2.5 Scope of Practice, Delegation, and Chain of Command
Key Takeaways
- A CNA performs assigned, trained tasks under nurse supervision and reports observations; the CNA does not assess, diagnose, prescribe, or change the care plan.
- Texas nursing delegation follows the Five Rights of Delegation: right task, right circumstances, right person, right direction, and right supervision.
- Medication administration, sterile or invasive procedures, tube insertion/removal, injections, and restraint decisions are outside CNA scope.
- The chain of command moves a concern from CNA to nurse, then supervisor, director of nursing, administrator, and required HHSC channels when the resident stays at risk.
Scope Keeps Care Safe
Scope of practice is the set of tasks a CNA may perform based on training, law, facility policy, and nurse delegation. In Texas, the Board of Nursing (BON) governs delegation by licensed nurses to unlicensed personnel, while HHSC governs facility operations. A CNA provides direct personal care and basic nursing support: bathing, grooming, dressing, feeding assistance, toileting, positioning, transfers, ambulation, vital signs, intake and output (I&O), weights, bed-making, observing changes, and reporting to the nurse.
A CNA does not assess, diagnose, prescribe, interpret clinical findings, take provider orders, or create or change a care plan. A CNA does not decide a safety measure is no longer needed, perform sterile procedures, insert or remove tubes (urinary catheters, feeding tubes, IVs), give injections, administer or adjust medications, or apply a restraint without an order. Note the difference between collecting and interpreting: a CNA may take a temperature, but deciding whether to start a treatment based on it is the nurse's job.
The Five Rights of Delegation
Delegation means a licensed nurse assigns a task to the CNA while keeping responsibility for nursing judgment and supervision. Texas BON rules frame safe delegation as five checks:
| Right | Question to ask | Example |
|---|---|---|
| Right task | Is this a task that can be delegated to a CNA? | Routine vital signs yes; IV push no |
| Right circumstances | Is the resident stable and the setting safe? | A stable transfer yes; a new chest-pain resident no |
| Right person | Am I trained and competent for this resident? | Trained on the mechanical lift in use |
| Right direction | Are the instructions clear and complete? | 'Weigh before breakfast and report the number' |
| Right supervision | Is the nurse available to monitor and follow up? | Nurse on the unit to receive the report |
The CNA is responsible for accepting only tasks they are trained and competent to perform, asking when directions are unclear, doing the task exactly as assigned, and reporting results or concerns. A CNA must never "guess through" a task that could harm a resident.
A CNA also has the right and duty to refuse an unsafe or out-of-scope assignment — and refusing protects the resident, the CNA's certification, and the nurse's license. If a nurse delegates a task the CNA was never trained to perform, the correct response is to say so and ask for direction, not to attempt it. Performing a task outside scope can itself become a registry finding if a resident is harmed.
Watch the line between observing and interpreting: a CNA may measure and report a blood pressure, count and report a pulse, note that a resident's urine looks dark, or report that a resident 'feels hot,' but the CNA never names a diagnosis, decides a reading is 'fine,' or starts a treatment based on it. The data belongs to the CNA's eyes and hands; the judgment belongs to the nurse.
The Chain of Command
The chain of command is the route for moving concerns to the person with authority to act. The CNA reports to the charge nurse or assigned nurse first. If the concern is not addressed and the resident remains at risk, facility policy directs escalation to the supervisor, the director of nursing (DON), the administrator, and finally required external channels. For suspected abuse, neglect, exploitation, or misappropriation, use HHSC Complaint and Incident Intake (1-800-458-9858) within the Texas reporting timelines covered in section 2.4. Fear of conflict never justifies leaving a resident unsafe.
Use the chain of command for unclear orders, unsafe equipment, staffing concerns, family demands, privacy questions, and changes in condition. If a family member asks the CNA to give medication, change oxygen settings, remove a fall alarm, or take a resident outside without approval, the CNA politely declines and gets the nurse.
Scope Decision Aid
Work through these checks before acting on an unusual request:
- Am I trained and allowed to do this task? If no, stop and tell the nurse.
- Is it assigned by the nurse or care plan? If no, ask for direction first.
- Are the resident's condition and equipment safe for this task? If no, get help and report.
- Do I understand exactly what to do and what to report? If no, ask before starting.
- Did something change during care? If yes, stop if needed and report promptly.
A handful of tasks sit right at the boundary and are worth memorizing as 'nurse only' in the long-term-care setting: administering or setting up any medication (oral, topical, eye drops, or oxygen flow changes), inserting or removing urinary catheters or feeding tubes, sterile dressing changes, tube feedings, suctioning, giving injections, and starting or stopping any treatment. Some facilities train aides for select expanded tasks under specific certification, but the default exam answer assumes the standard CNA scope above.
When in doubt, the rule is simple: if the action requires nursing judgment about whether, when, or how much, it belongs to the nurse.
Scope items on the test usually include a tempting "helpful" action — giving a resident a spouse's pill, adjusting oxygen, interpreting a blood pressure, applying a medicated dressing, or reassuring family that a symptom is "normal." The correct answer is almost always to stay within role, keep the resident safe, and notify the nurse. Chain of command does not mean complaining to everyone; it means using the correct route so the authorized person can act, and documenting objectively: what you saw, heard, did, and reported.
Following scope is not about doing less — it is about doing exactly the right things and routing everything else to the person licensed to handle it.
A resident asks the CNA to give a pill from the bedside drawer because the nurse is busy, saying, "I take it every day." What should the CNA do?
The care plan requires two staff and a mechanical lift for a resident's transfers. The unit is busy and another aide says, "We can do it ourselves just this once." What is the best response?
While bathing a resident, the CNA notices new one-sided weakness and slurred speech. What should the CNA do?