Framework for a
Comprehensive
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Table of
Contents |
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Introduction |
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Introduction
The
Occupational Safety and Health (OSH) Act of 1970 strives to "assure safe
and healthful working conditions for working men and women..." and
mandates that "each employer shall furnish to each of his employees
employment and a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious physical harm to his
employees."
Numerous
occupational health and safety hazards are potentially present throughout a
nursing home. Traditionally, the nursing home's focus of health care has been
oriented to the resident, but over the last few years there has been an
increased public awareness of the hazards facing nursing home workers. This
heightened awareness can provide an opportune time for developing a
comprehensive occupational health and safety program in the nursing home
which will promote recognition, evaluation and control of hazards found in
nursing homes.
Table 1: Occupational
injuries and illnesses data*
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Nursing home |
Private Industry |
|
Incidence rate of occupational injury and illness cases per 100
full-time workers (1994) |
16.8 |
8.4 |
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Incidence rate of lost workdays per 100 full-time nursing home
workers (1994) |
8.4 |
3.8 |
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Number of employees in the nursing home industry |
1,650,000 |
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* Source: Bureau of Labor
Statistics.1994
The
Occupational Safety and Health Administration (OSHA) sets
standards to protect employees' health and safety. OSHA develops and
publishes standards some of which are applicable to the nursing home
environment, and some of which may be applicable depending on the scope and
application of the work or duties to be performed by the employees. These
standards are recorded in the Code of Federal Regulations (CFR)(1). OSHA standards are specifically identified in the
Labor Department under 29 CFR, and are available from the Government Printing
Office (see Appendices A and B for ordering information). The
standards describe the exposure limits, required programs, and safety and
health requirements for OSHA compliance.
__________
Footnote(1) The 29 CFR Volumes are available at cost from the
U.S. Government Printing Office. See Appendices A and B of this document for
further information.
Purpose
This
document provides a framework for a comprehensive occupational health and
safety program in the nursing home setting. It can be used by nursing home
occupational health and safety professionals charged with the responsibility
of developing a health and safety program, or by those evaluating an existing
program. Once the framework of a comprehensive program is established, the
resources and references listed in the appendices can be helpful in meeting
any special needs, and in tailoring the program.
This
training and outreach document will serve, along with other available
reference materials, as a resource to assist employers in the nursing home
industry to reduce the number and severity of occupational injuries and
illnesses in their facilities through the development of a safety and health
program.
Examples
and statements presented in the reference material will not be the only means
of achieving the goal of a safe and healthful workplace. An employer who
wishes to further enhance his/her program may undertake additional measures
designed to reduce injuries and illnesses of the staff.
This
is a training resource document only and is not a substitute for any of the
provisions of the Occupational Safety and Health Act of 1970 or for any
standards issued by the U.S. Department of Labor's Occupational Safety and
Health Administration. This framework may be applicable to most nursing homes
because it is based on the many similarities in program needs for health and
safety in all types and sizes of nursing homes.
An effective safety and health program is comprised of many elements,
including management leadership and employee participation, workplace
analysis, accident and record analysis, hazard prevention and control,
emergency response, and safety and health training. These elements are
discussed briefly in the following paragraphs.
Program Elements
Management Leadership
and Employee Participation
Visible management leadership provides an essential foundation for an
effective health and safety program. Employee participation is also a vital
part of an effective safety and health program.
Top
management must demonstrate its commitment by following all safety rules and
giving visible support to the safety and health efforts of others. Management
should convey leadership which:
- Includes
commitment to provide safe and healthful work and working conditions in
the nursing home's mission statement, establishing this as an
organizational priority.
- Develops
clear goals for the health and safety program and an action plan for
meeting these goals.
- Ensures
that the goal and the action plan are communicated to all members of the
organization, so that all members of the organization understand the
results desired and the action plan for achieving them.
- Endorses
and supports the program by providing implementation tools such as
budget, information, personnel with assigned responsibility and adequate
expertise and authority, line accountability, and program review
procedures. (See Appendix C for Safety and Health Program
Assessment).
- Assigns
the responsibility for development and management of the comprehensive
program to a person or team with expertise in hazard recognition and
applicable OSHA requirements. Ensures that this person or team keeps or
has access to applicable OSHA standards at the facility and seeks
appropriate guidance information for interpretation of OSHA standards.
Also, ensures that this person or team has the authority to
order/purchase safety and health equipment.
- Ensures
that performance evaluations for all line managers and supervisors
include specific criteria relating to safety and health protection.
- Ensures
that the designated program manager protects all personnel in the
facility including employees of contractors, subcontractors, and
temporary employees. This person or team should also have the authority
to monitor contractor safety and health practices and have the authority
to stop contractor practices that expose contractor employees to
hazards. Management must also inform contractors and employees of
hazards present at the facility and encourage them to report hazards
that they may encounter or may result from their work at the facility.
- Establishes,
communicates, and enforces a disciplinary system that applies equally to
all employees (managers, supervisors, and staff) who break or disregard
safety rules, safe work practices, proper material handling and
emergency procedures.
Employee participation provides the means through which employees identity hazards, recommend and monitor
abatement, and otherwise participate in their own protection. Participation
in the decision making process empowers and motivates employees to actively
participate in achieving program objectives and goals.
