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Medicare hospice (42 CFR §418) requires physician certification of terminal prognosis of 6 months or less if the disease runs its normal course, and the patient elects to forgo curative treatment in favor of comfort. Palliative care addresses symptoms (pain, nausea, dyspnea) at any stage of serious illness and can be combined with curative therapy. Both include spiritual care. The CNA on a hospice case follows the plan of care from the hospice interdisciplinary team and focuses on comfort, dignity, and family support.

Cheyne-Stokes is a cyclic pattern of crescendo-decrescendo respirations alternating with apnea, common in the active dying phase. It is NOT an emergency in the dying patient and CPR is not appropriate if the resident has a DNR. Kussmaul (b) is deep rapid breathing in metabolic acidosis. Eupnea (a) is normal breathing. Apneustic (c) involves prolonged inspiration and is a brainstem sign — also not CPR-indicated in dying. The CNA reports changes to the nurse, positions for comfort, provides mouth care, and supports the family per 42 CFR §483.25(k) (end-of-life care).

Active dying signs include mottling (livedo reticularis from poor perfusion) starting in feet and progressing upward, cool/cyanotic extremities, decreased urine output, decreased LOC, Cheyne-Stokes respirations, 'death rattle' (oral secretions), and sometimes terminal restlessness. These are expected and the CNA's role is comfort care: repositioning gently, mouth care for dryness, clean linens, calm environment, and family presence. Improving signs (a, b, d) are not features of active dying. 42 CFR §483.25(k) addresses end-of-life care.

Pain in non-verbal residents is assessed by behavior: grimacing, moaning, guarding, restlessness, tachycardia, withdrawal. Validated tools include PAINAD (Pain Assessment in Advanced Dementia). The CNA must report observations promptly so the nurse can administer PRN comfort medications under 42 CFR §483.45 (pharmacy services). Assuming no pain (c) is harmful and a quality-of-care failure under 42 CFR §483.25. Stopping necessary care (a) like repositioning leads to pressure injuries. Telling the resident to relax (d) is dismissive of suffering.

POLST (CA Probate §4780 et seq.) is a physician/NP/PA-signed medical order that travels with the resident and is honored in all settings. DNR means no CPR. The CNA verifies the order, notifies the nurse, provides dignity (close eyes, smooth linens), and assists with post-mortem care after the nurse pronounces or contacts the physician. Initiating CPR against a valid DNR (a, d) violates resident rights under 42 CFR §483.10 and may constitute battery. Waiting passively without notifying the nurse (c) breaches duty. Facilities must follow valid advance directives.

Under CA Probate §4670 et seq., an Advance Health Care Directive (often called a living will) lets a competent adult state future care wishes and appoint a Durable Power of Attorney for Health Care (DPOA-HC). It applies when the resident loses decisional capacity. A POLST (Probate §4780) is a SIGNED MEDICAL ORDER reflecting current wishes for present care and is immediately actionable by any provider. The CNA must know if a resident has either, where to find them, and to follow them per 42 CFR §483.10(c)(6) (right to formulate advance directives).

Medicare hospice regulations (42 CFR §418.64) require hospice programs to provide bereavement services to the family/caregivers for at least 13 months following the patient's death. Bereavement services include counseling, support groups, and check-in calls. The CNA contributes by treating families with compassion before, during, and after death, sharing memories, and referring to the hospice social worker or chaplain. Acute hospitals, cosmetic clinics, and PT (a, b, d) do not typically provide structured long-term bereavement programs.

42 CFR §483.10(f)(11) protects the right to religious practice. The Anointing of the Sick (formerly Extreme Unction) is a sacrament administered by a Catholic priest, ideally while the resident is still conscious. The CNA's role: notify the nurse, contact the chaplain or family's priest urgently, ensure privacy and a calm environment, and prepare a small table with a white cloth, candle, and crucifix per Catholic tradition. The CNA does not perform the rite (b). Denying the rite (d) or delaying (c) violates rights and causes spiritual distress.

Many Buddhist traditions teach that the consciousness departs over hours and the body should not be disturbed during that time. The CNA respects the practice, notifies the nurse and administrator, coordinates with the family and mortuary, and accommodates where feasible (private room, do-not-disturb sign, delayed post-mortem care). Refusing outright (c, d) or rushing the body (a) violates religious/cultural rights under 42 CFR §483.10 and may cause profound family distress. The facility balances accommodation with reasonable public health requirements under 42 CFR §483.70.

