2.5 Scope of Practice, Delegation, and Chain of Command
Key Takeaways
- A CNA performs assigned, trained tasks under supervision and reports observations; the CNA does not assess, diagnose, prescribe, or change the care plan.
- Delegation requires clear instructions, proper training, safe circumstances, and nurse supervision.
- A CNA should question or refuse tasks outside scope and immediately report unsafe assignments or resident changes.
- The chain of command protects residents by moving concerns from CNA to nurse, supervisor, administration, and required reporting channels when needed.
Scope Keeps Care Safe
Scope of practice means the tasks a CNA may perform based on training, law, facility policy, and nurse delegation. A CNA provides direct personal care and basic nursing-related support. Common tasks include bathing, grooming, dressing, feeding assistance, toileting, positioning, transfers, ambulation assistance, vital signs, intake and output, weighing, making beds, observing changes, and reporting to the nurse.
A CNA does not assess, diagnose, prescribe, create a care plan, change a care plan, give clinical interpretations, take provider orders, or decide that a resident no longer needs a safety measure. A CNA does not perform sterile procedures, insert tubes, remove tubes, give injections, adjust medication doses, or decide to use a restraint. If a facility has special additional training for a task, the CNA still follows facility policy and nurse direction.
Delegation means a licensed nurse assigns a task to the CNA while keeping responsibility for nursing judgment and supervision. The CNA is responsible for accepting only tasks they are trained and competent to perform, asking questions when directions are unclear, doing the task as assigned, and reporting results or concerns. A CNA should never guess through a task that may harm a resident.
Safe delegation depends on the right task, right resident circumstances, right person, right directions, and right supervision. For example, taking a routine temperature may be appropriate. Taking a temperature and deciding whether to start a treatment plan is not. Assisting a stable resident with a care-planned transfer may be appropriate. Transferring a resident alone when the care plan requires two staff is not.
The chain of command is the route for reporting concerns. Usually, the CNA reports to the charge nurse or assigned nurse first. If the concern is not addressed and the resident remains at risk, follow facility policy to reach the supervisor, director of nursing, administrator, or required reporting channel. For suspected abuse, neglect, exploitation, or misappropriation, use facility and HHSC required reporting channels. Do not let fear of conflict keep a resident unsafe.
A CNA also uses the chain of command for unclear orders, unsafe equipment, staffing concerns, family demands, privacy concerns, and changes in condition. If a family member asks the CNA to do something outside the care plan, such as give medication, change oxygen settings, remove a fall alarm, or take the resident outside without approval, the CNA should politely decline and get the nurse.
CNA Scope Decision Aid
| Question | If yes | If no |
|---|---|---|
| Am I trained and allowed to do this task? | Continue to next question | Stop and tell the nurse |
| Is it assigned by the nurse or care plan? | Continue to next question | Ask for direction before acting |
| Are the resident's condition and equipment safe for this task? | Perform as directed | Get help and report the concern |
| Do I understand exactly what to do and what to report? | Complete the task and report results | Ask the nurse before starting |
| Did something change during care? | Stop if needed and report promptly | Finish and document per policy |
Scope questions on the exam often include a tempting helpful action. The CNA may want to give a resident a spouse's medication, adjust oxygen, interpret blood pressure, apply a medicated dressing, or promise a family member that a symptom is normal. The correct answer is usually 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 person with authority can act. Start with the nurse for routine care concerns. Move higher when the concern is serious, unresolved, or covered by required reporting procedures. Document only according to facility policy and keep the report objective: what you saw, heard, did, and reported.
A resident asks the CNA to give a pill from the bedside drawer because the nurse is busy. The resident says, I take it every day. What should the CNA do?
The care plan says a resident needs two staff and a mechanical lift for transfers. The unit is busy, and another aide says, We can do it by ourselves 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?