Medical Record Documentation and Legal Aspects for CNAs and HHAs

Certified Nursing Assistants (CNAs) play a very important role in Long Term and Home Health care. CNAs work closely with their residents, giving personal care, listening to their life stories, and having access to private health care issues. CNAs are required to work closely with the Registered Nurses and the Licensed Practical Nurses, working within their scope of practice.

According to Florida State regulations, a nursing assistant means providing care and assisting persons with tasks relating to the activities of daily living. These include personal care, residents’ or patient rights, and documentation of nursing assistant services (Florida Legislature, 2009). When the laws are not obeyed, the CNA can be held liable and may lose their license to practice.

The Florida Statutes (Laws) are very specific about the role of the CNA in long-term and home health care. They can only work under the direct supervision of a licensed nurse. Direct supervision means the physical presence within the patient care unit of a healthcare facility or physical presence within a healthcare agency of a program instructor who assumes responsibility for the practice of the certified nursing assistant (Nurse Practice Act, 2009). All this means is that the certified nursing assistant cannot work alone or make any nursing decisions regarding resident care.

The Nurse Practice Act and Standards of Care define what the certified nursing assistant can and cannot do, even with supervision. The tasks associated with Activities of Daily Living (ADLs) are maintaining mobility, tasks regarding feeding, elimination, and information gathering (Nurse Practice Act, 2009). The information a CNA collects may be how much the resident has eaten, bowel movements, height and weight, temperature, pulse, and respirations. You must know what is normal and what must be reported to your nurse. As you can see, this information is very important to the nurse. You are the eyes and ears of the nurse you are working with. Just remember to stay within your guidelines (scope of practice) to ensure you will not get into legal trouble. All healthcare facilities have policy and procedure books readily available to the staff. CNAs should look at these books if there are any unanswered questions.

Standards of care explain what a nursing assistant should do, both legally and ethically. The nursing assistant must report any changes seen in their residents. For example, if the resident has lost or gained five pounds, it must be reported to the nurse. All facilities and home health care agencies have policy and procedure manual. It is the CNA’s duty to be familiar with these manuals. It is also the CNA’s duty to ask questions if they are not sure of the right thing to do. Unprofessional behavior is when the CNA does not follow the rules. This may include coming to work after drinking alcohol or using illegal drugs. You may not do harm, but you are still putting the resident at risk for harm because your judgment is impaired.

Ethics is the knowledge of right and wrong (Alvare, S., Fuzy, J., &Rymer, S., 2009). All residents and patients have the right to:

• Respect and dignity
• Privacy
• Confidentiality
• Freedom from abuse and neglect
• Control over their own money
• Have their personal property
• Know about their medical condition and treatments
• Choose their own doctor(s)
• Make decisions about their medical care

All residents and patients have the right to be respected and treated with dignity. Dignity affords the resident pride and self-respect (Webster’s New World College Dictionary, 2009). We must remember that your residents have been fully functional beings before getting frail and sick. They do not need to be talked to with “baby talk.” This is disrespectful not only to the resident but to the family as well.

Dignity is an important issue when working with residents and patients. Be sure to knock on the door before entering a room. Keeping the resident covered during care is very important. Think about how you would want to be treated. Maintaining privacy means pulling the curtain between beds and closing the curtains or blinds in the window.

Confidentiality is one of the most important issues in resident care. CNAs must keep private things private. You are not allowed to talk about anything to family and friends, only to your nurse and health care team. If you see a person in the grocery store and they ask about one of your residents, you cannot even say they are in your facility. HIPAA laws are very specific about privacy. You can be fined from $50,000 to $250,000 if you discuss your resident’s and/or patient’s private matters (HIPAA training, 2009).

It is very important to know what malpractice is and what can happen to the nursing assistant if malpractice is alleged. Malpractice is an injury to a person due to professional misconduct through negligence, carelessness, or lack of skill (Alvare, S., Fuzy, J., & Rymer, S., 2009). Malpractice is treating the residents poorly. It may be that the CNA did not feed someone, did not bathe someone, treated someone roughly, or did not speak to someone politely and with respect. You have to be aware of everything you do and say. The consequences of malpractice are that you personally can be sued, as well as the facility and the nursing department. If you lose your license, you will not be able to work in the nursing field again. Every facility does a screening background check, looking for abuse and negligence.