Orthodox Jewish practice: the chevra kadisha (sacred burial society) performs tahara (ritual washing and shrouding); embalming is generally avoided; burial occurs as soon as possible, ideally within 24 hours. Muslim practice (c) is the opposite of cremation — ghusl (ritual washing) is performed and burial (not cremation) occurs as soon as possible, ideally within 24 hours. Catholic anointing (d) is performed by a priest, not family. Hindu practice (b) is typically cremation, not burial at sea. The CNA asks the family about specific practices rather than assuming.

Standard post-mortem care: supine, good body alignment, head slightly elevated on a pillow (to prevent facial discoloration from blood pooling), eyelids gently closed, dentures replaced before rigor mortis (begins ~2-4 hours after death), clean linens, and dignity maintained. Identify body per facility policy (usually two ID tags: wrist/ankle and outside of shroud or bag). Honor cultural practices first. Side-lying (b), prone (c), and fetal (d) are not standard and may impair dignity and identification. 42 CFR §483.10 protects dignity in all care, including post-mortem.

Title 22 CCR §72527 and 42 CFR §483.10(g) protect residents' property rights. Standard procedure: two staff members witness and inventory all personal items at death (or at admission), document on the personal property/valuables form, secure items, and release ONLY to the legally authorized representative (executor, next of kin per will or law) with a signed receipt. Taking items home (c), discarding (d), or redistributing (b) constitute theft, financial abuse under W&I §15610.30, and grounds for termination, criminal prosecution, and license revocation.

Elisabeth Kübler-Ross's five stages of grief are: Denial, Anger, Bargaining, Depression, Acceptance (DABDA). They are not linear — people may revisit stages, skip some, or experience them simultaneously. The CNA recognizes these as normal responses, listens nonjudgmentally, and reports prolonged or dangerous responses (suicidal statements, complete withdrawal) to the nurse. Each stage is honored as a coping mechanism, not pathology. 42 CFR §483.40 requires psychosocial support to meet each resident's behavioral health needs, including grief.

Therapeutic presence — quiet companionship, simple offers (tissues, water, a chair), and respectful silence — is more comforting than words. Touch (a hand on the shoulder) helps IF welcomed; ask first if uncertain about cultural norms. Avoid clichés ('they're in a better place', 'it's for the best') which dismiss grief. Forcing the spouse out (c) violates the right to be present. Medical lectures (d) increase distress. Avoidance (a) is emotional abandonment. 42 CFR §483.10 protects dignity for both residents and families.

Holding a hand at the resident's invitation is a humane, therapeutic gesture and within CNA scope when professional, non-sexual, and consensual. The CNA should always confirm consent ('Would you like me to hold your hand?'), respect cultural norms about touch (some cultures restrict opposite-sex touch outside care tasks), and document significant interactions. Touch that is sexualized, prolonged inappropriately, or unwanted is misconduct and may constitute abuse. Family presence (a) and physician orders (d) are not required for ordinary comforting touch under 42 CFR §483.10 (dignity).

Honoring cultural and religious rituals at end-of-life is protected under 42 CFR §483.10(f)(11). Many Mexican-American/Latinx families create a small altar (altar/ofrenda) with the Virgen de Guadalupe, photos, and candles. Most facilities prohibit open flames for fire safety, so the CNA offers a flameless LED candle — accommodating the tradition while preserving safety. Outright refusal (b, c) violates rights. Ignoring fire safety (a) endangers all residents and may violate Title 22 fire codes. Coordinate through the nurse and chaplain to integrate the ritual with the plan of care.

Under HSC §1337-1338 and Title 22 CCR §71835, a California CNA performs basic nursing services under the supervision of a licensed nurse: ADLs, vital signs, intake/output, ambulation, observation, and reporting. CNAs DO NOT administer injectable or oral medications (a Certified Medication Aide/CMA is a separate credential), do not perform sterile procedures, do not insert/remove catheters except as specifically delegated, do not perform initial admission nursing assessments, and do not give telephone/verbal orders. Working outside scope is grounds for CDPH discipline, civil liability, and possibly criminal practice without a license.

