perform a task or is unsure what to do, and you must pick the answer that stays inside the CNA scope and respects the chain of command. Knowing exactly which tasks belong to the nurse, the doctor, the therapist, or the dietitian protects residents and prevents license problems.
The Interdisciplinary Healthcare Team
Long-term care in North Carolina is delivered by a team. Each role has a defined, regulated scope.
| Role | Primary Responsibility | Can Delegate to CNA? |
|---|---|---|
| Attending physician (MD/DO) | Diagnoses, writes orders, prescribes medications | No (orders go through nurse) |
| Registered Nurse (RN) | Assesses, develops care plan, administers meds, delegates tasks | Yes |
| Licensed Practical Nurse (LPN) | Provides nursing care, gives most meds, supervises CNAs | Yes (within their own scope) |
| Certified Nursing Assistant (CNA I/II) | Direct personal care, ADLs, vitals, observation, reporting | No |
| Physical Therapist (PT) | Gross motor, mobility, transfers, strengthening | No (gives instructions only) |
| Occupational Therapist (OT) | Fine motor, ADLs, adaptive equipment | No |
| Speech Therapist (ST/SLP) | Speech, swallowing, communication | No |
| Registered Dietitian (RD) | Diet orders, nutrition plan, therapeutic diets | No |
| Medical Social Worker (MSW) | Psychosocial support, discharge planning, family liaison | No |
| Activities Director | Recreation, group programs, cognitive stimulation | No |
The Chain of Command in NC
If the CNA has a question, a concern, or a problem they cannot solve, the answer is always to move up one level, never to skip a level.
CNA -> Charge Nurse (LPN/RN) -> Director of Nursing (DON) -> Administrator -> Owner/Governing Body
|
+--> NC Division of Health Service Regulation (DHSR) for unresolved safety issues
On the exam, the first person a CNA always reports to is the charge nurse on duty. Going directly to the family, the doctor, the administrator, or NC DHSR before telling the charge nurse is wrong unless the nurse is the suspected wrongdoer.
CNA I Scope of Practice (NC)
A NC CNA I provides supportive personal care under nurse delegation. Approved tasks include:
- Bathing, dressing, grooming, oral care, perineal care, denture care, shaving
- Toileting, bedpan/urinal, incontinence care, ostomy emptying (not changing the wafer)
- Feeding, assisting with meals, recording intake and output
- Transfers, ambulation, positioning, range-of-motion exercises
- Taking and recording vital signs (T, P, R, BP, pulse ox, weight, height)
- Routine, non-sterile dressing changes (clean technique, not sterile)
- Specimen collection (clean-catch urine, stool, sputum)
- Bed making, room tidying, restocking supplies
- Observing and reporting changes in resident condition
What a NC CNA I May NOT Do (High-Yield Exam Content)
If any answer choice has the CNA performing one of the tasks below, that answer is wrong unless the question explicitly says the CNA is a CNA II and the RN delegated the task.
- Administer medications of any route - PO, topical, eye/ear drops, suppositories, SQ, IM, IV. (This includes a friendly "hand the resident their pill cup.")
- Insert or remove urinary catheters (CNA I may give catheter care - washing the meatus and tubing - but never insert or remove).
- Perform sterile procedures or sterile dressing changes.
- Perform tracheostomy care, suctioning, or manage a tracheostomy.
- Administer or manage IV fluids, IV medications, or blood products.
- Insert, irrigate, or feed through a nasogastric (NG) or gastrostomy (G) tube.
- Take verbal or telephone orders from a physician.
- Perform initial assessment, develop or change the care plan, or triage.
- Diagnose, prescribe, interpret labs, or counsel on medical decisions.
- Pronounce death.
- Cut toenails on a diabetic resident (podiatry/RN task).
- Apply or remove restraints without nurse direction and a physician order.
NC CNA II - Expanded Scope
A CNA II in North Carolina is listed on a separate NC Board of Nursing (NCBON) Nurse Aide II Registry after completing an approved CNA II training program (typically 160-180 hours of additional theory and skills) and demonstrating competency. CNA II skills are still delegated by an RN - they are not independent.
Approved CNA II tasks (selected high-yield list):
- Sterile dressing changes (clean wound, no irrigation)
- Ostomy care including pouch change and stoma assessment
- Tracheostomy care of an established trach and oropharyngeal suctioning
- Urinary catheter care including insertion of a straight or indwelling catheter under nurse direction, and discontinuation
- Nasogastric tube care and bolus or gravity feeding of an established NG (not initial insertion of the tube)
- Oxygen administration by nasal cannula or mask at a set, ordered rate
- Application of warm or cold compresses and sitz baths
- Collection of sterile specimens
- Administration of certain enemas
A CNA II still may not administer medications, manage IV access, draw blood, or insert an NG/G-tube.
Refusing an Out-of-Scope Task
If a nurse, family member, or coworker asks the CNA to do something outside the CNA scope, the safe, exam-correct response is:
- Respectfully decline the task.
- State the reason: "That is outside my scope of practice as a CNA."
- Notify the charge nurse so the task is performed by someone qualified.
- Document what happened.
Doing the task because "the nurse told me to" is not a defense. The CNA is personally responsible for staying inside scope.
Five Rights of Delegation (How the Nurse Decides What to Delegate)
The RN uses the Five Rights of Delegation when assigning tasks to a CNA. The exam can ask you to recognize these as a safety check:
- Right Task - is this task within the CNA scope?
- Right Circumstance - is the resident stable enough for a CNA to do it?
- Right Person - is this specific CNA trained and competent?
- Right Direction/Communication - has the CNA been told clearly what to do?
- Right Supervision/Evaluation - will the nurse follow up and check the outcome?
Reporting vs. Assessing
This distinction shows up constantly. A CNA observes and reports. A nurse assesses. If a question describes the CNA "deciding," "diagnosing," "determining the cause," or "interpreting," that answer is almost always wrong. The CNA's correct verb is report.
Internal Links
- See Section 2.2 Effective Communication for SBAR reporting to the nurse.
- See Section 2.3 Documentation and Reporting for what to chart vs. what to verbally report.
- See Section 2.4 Residents' Rights for restraint rules that intersect with scope of practice.
A new CNA in a North Carolina skilled nursing facility is asked by an LPN to crush a resident's blood pressure pill and mix it into applesauce because the resident is refusing it. What is the most appropriate action?
Which task is within the scope of practice for a North Carolina CNA II but NOT a CNA I?