5.1 CNA Scope of Practice & Delegation

CNA Scope of Practice & Delegation

In long-term care facilities, skilled nursing environments, and acute healthcare organizations across North Dakota, the Certified Nursing Assistant (CNA) serves as the primary hands-on caregiver. CNAs spend more direct time interacting with residents than any other member of the interdisciplinary healthcare team. Because of this intimate proximity to the resident, understanding the precise legal boundaries of the CNA role—known as the Scope of Practice—is essential to resident safety, professional ethics, and regulatory compliance.

The scope of practice defines the specific tasks, procedures, and responsibilities that a healthcare provider is legally permitted and certified to perform under state and federal law. Practicing within these boundaries ensures safe care delivery, whereas performing tasks outside one's legal scope constitutes illegal practice, endangers vulnerable residents, and subjects the caregiver to disciplinary action, termination, and potential criminal liability.

+-----------------------------------------------------------------------------+
|                   HEALTHCARE TEAM HIERARCHY & SUPERVISION                   |
|                                                                             |
|   [PHYSICIAN / ADVANCED PRACTICE PROVIDER (MD / DO / NP / PA)]              |
|       Diagnoses conditions, prescribes medical treatments and medications   |
|                                  │                                          |
|                                  ▼                                          |
|   [REGISTERED NURSE (RN)]                                                   |
|       Performs comprehensive assessment, formulates nursing care plans,     |
|       manages IV therapy, delegates tasks, and evaluates clinical outcomes  |
|                                  │                                          |
|                                  ▼                                          |
|   [LICENSED PRACTICAL NURSE (LPN)]                                          |
|       Provides bedside nursing, administers medications, monitors care,     |
|       and superintends CNAs under the direction of an RN                    |
|                                  │                                          |
|                                  ▼                                          |
|   [CERTIFIED NURSING ASSISTANT (CNA)]                                       |
|       Delivers direct personal care, assists with ADLs, monitors vitals,    |
|       observes changes, and reports findings to supervising licensed nurses |
+-----------------------------------------------------------------------------+

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1. Regulatory Foundations: OBRA 1987 & North Dakota Nursing Laws

The modern role of the nursing assistant is grounded in landmark federal legislation and state-specific nursing statutes:

The Omnibus Budget Reconciliation Act of 1987 (OBRA '87)

Prior to 1987, training and quality standards for nursing assistants in long-term care varied widely across the United States, leading to inconsistent and sometimes hazardous care. Congress enacted OBRA 1987 (often called the Federal Nursing Home Reform Act) to establish strict national standards for nursing home care, protect resident rights, and ensure baseline competency for direct care staff.

Key OBRA 1987 Mandates for Nursing Assistants:

• Mandates that every state establish and maintain an official Nurse Aide Registry.
• Establishes a minimum training requirement of at least 75 hours of state-approved education (some states require more; North Dakota enforces the 75-hour standard).
• Requires passing both a standardized written/oral knowledge examination and a manual clinical skills evaluation.
• Mandates a minimum of 12 hours of continuing education (in-service training) per year for all employed CNAs.
• Establishes regular performance reviews and registry verification prior to employment.

North Dakota State Regulatory Oversight

Nurse aides in North Dakota are not licensed by the Board of Nursing. Nurse aide regulation sits entirely with the North Dakota Department of Health and Human Services (ND HHS) under NDCC chapter 23-44 and N.D. Admin. Code article 33-43, and the Board of Nursing enters the picture only through the licensed nurses who supervise you:

• ND HHS approves nurse aide training programs, contracts testing to D&S Diversified Technologies / Headmaster, maintains the Nurse Aide Registry, processes renewals, and investigates allegations of abuse, neglect, or misappropriation of resident property. Every rule that governs your certification is in N.D. Admin. Code chapter 33-43-01.
• The North Dakota Board of Nursing (NDBON) defines the scope of practice of registered nurses and licensed practical nurses, including the standards governing delegation of nursing interventions to unlicensed assistive personnel. Those rules bind the nurse who delegates a task to you, which is why a nurse may lawfully refuse to delegate something a CNA is otherwise trained to do.

[!IMPORTANT] Supervisory Rule: A CNA never works independently. A Certified Nursing Assistant must always practice under the direct supervision, assignment, and direction of a licensed nurse (Registered Nurse [RN] or Licensed Practical Nurse [LPN]).