IV insertion is the practice of nursing (BPC §2725) and is outside California CNA scope under Title 22 CCR §71835. A CNA must refuse any task beyond scope, even if directed by a nurse — performing it could harm the resident and is grounds for CDPH certification revocation under HSC §1337.9 and possibly criminal charges for unlicensed practice. The CNA should refuse politely, document, and notify the charge nurse or supervisor. 'Helping' (d) by acting outside scope is unsafe. Delegating to another CNA (a) just shifts the violation.

Under 42 CFR §483.70(i) and Title 22 CCR §72543, facilities must maintain complete, accurate, accessible records on each resident. The medical record is a legal document. If care is not documented (or is documented late, falsely, or vaguely), it cannot be defended in court, audits, or surveys — and the facility/CNA may face citations, civil liability, and disciplinary action. CNAs must chart promptly, factually, in the resident's own words when quoted, and never document a task before performing it. Late entries are made as 'late entry' with current date/time.

HIPAA's minimum necessary standard (45 CFR §164.502(b)) requires covered entities to limit uses, disclosures, and requests for PHI to the minimum necessary to accomplish the intended purpose. A CNA accesses only the records of assigned residents and only the information needed to provide care. Browsing charts for non-assigned residents (c), looking up coworkers (b), or sharing with unauthorized friends/family (a) is a HIPAA violation, grounds for termination, and may carry civil penalties up to $50,000 per violation (max ~$1.5M/yr) and criminal penalties up to $250,000 and 10 years for malicious disclosure under 42 USC §1320d-6.

45 CFR §164.512 permits disclosure of PHI without individual authorization for specified public-interest purposes, including reports required by law (such as elder abuse reports under W&I §15630 and child abuse reports under PC §11166), public health activities, judicial proceedings, and law enforcement subject to limits. Social media posts (b) — even 'de-identified' — typically still constitute PHI disclosure and are HIPAA violations. Neighbor gossip (d) and journalist disclosures (c) are violations. Mandated reporting is both permitted under HIPAA and required under California law; the reporter's identity is also confidential.

Under HIPAA 45 CFR §164.524, individuals have the right to inspect and obtain a copy of their PHI maintained in a designated record set; covered entities generally must respond within 30 days (with one 30-day extension). The CNA must not deny the right (a) or hand out records on their own (d) — release is handled by medical records following identity verification, applicable fees (cost-based, reasonable; not arbitrary cash demands as in b), and any state-specific requirements. CNAs facilitate by acknowledging the request, telling the nurse, and explaining the process to the resident.

Any image or video that allows identification of a patient in a healthcare setting is PHI under HIPAA (45 CFR §160.103); posting without explicit written authorization violates 45 CFR §164.502. Civil penalties (42 USC §1320d-5) tier from $100 to over $50,000 per violation up to ~$1.9M per year per identical violation. Criminal penalties (42 USC §1320d-6) can reach $250,000 and 10 years imprisonment for wrongful disclosure with malicious intent. The CNA must delete, self-report, and cooperate with the privacy officer. Background appearance, post-hoc blurring, or manager approval do not cure the violation.

Informed consent under CA law (Probate §4670 et seq.; common-law Cobbs v. Grant) requires the provider to disclose the nature of the proposed treatment, material risks, benefits, and alternatives; the patient (or surrogate if patient lacks capacity) must have decisional capacity, understand the information, and agree voluntarily without coercion. The CNA does not obtain consent for medical treatments but ensures the resident's expressed wishes are respected and reported. A signature alone (d), unilateral family override (a), or assumed consent for 'routine' care (b) do not satisfy the legal standard.

42 CFR §483.10(c)(6) protects a resident's right to refuse treatment. A competent resident may refuse care; staff must honor the refusal, ensure the resident understands consequences (educated via the nurse/physician), document the refusal verbatim, and notify the nurse. Covert medication (b) is battery, fraud, and abuse — and often illegal absent specific physician orders and an established surrogate process. Force (d) is battery (PC §242). Threatening discharge (a) is coercion and may violate transfer/discharge protections under 42 CFR §483.15. CNAs do not administer medications regardless.

