Patient Rights for CNAs and HHAs

What are rights, and what are patient rights? Rights are something that every human being has.  Rights protect the person in every aspect of life. For example, people have the right to be treated fairly at work and in the communities where they live. In this course, we examine patient rights.

Patient rights protect those who are ill and require medical care. All caregivers must be aware of patients' rights and respect them. Patient rights are not a nice idea that makes things better for the patient; they are the law. As with all laws, not following them can have serious consequences for those involved. Many areas are protected under the Patient’s Bill of Rights, which became law in 1999 (U.S. Office of Personnel Management [OPM], n.d.).

Some rights relate to patient care. For example, patients have the right to emergency care, the right to refuse care, and the right to make decisions about their end-of-life care (Torrey, 2024).

 Some patient rights are the responsibility of licensed staff, the doctors, and nurses. However, many patients' rights are the responsibility of the entire healthcare team, including certified Nursing Assistants (CNAs) and Home Health Aides (HHAs).

These include:

• The right to be treated with respect and dignity.
• The right to privacy (Hicks, 2024).
• The right to refuse treatment.
• The right to be free of abuse.

All patients have the right to be treated with respect and dignity. Patients cannot be treated differently based on their:

• Race, their background, or the country they come from.
• Age: young, middle-aged, or elderly.
• Sex, the gender that they identify with and live by.
• Military service.
• Their religious beliefs.
• Any other type of discrimination that is banned by federal, state, or local law. For example, a person with a disability cannot be discriminated against (Hicks, 2024).

What does it mean to treat a patient with dignity? It means treating each patient with kindness, respect, and acceptance. Working with a patient can either uphold their dignity or diminish it. How do we show that we are treating a patient with dignity? There are many ways to do this. One of the most important things is how we address the patient. Start with a polite introduction. “Good morning, Mr. Brown. My name is John. I’m a certified nursing assistant. I’m going to be helping you today.’ Refrain from using the patient’s first name unless they ask you to use it. If a patient asks you to use their first name, do so respectfully. Do not take this as a sign to become familiar with the patient. When you introduce yourself to the patient, state your name and title. Patients find it stressful when they cannot tell their caretakers apart. Patients have the right to know the role of each of their caretakers. The CNA or HHA should make sure that their name badge is visible to the patient.

Listen to what the patient has to say. Please give them your full attention. This shows the patient they are valued and their opinions are important. If you don’t fully understand what the patient is saying, repeat what you have heard and wait for their response. Do not use your personal phone when you are working with patients, making calls, or checking text messages. This includes the patient’s room, dining room, or activity area. Do not share your personal stories or complaints with patients. This can cause them anxiety and stress. In a work situation, the focus should always be on the patient and their needs. Do not embarrass a patient who has problems using technology. “You don’t know what an app is!” Instead, offer to help.

Healthcare workers need to know their workplace's policy on accepting gifts from patients. These rules are put in place to ensure that all patients receive equal treatment. Care is not based on a patient’s ability to give gifts to those caring for them.

Give each patient as much control as possible over their routine. This helps to maintain their dignity and sense of self-worth. Listen to and respect patients’ choices. Ask about their preferences, and help them fill out meal menus. A simple choice can make a big difference to a patient. For example, ask if they would like ice in their glass of water or what beverages they want. However, check with the nurse to make sure none of these are restricted for medical reasons.

It is easy to be kind and accept people we like and people who we see as being the same as us. It can be harder to show the same level of respect to people we see as different. They may be of a different race or speak a different language. They may come from a part of the world that we know very little about. Their customs may differ from ours, which can make us feel uncomfortable around them. How do we handle these situations?  Firstly, we admit that we have these feelings and then find a way to work around them. The bottom line to remember is that every patient deserves the same care. They have a legal right to be treated with respect and dignity.

If a caretaker has concerns about caring for a patient, they should talk with their supervisor and explain what their concern is. “I’ve never cared for a patient from a foreign country before. I’m not sure how to go about it.” “What if I say or do the wrong thing?” Caring for patients from different cultures should be a part of staff training. Suppose this is not part of the education offered at a facility. In that case, caretakers should inform management that this is something they need. It ensures they are providing good care to all patients.

Treating a patient with kindness can make a big difference. This writer had an outpatient procedure done a few years ago. The staff were good. But what I remember most was the nursing assistant asking, “Would you like a warm blanket?” Her kind gesture made all the difference.