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2. Permitted CNA Responsibilities vs. Prohibited Invasive Tasks

Every nursing assistant must maintain an absolute understanding of which clinical activities fall within their permitted scope of practice and which tasks are strictly prohibited.

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|                   PERMITTED VS. PROHIBITED CNA RESPONSIBILITIES             |
|                                                                             |
|   [PERMITTED CNA RESPONSIBILITIES]     [PROHIBITED / OUTSIDE SCOPE]         |
|   ✔ Activities of Daily Living (ADLs)   ✘ Administering any medications     |
|   ✔ Vital signs (T, P, R, BP, Pain)    ✘ Prescription eye/ear drops/creams  |
|   ✔ Height, weight, Intake & Output    ✘ Inserting/removing Foley catheters |
|   ✔ Safe transfers & repositioning     ✘ Starting/adjusting IV infusions    |
|   ✔ Passive/active ROM exercises       ✘ Administering tube feedings        |
|   ✔ Non-invasive comfort measures      ✘ Performing sterile wound care      |
|   ✔ Skin checks & preventive care      ✘ Taking telephone/verbal MD orders  |
|   ✔ Observing & reporting changes      ✘ Performing diagnostic assessments  |
|   ✔ Objective chart documentation      ✘ Developing nursing care plans      |
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Permitted Core Responsibilities (Within CNA Scope)

1. Personal Hygiene & Activities of Daily Living (ADLs):
   • Assisting with complete, partial, tub, or shower baths.
   • Providing routine oral care, special mouth care for unconscious residents, and denture cleaning.
   • Assisting with grooming, hair care, shaving (using safety or electric razors), and non-diabetic fingernail care.
   • Assisting with dressing and undressing (following the Dressing the Affected Side First rule).
   • Providing routine perineal care and toileting assistance (bedpan, urinal, commode, or bathroom).
2. Measurement & Data Collection:
   • Measuring and recording vital signs (oral, rectal, tympanic, temporal, and axillary temperature; radial and apical pulse; respiratory rate; blood pressure; and numeric/faces pain ratings).
   • Measuring height (standing stadiometer or supine tape measurement) and body weight (standing, wheelchair tare, or mechanical lift scales).
   • Calculating and recording fluid intake (converting ounces to milliliters) and fluid output (measuring urine, emesis, and liquid stool using calibrated graduates).
   • Collecting non-invasive routine specimens (clean-catch midstream urine, routine voided urine, stool specimens, and sputum).
3. Mobility, Positioning, and Restorative Care:
   • Turning and repositioning bedbound residents at least every 2 hours to prevent pressure injuries.
   • Assisting with transfers using proper body mechanics, gait belts, slide boards, and mechanical lifts (operating mechanical lifts with at least two staff members present).
   • Assisting with ambulation using assistive devices (canes, walkers, crutches) while walking slightly behind and to the resident's weaker side.
   • Performing passive and active Range of Motion (ROM) exercises according to the care plan.
4. Nutrition & Hydration:
   • Preparing meal trays, opening containers, and assisting or feeding residents who cannot feed themselves.
   • Monitoring chewing and swallowing for signs of dysphagia (coughing, choking, wet gurgling voice, pocketing food).
   • Implementing aspiration precautions (sitting upright at 90 degrees during meals and for at least 30 to 60 minutes post-meal).
   • Providing fresh ice water and offering fluids to prevent dehydration (unless contraindicated by a fluid restriction order).
5. Observation, Reporting, and Documentation:
   • Continuously monitoring physical appearance, skin integrity, emotional state, and behavior.
   • Immediately reporting abnormal vital signs, acute pain, breathing distress, sudden weakness, mental confusion, falls, or signs of skin breakdown to the charge nurse.
   • Documenting completed care, measurements, and factual observations accurately and promptly in the resident's chart.

Tasks Strictly OUTSIDE the CNA Scope of Practice

[!CAUTION] The CMA Distinction in North Dakota: In North Dakota, a standard Certified Nursing Assistant is strictly forbidden from administering any medications, including over-the-counter creams, prescription eye drops, or Tylenol. Only nursing assistants who undergo additional accredited coursework and pass the North Dakota Board of Nursing Medication Assistant (CMA / MA-C) certification exam may administer specific scheduled non-parenteral medications under RN supervision.