Under W&I §15630(b)(1)(A), in a long-term care facility, when physical abuse results in serious bodily injury, the mandated reporter must telephone local law enforcement IMMEDIATELY (and the ombudsman) and submit a written report within 2 hours. For physical abuse without serious bodily injury, the phone report is immediate/ASAP and written report within 24 hours. Other forms of abuse generally require report within 2 working days. HSC §1418.91 also requires the facility to report alleged abuse to CDPH within 24 hours. Supervisor approval is not required (a) and may not delay reporting.

W&I §15634 grants mandated and non-mandated reporters who report suspected elder/dependent adult abuse in good faith immunity from civil or criminal liability arising from the report, even if the report turns out to be unfounded. This protection encourages reporting without fear of retaliation. The reporter's identity is also confidential and may only be disclosed in limited circumstances. Conversely, FAILURE to report is a misdemeanor with up to 6 months jail and a $1,000 fine (or higher with great bodily injury/death) under W&I §15630(h).

CDPH Licensing & Certification, under HSC §1417 et seq., licenses skilled nursing facilities, intermediate care facilities, and similar providers, and certifies nurse assistants under HSC §1337. CDPH conducts annual surveys, investigates complaints under HSC §1420, issues citations (Class AA-A-B), and may suspend or revoke licenses. CDPH does not provide direct medical care (a), set Medicare rates (b — that is CMS), or run the Ombudsman (c — that is the CA Dept of Aging under the Older Americans Act). Anyone can file a CDPH complaint by phone, mail, or online and remain anonymous.

Labor Code §1102.5 prohibits employer retaliation against employees who disclose information to government or law enforcement agencies, or to a person with authority to investigate, where the employee reasonably believes the information discloses a violation of law. HSC §1432 specifically protects LTC workers who report quality-of-care concerns. Remedies include reinstatement, back pay, civil penalties (up to $10,000 per violation), and attorney's fees. Whether the complaint is ultimately sustained does not change protection; the test is the reporter's reasonable belief and good faith.

Penal Code §240 defines assault as an unlawful attempt, coupled with a present ability, to commit a violent injury on another. PC §242 defines battery as any willful and unlawful use of force or violence upon the person of another. Slapping, grabbing, or forcibly medicating a resident without consent can constitute battery. Threatening to hit (without contact) can be assault. No weapon is required (a). A CNA who commits assault or battery on a resident faces criminal prosecution, CDPH certification revocation under HSC §1337.9, immediate termination, and exclusion from federal healthcare programs.

Confining a resident against their will without medical justification, physician order, and informed consent is false imprisonment (civil and criminal tort) and unlawful restraint under federal nursing home regulations. Duration (c), door windows (d), or family approval (b) do not legalize unlawful confinement. The resident has the right to be free from restraints not required for medical symptoms. CDPH may issue immediate jeopardy citations; the CNA faces termination, certification revocation under HSC §1337.9, and possible criminal prosecution. Always use approved behavior plans and least restrictive interventions.

The common-law elements of negligence (California Civil Jury Instructions, CACI 400) are: (1) Duty — the CNA owes a duty of care to the resident; (2) Breach — the CNA failed to meet the standard of care expected of a reasonably prudent CNA; (3) Causation — the breach caused the harm; and (4) Damages — actual injury or loss. Failing to turn a resident leading to a pressure injury, dropping a resident during a one-person transfer, or not reporting a change in condition can all create negligence claims. Intent (d) is not required for negligence — recklessness is enough.

Civil cases are brought by private parties (the resident or family) seeking monetary damages or injunctions; the standard of proof is 'preponderance of the evidence' (more likely than not). Criminal cases are brought by the government (People of the State of California) seeking punishment such as fines, probation, or jail; the standard of proof is 'beyond a reasonable doubt.' The same act (e.g., striking a resident) can result in BOTH a civil suit (battery damages) and criminal prosecution (PC §242 battery). CDPH administrative action is a third, separate track.

Drug diversion endangers residents (under-medication, contamination, errors). The CNA must report suspicion to the charge nurse, administrator, or DON immediately. The facility is required to investigate, report losses of controlled substances to the DEA under 21 CFR §1301.76(b), notify the nurse's licensing board (BRN for an RN/LVN), and report to CDPH under HSC §1418.91. Confronting the coworker (a) compromises investigation. Waiting (b) risks resident harm. Inaction (c) violates the duty owed to ALL residents. Failure to report may also be misconduct under HSC §1337.9.