Nursing homes and assisted living facilities are different from a regular hospital. Most residents are not there for a short period. They do not see themselves as patients. For the staff, it’s a place to go to work and leave after their shift is over. But for the residents, it’s their home. Caregivers should keep this in mind and consider how they’d like to be treated in their own home. For many people, moving to live in an assisted living facility or a nursing home is not a choice they welcome. It is often something they must do. Nursing home residents will frequently say the kindness of the staff is what is most important to them (Harris, 2023).

This right includes many areas. The patient has a right to privacy during bathing, toileting, and dressing. For many, a hospital stay can be the first time they have used a bedpan or bedside commode. It may be their first time using the toilet in front of a stranger or asking for assistance getting to the restroom.  Some basic actions on the part of the assistant can make this easier for the patient. Put a ‘do not disturb’ sign outside the patient’s door and draw the curtains around the bed. The care assistant can wait outside the curtain if the patient is safe to be alone. Give the patient the call light. These actions help to protect the patient’s right to privacy.

The patient’s right to privacy must also be respected during grooming and dressing. Patients can feel more vulnerable when they need help with personal care. Sometimes they may be too embarrassed or too timid to voice their concerns. The patient may prefer personal care assistance from an assistant of the same gender. Patient care can shape a patient's perception of their ability to recover from an illness (Skills for Health, 2024).

The right to privacy also includes the privacy of healthcare information. The Health Insurance Portability and Accountability Act (HIPAA) became law in 1996. Privacy is a key part of HIPAA. It enacted rules about sharing a patient’s healthcare information. These rules apply to all healthcare workers. Protected healthcare information can identify a patient. It has data about their health, illnesses, tests, and treatments they may have received. Protected healthcare information can be written in a patient’s chart. It can also be in an electronic record or discussed among healthcare staff (The HIPAA Journal, n.d.).

It is important that protected healthcare information is only shared when it is needed to:

• Provide patient care.
• Protect patient safety.
• Share with staff members who need to become familiar with a patient, such as a new admission to the facility.

Only the information needed to provide care for the patient is shared. For example, a CNA must know that a patient cannot bear weight on their right leg. However, they don’t need to know the patient’s liver biopsy results unless the results relate to the patient's care.

Angela, a Certified Nursing Assistant, gets on the elevator. Her friend Marcie asks, “Hey Angela, why are you so late going on break?” Angela says, “The patient in number 9 is something else. I couldn’t get out of her room this morning. She wanted one thing after another. She isn’t that sick. She had a knee replacement done. It put me behind with my other patients.” Angela was careful not to mention the patient’s name. However, one of the other people on the elevator was this patient’s niece, who knew that her aunt was staying in room number 9. She complained to the unit manager that Angela had publicly said negative things about her aunt. Angela was reprimanded for not respecting patient privacy. Although Angela did not mention the patient’s name, she provided ‘identifying information’ about the patient. Stating the patient’s room number, her health condition, and the fact that she had had knee surgery. This was information that the patient’s niece was able to recognize. Talking about a patient in a public area, such as an elevator, hallway, or cafeteria, should be avoided.

Social media is another area where patient privacy must be protected. It may be tempting to share stories online about where you work and situations you have dealt with. It may sound harmless and funny. Even if you don’t mention a patient’s name, the story you tell could give away the patient’s identity. Care must also be taken when posting pictures online, even if it’s just a fun picture of you and your coworkers. Before you post anything, carefully check what can be seen in the picture's background. Is there a patient or a family member visible in the background?  All staff should know and follow the facility's social media policy carefully (ANA Nursing Resource Hub, 2024). Posting information on social media about a patient can cause a healthcare worker to lose their job. They can also lose their certification. In serious cases, the healthcare worker can face legal charges (Alder, 2024).

If a CNA has concerns about a patient, they should inform the patient’s nurse. It may be something the CNA has seen or overheard. But do it in private. Find an office or a meeting room where it is possible to have a private conversation. Don’t talk about patients with coworkers. Even if you believe the person you share information with will keep it private. If information about a patient is not related to their care, it should not be discussed.