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3. The 5 Rights of Nursing Delegation

Delegation is the formal transfer of responsibility for the performance of a specific nursing activity from a licensed nurse (RN or LPN) to a competent unlicensed assistive personnel (such as a CNA), while the licensed nurse retains ultimate accountability for the outcome.

The National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) have established the Five Rights of Delegation to guide safe delegation practices:

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|                        THE FIVE RIGHTS OF DELEGATION                        |
|                                                                             |
|   1. [RIGHT TASK]            ---> Is the task within CNA scope & facility?  |
|   2. [RIGHT CIRCUMSTANCE]    ---> Is the resident stable and predictable?   |
|   3. [RIGHT PERSON]          ---> Does the CNA have training & competence?  |
|   4. [RIGHT DIRECTION /      ---> Are instructions clear, concise, and      |
|       COMMUNICATION]              understood with specific reporting limits?|
|   5. [RIGHT SUPERVISION /    ---> Is the nurse available to monitor, assist,|
|       EVALUATION]                 and evaluate the clinical outcome?        |
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In-Depth Breakdown of the 5 Rights:

               +--------------------------------------------+
               |         LICENSED NURSE ASSIGNMENT          |
               +--------------------------------------------+
                                     │
                                     ▼
               +────────────────────────────────────────────+
               | 1. RIGHT TASK:                              |
               |    Is it permitted by law & policy?        |
               +────────────────────────────────────────────+
                                     │ YES
                                     ▼
               +────────────────────────────────────────────+
               | 2. RIGHT CIRCUMSTANCE:                      |
               |    Is the resident clinically stable?      |
               +────────────────────────────────────────────+
                                     │ YES
                                     ▼
               +────────────────────────────────────────────+
               | 3. RIGHT PERSON:                            |
               |    Has the CNA been trained & checked off? |
               +────────────────────────────────────────────+
                                     │ YES
                                     ▼
               +────────────────────────────────────────────+
               | 4. RIGHT DIRECTION & COMMUNICATION:         |
               |    Are parameters & limits clearly defined?|
               +────────────────────────────────────────────+
                                     │ YES
                                     ▼
               +────────────────────────────────────────────+
               | 5. RIGHT SUPERVISION & EVALUATION:          |
               |    Does the nurse monitor & assess results?|
               +────────────────────────────────────────────+
                                     │
                                     ▼
               +--------------------------------------------+
               |         SAFE CARE EXECUTION & REPORT       |
               +--------------------------------------------+

1. Right Task:
   • The task must be one that recurs frequently in daily care, does not require complex clinical decision-making or nursing assessment, utilizes a standardized procedure, and is authorized by state regulation and facility policy.
   • Example: Delegating routine blood pressure measurement or morning bed baths is a Right Task. Delegating a sterile tracheostomy dressing change is NOT a Right Task.
2. Right Circumstance:
   • The resident's health status must be stable and predictable. If a resident's physiological condition is rapidly changing, deteriorating, or acutely unstable, the licensed nurse must provide direct care personally.
   • Example: Ambulating a stable resident three weeks post-knee surgery is appropriate. Ambulating a resident who is acutely dizzy, hypotensive, and experiencing chest pain is an UNSAFE circumstance.
3. Right Person:
   • The delegating nurse must verify that the specific CNA has received appropriate training, demonstrated documented competency, and holds the skill set required for the specific resident's care needs.
   • Example: Assigning a complex mechanical ceiling lift transfer to a CNA who has been formally checked off on lift operation is appropriate. Assigning it to a new hire who has never seen the machine violates the Right Person.
4. Right Direction and Communication:
   • The licensed nurse must provide clear, concise, complete, and unambiguous instructions. This includes specifying exactly what data to collect, specific resident limitations, target completion times, and exact thresholds for when to notify the nurse immediately.
   • Example: The nurse states: "Please measure Mrs. Adams's blood pressure while seated before 0900, and notify me immediately if her systolic pressure is below 100 mmHg or above 150 mmHg." (Clear direction with defined reporting parameters).
5. Right Supervision and Evaluation:
   • The licensed nurse must remain accessible, oversee the care delivery, provide guidance if needed, verify that the task was completed according to standards, and evaluate the resident's physiological and behavioral response.