Under HSC §1337.3 and Title 22 CCR §71831, California CNA certification is renewed every 24 months. Renewal requires at least 48 hours of approved continuing education during the two-year period (with a minimum of 12 hours each year), most of which is provided as in-service by the SNF. The CNA must also have performed nursing-related services for pay within the previous 24 months. Failure to renew on time results in lapse; an expired CNA cannot work as a CNA. Falsifying CE records is grounds for certification denial or revocation.

Under HSC §1337.9 and §1338.5, CDPH performs a criminal background check (live scan fingerprints with DOJ and FBI) on every CNA applicant. Convictions for offenses such as elder/dependent adult abuse, sexual assault, child abuse, serious/violent felonies (PC §667.5(c), §1192.7(c)), or substantiated findings of abuse, neglect, or misappropriation of resident property generally bar certification. Some non-serious convictions allow a criminal record waiver if the applicant demonstrates rehabilitation. Speeding tickets, jaywalking, and unrelated minor misdemeanors are generally not disqualifying.

Title III of the ADA (42 USC §12181 et seq.) requires places of public accommodation, including healthcare facilities, to provide auxiliary aids and services (qualified interpreters, captioning, written materials) to ensure effective communication with persons with disabilities at no cost to the individual. Section 504 of the Rehabilitation Act extends similar requirements to entities receiving federal funds (Medicare/Medicaid). Charging (d), refusing (a), or waiting for a lawsuit (c) are unlawful. The CNA reports the request to the nurse/social worker to arrange the service promptly.

Under HSC §1420, ANY person may file a complaint with CDPH about conditions or care in a licensed facility. The complainant's identity is confidential by law and may remain anonymous. CDPH must investigate complaints (with statutory timelines for entry — generally on-site within 10 working days for non-immediate-jeopardy; within 24 hours for IJ). Retaliation against an employee, resident, or family member for filing a complaint is prohibited (HSC §1432, Labor Code §1102.5). Complaints may be submitted by phone, mail, or the CDPH website.

HSC §1276.65 (the staffing rule that succeeded §1276.5's earlier 3.2 standard, effective 2018) requires SNFs to provide a minimum of 3.5 direct-care nursing hours per resident day (NHPRD), with at least 2.4 hours of those provided by CNAs and the remainder by licensed nurses (RN/LVN). Title 22 CCR §71203 contains related staffing standards. The 160-hour CNA training requirement is HSC §1337(c)(2)/Title 22 CCR §71835 (CDPH approved, exceeds the 75-hour federal minimum under 42 CFR §483.152). Facilities cite for failing to meet staffing minimums.

Under Title 22 CCR §72527 and 42 CFR §483.10(c)(6), residents have the right to refuse treatment, including bathing, and to participate in scheduling. The CNA should respect the refusal, offer alternatives (partial bath, different time, different staff, shower vs. bath), explore the reason (pain, cold, fear, modesty, cultural), document the refusal verbatim, and notify the nurse. Forcing a bath (a) is battery. Skipping all hygiene (d) is neglect. Threats and coercion (b) violate dignity and the right to choose. The IDT may revise the bathing plan.

PC §11166(c) makes failure to report by a mandated reporter (PC §11165.7 lists CNAs and other health practitioners) a misdemeanor punishable by up to 6 months in county jail, a fine up to $1,000, or both. If the abuse or neglect resulted in death or great bodily injury, the penalty rises to up to 1 year in county jail and/or up to $5,000 fine. Mandated reporters must telephone a child protective agency immediately or as soon as practicably possible, followed by a written report within 36 hours. Good-faith reporters have civil and criminal immunity under PC §11172.

Title VI of the Civil Rights Act (42 USC §2000d) and 42 CFR §483.10(b)(3) require facilities receiving federal funds to provide meaningful language access. Best practice: use a QUALIFIED medical interpreter (in-person preferred, telephone or video acceptable), translate vital documents, and document interpreter ID and language for each encounter. Using minor children (a) is widely discouraged and may breach confidentiality. Machine translation (b) is unreliable for medical content. English-only (c) violates federal civil rights law and may trigger Office for Civil Rights enforcement.