Suppose the patient tells the CNA they want to share something with them. But first, the CNA must promise they will tell no one else. In this case, the CNA must be careful. The patient has a legal right to privacy, but this right has certain limits. The CNA must report anything they are told that endangers a patient or someone else. The best response to the patient is, “Mr. Jones, I can’t promise you that. I don’t know what you’re going to tell me. But if there is someone that you don’t want to be told, then I can do that.” The patient may say, “Okay, but don’t tell my nephew.” The CNA can agree to this. They can talk with the nurse or unit manager if they need to share what the patient has told them. If the patient refuses unless the CNA promises to tell no one else, then the CNA must politely refuse. Even if the patient says, “I thought I could trust you.” The CNA needs to share this conversation with the nurse or unit manager, since they will need to follow up on it.

Most facilities are now using electronic patient records. These require the same level of care as paper charts. Healthcare workers know to put a patient’s chart back in the chart rack when they finish it. This care must also be taken with electronic records. Staff using electronic records must receive training in their use. This includes keeping the electronic record secure. Each healthcare worker who uses an electronic record will have their own password. A password should not be shared with anyone else. Electronic medical records have what is called an ‘audit log.’ This shows who logged into the system and when. The caretaker signs into the electronic record to document notes. Once they have completed their work, they log out of the electronic system. This closes the chart and prevents anyone else from reading the patient’s record. The healthcare worker must remember to take this step. Not logging out and leaving a chart open could lead to a HIPAA violation.

A patient has the right to refuse treatment. This means they can refuse any procedure, such as having their blood sugar checked. For example, the CNA must check the blood sugar levels of several patients and report them to the RN. However, one patient refuses to have her blood sugar checked. The nursing assistant tries to reason with her. “Ms. Jones, I need to do this so your nurse will know how much insulin to give you.’ But the patient refuses. The CNA is pressed for time, and the patient is confused and upset. Why won’t the patient cooperate? This is for their own good. They shouldn’t be able to say no to something that they need. If they don’t want to get better, why are they here? But the patient can say no. Even if the CNA doesn’t understand why, they must accept the patient’s right to refuse treatment. The nursing assistant pointed out to the patient why they needed to have their blood sugar checked, which is fine. However, the nursing assistant cannot tell the patient that they must have the test done, that they don’t have a choice, or that the CNA will just do it anyway. Instead, the nursing assistant should report what has happened to the RN. If the patient refuses a procedure, such as having a shower, the nursing assistant can also try to negotiate with the patient. “Mr. Kelly, I understand why you don’t want to shower now. You’ve had a busy morning with therapy. I can come back after lunch and see if you want to shower.”

Patients have the same rights regardless of the care setting. These settings include hospitals, rehabilitation facilities, assisted living facilities, nursing homes, and at-home care. In addition to the rights discussed above, patients have the right to be free from all forms of abuse.

Patient abuse can be defined as any harmful activity aimed at a patient. This abuse can take many forms:

• Physical abuse. This can include pushing, hitting, or kicking a patient.
• Sexual abuse. Forced or unwanted sexual contact.
• Emotional abuse. This can include verbal abuse, such as name-calling, threatening the patient, pestering, or annoying a patient.
• Patient neglect. The patient’s basic needs for care are not being met, such as assisting with toileting and bathing.
• Financial abuse. Taking financial advantage of the patient. Illegal or improper use of the patient’s money or property (Centers for Disease Control and Prevention [CDC], 2024).

All types of abuse can have serious effects on the patient. Physical abuse can result in patient injury or even death. Emotional abuse can lead to patient fear and anxiety.

A patient’s right to be free from abuse is protected under the law. The Elder Justice Act became law in 2010 (Administration for Community Living [ACL], 2024). It aims to protect older patients from abuse and neglect. It also puts in place immediate reporting of wrongdoing or suspected wrongdoing committed against residents in long-term care facilities (Mandated Reporter Training, 2023).

What does the term ‘mandated reporter” mean? It describes people who are required by law to report suspected or real abuse. This includes suspected or real abuse towards children, older people, and those who are dependent on others for help (Childers, 2024).

CNAs and HHAs are mandatory reporters in all States with mandatory reporting laws. This means that they must report abuse or suspected abuse of a patient. In California, healthcare workers, including CNAs, must immediately report possible abuse of a patient. They must also do a written follow-up report before the end of two working days. In Louisiana, healthcare workers must report abuse using the State hotline at (1-855-452-5437). A written report must be submitted within five days (Nurse Groups, n.d.). Each healthcare provider must understand the mandatory reporting requirements in the state where they work!