Abuse is a serious accusation and is never taken lightly. If you are accused of abuse, whether or not you are guilty, you are escorted off the premises. The abuse may not be intentional, but it is still abuse. The types of abuse include physical, verbal, sexual, psychological, and financial. Using restraints is also a form of abuse. It is easy to dupe older people, especially with their money and belongings. Never take money from your residents, even as a gift.

Physical abuse is obvious, with bruising and excessive skin tears. It is either intentional or not. This includes slapping, cutting, burning, pushing and shoving, restraining, or even rough handling (Alvare, S., Fuzy, J., & Rymer, S., 2009). This is a very serious offense. It is often difficult to take care of older people, and it is easy to lose your temper. Just make sure you do not take your ill feelings out on your residents.

Verbal abuse includes talking back, using offensive language, and using “baby talk.” It is demeaning to older people. Using offensive language makes the resident feel bad. Verbal abuse has no physical signs, but the effects can be felt for a long time.

Sexual abuse is another serious issue. Sexual abuse is unwanted sexual contact with an elder, including touching, sexual assault, and rape (Brayton & Purcell, 2009). Many times, the resident is unable to report the abuse, but physical signs are there. Sometimes, the residents will not report the abuse because they feel ashamed and humiliated. It is everyone’s duty to report suspicions of sexual abuse. Talk to your charge nurse as soon as you realize or suspect that abuse has occurred. If you do not report abuse, you can be held responsible along with the abuser.

Neglect is causing harm to the resident by NOT doing a needed task. Some things that may be considered as negligence include poor hygiene, not providing privacy, not feeding the resident, and soiled clothing. Neglect is as serious as any other kind of abuse.

Abandonment is when the CNA does not finish an assignment and/or leaves work early without attending to their resident’s needs. Older people depend on others to help them do their Activities of Daily Living.

Exploitation, another form of abuse, is when money or property is taken from the resident. Never take or ask for money. There have been cases of nursing assistants asking for a “loan.” This is illegal!

Legal documentation involves careful charting. The old saying “If it is not charted, it is not done” is very important. CNAs are usually responsible for charting on bathing, grooming, eating, elimination and mobility. Learning to chart the facts, just what you SEE, and not what you feel, is difficult.

If you have poor handwriting, then print. If it can not be read, it is not credible. Attorneys look at charting by the nursing staff. They consider the chart the most reliable source of information. So, be careful and prudent in what you are charting. And, do not ever chart an activity you have not completed. If you are asked to chart for someone else, do not do it! If this person continues to insist, tell your charge nurse. It is illegal to chart for someone else.

Never use abbreviations, even if you run out of room on the paper. In no way are you to make up your own abbreviations. Charts are legal documents. Everything you write can be used in a court of law. This is why it is so important to be honest, and to have no feelings interjected into your charting.

Let us do some charting:

Resident refused shower, reported to charge nurse. She looked like she did not want to take a shower, so I left the room.

Is this the right way to chart? The first half of the statement is written well, but the second part is not correct. Remember! Do not put your own thoughts and feelings into your charting. Just chart what you see, and what you do!

CNAs play a very important role in Long Term Care, and have access to private information about their residents. CNAs must work within their scope of practice and be mindful of the Nurse Practice Act. Ethics is treating the residents with respect and dignity. Dignity is an important issue. Residents must be covered during care and have privacy. The residents must have freedom from abuse, neglect and abandonment. Even if the alleged abuse is unintentional, it is still abuse. If the CNA works within the legal boundaries and takes good care of their residents in a dignified manner, the residents will be safe.

Alvare, S, Fuzy, J., & Rymer, S. (2009). Nursing assistant care. Albuquerque. Hartman Publishing, Inc.

Brayton & Purcell (2009). Seniors may become victims of sexual abuse. Retrieved December 15, 2009 from Elder-Abuse-Information.com.

Florida Legislature, 2009). Regulation of professions and occupations.

Hipaa Training, 2009). Retrieved December 17, 2009.

MQA (2009).Nurse practice act. Retrieved December 17, 2009.

Respect (2009)..In Merriam Webster on line dictionary. Retrieved December 17, 2009.