Under HSC §1337.9 and 42 CFR §488.301/§483.156, CDPH maintains the Nurse Aide Registry. Substantiated findings of resident abuse, neglect, or misappropriation of resident property (theft) are entered on the registry permanently; the CNA cannot work in any Medicare/Medicaid certified nursing facility nationwide thereafter. Findings include physical/sexual/verbal abuse, financial exploitation, and willful neglect. The CNA receives notice and a right to a due-process hearing. Reporting abuse (d), complaining about staffing (c), and requesting ADA accommodations (b) are protected acts, not registry violations.

45 CFR §164.530 requires covered entities to implement administrative, physical, and technical safeguards to protect PHI from incidental disclosures. Discussing diagnoses (especially sensitive ones like HIV under 42 USC §300ff-25 and CA HSC §120975 confidentiality) in public spaces — elevators, hallways, breakrooms within earshot of others, or social media — is a violation. Status as a coworker (b) does not satisfy 'need to know' for unassigned residents. Resident absence (d) and elevator 'privacy' (a) are not defenses. The CNA self-reports and the privacy officer assesses breach notification under 45 CFR §164.404.

42 CFR §483.10(j) requires SNFs to provide a clear grievance policy, designate a grievance official, allow residents (and representatives) to voice grievances without discrimination or reprisal, investigate promptly, and provide a written decision. CA HSC §1599.2 reinforces resident bill of rights. The CNA forwards grievances, supports the resident, and never retaliates or discourages reporting (a, d). The resident may also contact the LTC Ombudsman, CDPH, or APS. Retaliation is grounds for citations and personnel action.

ADA Title I (42 USC §12112) and California's FEHA (Gov Code §12940(m)-(n)) require employers to engage in a timely, good-faith interactive process with employees who have known disabilities to identify reasonable accommodations (modified equipment, schedule changes, job restructuring) that allow the employee to perform essential job functions without undue hardship. Refusal (d), pay cut (a), or requiring the CNA to work through pain (b) violate disability rights laws and may also violate Cal/OSHA safe-patient-handling requirements (Labor Code §6403.5). The CNA may file with DFEH/CRD or EEOC.

A valid POLST/DNR (CA Probate §4780 et seq.) is a physician order that must be honored. Initiating CPR against a valid DNR is unwanted treatment, may constitute battery, and violates resident rights under 42 CFR §483.10(c)(6). The CNA's correct steps: do not begin CPR, summon the nurse immediately, provide privacy and dignity (clear bystanders, drape if needed), and follow facility post-arrest protocol (nurse pronouncement or physician notification, family notification, post-mortem care). Bystander pressure (d) does not override a valid medical order.

42 CFR §483.15(c) lists the only permissible reasons for involuntary transfer/discharge: (1) clinical needs cannot be met; (2) health no longer requires SNF services; (3) safety of others endangered; (4) health of others endangered; (5) non-payment after reasonable notice; and (6) facility closure. Filing complaints (b) is a PROTECTED activity (HSC §1432, 42 CFR §483.10(j)(4)); retaliatory discharge is unlawful and grounds for citation, civil penalties, and reinstatement. The resident has the right to 30-day written notice and to appeal to the state hearing office.

Title 22 CCR §72527 and the California Resident Bill of Rights (HSC §1599.74-§1599.84) preserve residents' rights to make personal choices, including legal alcohol use, unless contraindicated. The CNA's role: notify the nurse, verify there is no medical/medication contraindication and that facility policy allows, then permit the celebration with dignity. Unilateral confiscation (b) or blanket refusal (d) violate autonomy. Consuming alcohol with residents (c) is gross professional misconduct, grounds for termination and certification revocation under HSC §1337.9, and may constitute abuse if it impairs care.

HSC §1337(c)(2) and Title 22 CCR §71835 require California CNAs to complete a CDPH-approved Nurse Assistant Training Program totaling at least 160 hours: a minimum of 60 hours of classroom theory plus 100 hours of supervised clinical training in a long-term care facility. This exceeds the federal minimum of 75 hours under 42 CFR §483.152. Candidates must then pass the state competency examination (written/oral plus skills test administered by D&S Diversified Services), undergo a DOJ/FBI live scan, and submit the application before placement on the CA Nurse Aide Registry. Renewal is every 2 years (HSC §1337.3).