Reporting incidents of possible or real abuse can be stressful. No one wants to tell on a coworker. A nursing assistant can tell themselves, ‘if I can see what is going on, so can the nurses and the therapist. Taking care of this problem is above my pay grade.’ Let the nurses do it. They earn the big money.’ Thinking this way may make living with what is happening easier, but it is wrong. There are fines and penalties for mandated reporters who do not report what they are seeing. Abuse is a serious problem. A study on elder abuse showed that around 17% of CNAs surveyed had taken part in or seen the physical abuse of patients. Another reason why CNAs don’t report abuse is fear of consequences. Will they get their employer in trouble? Will they lose their job? A CNA cannot be fired for reporting abuse(Nurse Groups, n.d.).

It is not always easy to recognize abuse and to know the steps on how to report it. Many states now require training programs on mandated reporting for CNAs. For example, the state of Pennsylvania requires CNAs to have mandated reporter education. This education includes describing legal terms, interview skills, and documentation requirements. These training programs aim to give CNAs confidence in being mandated reporters. It also increases their ability to detect the less obvious signs of abuse (Nurse Groups, n.d.).

Many government agencies are involved in the care and protection of patients and nursing home residents. These include the Centers for Medicare and Medicaid (CMS). The ‘Omnibus Reconciliation Act’, passed in 1987, set new standards of care for nursing home residents. One important requirement of the act was training for nursing aides. New nursing aides must complete at least 75 hours of training and pass an ability assessment. A state registry is kept of all those who pass (Kelly, 1989).

Joe has been a certified nursing assistant in a long-term care facility for over ten years. He works evenings and nights and often picks up extra shifts. The facility is short-staffed. Joe complains that he is tired. Mr. Brown is an elderly patient who has been getting more confused over the past months. He sleeps during the day and is up wandering at night. Joe must take Mr. Brown back to his room several times most nights. Often, Mr. Brown doesn’t want to go to his room. He says that he wants to go home. If Joe has time to talk to Mr. Brown until he is willing to go back to his room, he does. But some nights it’s too busy for that. Joe sometimes shoves Mr. Brown back into his room or threatens to tie him up and lock him in the restroom. One of the other assistants overhears this and mentions to Joe that they don’t think he should treat Mr. Brown that way. Joe becomes angry. He responds that he didn’t want Mr. Brown to go outside. “Did you hear about the old guy upstate who froze to death?”

Two things are going on here: an action within an action. Joe wants to keep Mr. Brown safe. But shoving and threats are abuse. Does the second nursing assistant have a legal duty to report what is happening? Yes, they do.

Joe needs to see that what he is doing is wrong, even if he intends to keep the patient safe. Firstly, he needs to make sure that the staff and administration are aware of what is going on with Mr. Brown.  Mr. Brown’s daytime schedule needs to be looked at. He needs more activity and more out-of-room time, with a scheduled nap but not sleeping all day. Secondly, Joe needs to look at his own level of self-care. Caretaker burnout is real and can have damaging effects on how an employee acts. Some employers offer programs where employees can get confidential help. When they are available, these programs are free. They offer help with many issues, including anger control.

There are differences between a CNA and a home health aide (HHA). The main difference is that HHAs work in the client’s home. They provide one-on-one care in a setting that is familiar to the client. It’s important to remember that the person receiving at-home care does not usually see themselves as a ‘patient’. The HHA is going into the client’s home and territory. All that we have discussed about patient rights is still valid for the client receiving care at home, but there are others:

• HHAs should know all their agency's policies for providing client care.
• If they see several clients on the same day, each client’s paperwork should be put in a separate folder.
• Only bring the paperwork for that client into the home. The other files should be safely locked in the trunk of the HHA's car.
• If the HHA is using an electronic device to record patient care, open the file only for the current client when in their home. Do not open files for other clients.

These steps will all help to protect the client’s right to privacy. Also, the client should know when the HHA will arrive at their home. If the HHA is running late, they need to call the client and let them know. The HHA should arrive at the client’s home on time and leave on time. The HHA should have a cell phone provided by their agency for contacting clients; they should not use their personal cell phone. Changes to their routine can be stressful for the client. The HHA should do everything possible to maintain the client’s schedule.