Accountability in Delegation: Nurse vs. CNA

A fundamental legal concept on the North Dakota CNA examination is the distribution of accountability:

• The Delegating Licensed Nurse (RN/LPN) retains ultimate accountability for the total nursing care of the resident, the appropriateness of the delegation decision, and the clinical evaluation of the outcome.
• The Certified Nursing Assistant (CNA) is personally accountable for their own actions—specifically, for performing the assigned task safely, adhering strictly to taught clinical procedures, refusing tasks they are not trained or permitted to perform, and promptly reporting all data and complications to the nurse.

$\begin{matrix} \textbf{Licensed Nurse Accountability} & = & \text{Assessment, Delegation Decision, Supervision, Clinical Evaluation} \\ \textbf{CNA Accountability} & = & \text{Competent Performance, Standard Adherence, Prompt Reporting, Legitimate Refusal} \end{matrix}$

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4. Professional Refusal of Delegated Tasks: Protocols & Communication

While CNAs work as supportive team members, they have a legal, ethical, and moral obligation to refuse a delegated task under specific, justifiable clinical circumstances.

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|                   WHEN A CNA MUST REFUSE A DELEGATED TASK                   |
|                                                                             |
|   [LEGITIMATE REASONS TO REFUSE]       [UNACCEPTABLE REASONS TO REFUSE]     |
|   ✔ Task is outside legal CNA scope    ✘ Personal dislike of the resident   |
|   ✔ CNA has never been trained/tested  ✘ Dislike of the task (e.g. stool)   |
|   ✔ Essential equipment broken/missing ✘ Believing "it is not my turn"      |
|   ✔ Task is unsafe / harms resident    ✘ Being busy with non-urgent tasks   |
|   ✔ Resident is acutely unstable       ✘ Interpersonal conflict with nurse  |
|   ✔ Directions are illegal / unethical ✘ Refusing without notifying nurse   |
+-----------------------------------------------------------------------------+

Legitimate Grounds for Refusing Delegation:

1. Outside Legal Scope: The requested task exceeds the statutory boundaries of a CNA under North Dakota law (e.g., nurse asks CNA to administer an insulin injection or flush an IV line).
2. Lack of Training or Documented Competency: The CNA has never been instructed or checked off on the specific procedure or piece of specialized medical equipment (e.g., operating a brand-new bariatric ceiling hoist).
3. Defective or Missing Safety Equipment: The equipment required to perform the task safely is broken, missing, or inappropriate (e.g., gait belt missing, lift battery dead, transfer sling torn).
4. Acute Resident Instability: The resident's condition has suddenly deteriorated or is acutely hazardous, requiring advanced licensed nursing assessment.
5. Unclear or Dangerous Directions: The nurse's instructions are contradictory, illegal, violate facility safety policy, or place the resident in clear, immediate danger.

How to Refuse a Delegated Task Professionally:

Refusing a delegated task must never be an act of insubordination or laziness. It must be handled with immediate, respectful, and assertive communication.

+-----------------------------------------------------------------------------+
|                 THE 4-STEP ASSERTIVE PROFESSIONAL REFUSAL                   |
|                                                                             |
|   [STEP 1: IMMEDIATE COMM]    ---> Speak directly & privately to the nurse. |
|   [STEP 2: CLEAR STATEMENT]   ---> Respectfully state what you cannot do.   |
|   [STEP 3: CLINICAL RATIONALE]---> Give the factual legal/safety reason.    |
|   [STEP 4: POSITIVE OFFER]    ---> Offer an in-scope constructive solution. |
+-----------------------------------------------------------------------------+

Clinical Example Scenario:

Scenario: A very busy charge nurse hands a bottle of prescription ear drops to a CNA and says, "I'm swamped with an admission. Please put two drops of this in Mr. Miller's right ear right away."

Incorrect CNA Response: The CNA takes the bottle and administers the drops to help out, or throws the bottle on the counter and shouts, "That's not my job!"

Correct CNA Response: The CNA approaches the nurse calmly and states: "Nurse Sarah, I cannot administer these ear drops because administering prescription medications is outside my legal scope of practice as a CNA. However, I will gladly measure Mr. Miller's morning vital signs and assist him with his breakfast while you administer his medication."

Outcome: Resident safety is protected, legal scope of practice is maintained, and the nursing assistant provides constructive support within authorized boundaries.