In the client’s home, the HHA should ask permission from the client before sitting down. They can say, “Can I sit here to talk to you?” This shows respect for the client and that this is their home. The HHA should only enter the areas of the client’s home related to the care they provide. For example, they may need to go into the bathroom to help the patient shower. They may need to go into the client’s bedroom to help the patient pick out the clothes they want to wear. However, they should not open doors or go into other rooms that are not involved in their work. The HHA may only want to have a quick look around, and no one will know. Keep in mind that many homes have in-home security systems with cameras. You may have to explain to your employer why you were walking around a home office when you had no reason to be in there.

Do not make personal calls from the client’s home or talk with another client while you are there. If you must make a call, explain to the client that you must go to your car for a few moments, but you will be back.  If, for any reason, you must leave in the middle of the visit, follow your agency’s policy for handling this event.

Home care is usually less formal and more intimate than caring for a patient in a facility. The HHA may be one of the few people the client sees during the week, and they will look forward to the visit. Let the client see that you are happy to see them, smiling and chatting with them will uplift their spirits. Conversations between the HHA and the client should be about what the client wants to talk about. This could be about their hobbies, favorite TV shows, or grandchildren. If the client asks about the HHA's family, telling them who the important people are in their life is fine. However, there should be no unburdening of the HHA problems and concerns to the client. Also, do not discuss other clients, even in general terms. A client may ask, “Do you have more people to see today?” The HHA should reply in very general terms, such as “Yes, I have other clients to see today.” Then, turn the conversation back to the client's care.

The HHA should know the client’s health condition. If they notice any changes in the client, no matter how small, they must report this to their supervisor. It is important for the HHA to follow the client’s care plan and ask if there is something they are not clear about. If the client requests to do something that is not in their plan of care, such as going for a walk outside, the HHA must explain that this is an activity the client cannot safely do right now. The HHA should let their supervisor know about the client’s request. A physical therapist can check if the client can walk outdoors and what assistive equipment would help them (Freedom Care, n.d.).

Clients living in their own homes can be victims of abuse. This can be any form of abuse. For example, the HHA notices that items are missing from the patient’s home. She has been working with the client for several weeks, and they have a good relationship. “Miss Jones, I don’t see your pretty vase anymore,” The client looks sad, “My niece took it. She took a lot of pieces. She said I told her she could have them.” The client had told the HHA in the past that several pieces she had collected were quite old and valuable. The HHA is concerned for the client and worried that she may be the victim of financial abuse. She immediately reports this incident to her supervisor.

Not everyone’s home is the same. Part of respecting the client is how the HHA reacts to their home setting. Some homes are clean and neat, others are not. The HHA should be careful of their facial expression and body language. The client may feel embarrassed about the state of their home and is watchful of how the HHA is reacting. They may even apologize for “everything being in a mess.” The HHA shows caring and understanding in their words and actions. They can ask the client if they have looked into any services that might be able to help with housekeeping. If the client responds that they haven’t, the HHA can offer to mention this to their supervisor. There may be housekeeping services available to the client.

You are leaving a client's home, and the neighbor from across the street is waiting for you outside. “How is poor John doing today? I see you are coming three times a week now. Linda is so lucky to have you. Is she able to work full-time? I want to bring supper over one of these nights, but I’m afraid. John doesn’t have anything contagious, does he? Do you think he could swallow pasta? Do you like pasta?” You are hit by a series of rapid-fire questions you weren’t expecting. The golden rule is to say nothing. Once you answer one question, even something as innocent as “Do you like pasta?”, you will find yourself answering other questions. In the end, you will likely give away some of the client’s private health information without meaning to. The best approach is to say nothing and not make eye contact. Walk to your car. You are protecting your patient’s privacy. Contact your supervisor and let them know what happened as soon as you can.

Another problem the HHA may face is unexpected visitors showing up while they are with the client. If this happens, ask the person to remain outside. If the client can decide who they want to see, you can ask them. If not, call the client’s responsible family member and ask them. If you cannot contact the client’s partner or spouse, call your supervisor at the agency.

Healthcare workers need to safeguard the rights of patients. To do this, the CNA or HHA must understand what patient rights are and how those rights affect the care they give. Good care protects the patient’s privacy and is respectful and kind.

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