Because
employees possess first-hand knowledge of the workplace, their input should
be a basic component of the health and safety program. The following
mechanisms can facilitate employee involvement:
- Designate
employees for assignments in the health and safety program, based on
employees' special interest and/or expertise.
- Ensure
that employees and their representatives are involved in the inspection
of the work area, and are permitted to observe the monitoring and that
they receive the results. Also, ensure that employees and their
representatives have right of access to information and that they
understand this right of access.
- Establish
a documented procedure that encourages employees to
promptly and accurately report complaints of hazards or discrimination,
unsafe work practices and occupational injuries and illness without fear
of reprisal.
- Ensure
that there there is documentation of employee
participation, for example, employee inspection reports, minutes of
employee-management or employee committee meetings.
- Provide
employees who have expressed health and safety suggestions or concerns
with a timely response or follow-up.
- Inform
employees about the provisions of the Occupational Safety and Health Act
of 1970.
OSHA
also requires the employers to post a Job Safety and Health Protection poster
(OSHA Publication 2203) in a conspicuous place where notices to employees are
customarily posted [29 CFR 1903.2].
Written Program
The
nursing home safety and health program should be in writing in order to be
effectively implemented and communicated.
The
written program must be tailored to the nursing home's mission and goals. It
should establish clear objectives and have an action plan. It should
communicate the nursing home health and safety policies, procedures and
protocols, and assign responsibility for the program. The written program
should be reviewed, updated, and revised as needed.
Multi-disciplinary Team(1) Approach
__________
Footnote(1) Note: Two recent decisions of the National Labor
Relations Board (NLRB) in the cases of Electromation
and Dupont have imposed certain limitations on an employer's role in
the formation and administration of employee participation programs such as
joint health and safety committees. In the wake of these two decisions, an
employer should ensure that it structures such programs to fit the safe
havens expressed therein by the NLRB.
A
multi-disciplinary or employee safety and health team approach is recommended
to meet the diverse and numerous needs of a comprehensive health and safety
program. The leader of this team must have expertise in occupational health
and safety with an understanding of occupational illnesses and injuries,
toxicology, epidemiology, ergonomics, and policy development sufficient to
recognize areas which require evaluation and control. The team leader must
also have management abilities in order to plan, develop and maintain an
effective program.
The
team should examine the conditions of the workplace to determine existing
hazards. Representatives of all jobs in the nursing home can contribute
valuable insights to the identification of the hazards. Many hazards can be
corrected with management and employees working together.
Depending upon the
expertise of the team members, however, it may be necessary to consult
outside experts to recommend controls for occupational safety and health
hazards.
Program Elements
Workplace Analysis
An effective, proactive safety and health program will seek to
identify and analyze all hazards.
Workplace
analysis describes how management will collect information on current and
potential hazards. It consists of a literature review, identification of
hazard categories, workplace surveys, and an analysis of trends. The purpose
of a workplace analysis is to recognize existing and potential hazards, to
identify employees at risk, and to establish and subsequently to evaluate the
control measures. The multi-disciplinary team should conduct the workplace
analysis.
Initially,
the workplace analysis will establish a baseline. Then it must become a
continuous and ongoing process to recognize, identify, and control
occupational hazards. The frequency of workplace analyses depends on the
specific characteristics of the hazards and the work environment.
The
workplace analysis may be performed on a specific area or problem or it may
be done on a regularly scheduled basis in an area where a hazard has been
identified. Workplace analyses also should be conducted when there are
changes in procedures, equipment, or processes.
Literature Review
To
facilitate the workplace analysis, a literature review may be helpful. This
review should include current publications that describe potential nursing
home hazards and effective control strategies. The review enables personnel
involved in the analysis to develop an understanding of potential hazards.
Identification of
Hazard Categories
Based
upon information gleaned from the literature, potential hazards can be
anticipated. Potential health and safety hazards in the nursing home
environment can be categorized as follows: biological, ergonomic, chemical,
environmental, mechanical, psychosocial, and physical (See Appendix D).
An inventory of these hazards should be maintained and used to develop and
manage appropriate programs and to anticipate potential emergency situations.
Worksite Surveys
With
a working knowledge of the potential health and safety hazards in the nursing
home environment, the next step is to perform a worksite survey, comprised of
a walkthrough survey, job hazard analysis and exposure monitoring.
The
purpose of the worksite survey is to identify and evaluate actual and
potential hazards in a specific workplace. OSHA recommends comprehensive
worksite surveys to establish safety and health hazard inventories. The
surveys should be updated periodically as expert understanding of hazards and
the methods of control in the nursing home change.
Walkthrough
Regular
site safety and health inspections, or walkthroughs, are recommended so that
new or previously unrecognized hazards and failures in hazard controls are
identified. A walkthrough of the worksite should begin with discussions with
the managerial staff, employees, and union representatives, when appropriate.
During this discussion, the leader of the group assigned to perform the
walkthrough should explain the process and purpose of the activity.
Departmental representatives should provide an explanation of activities and
present any departmental health or safety concerns. These discussions are
likely to reveal problems that are not easily detected by visual inspection
alone.
The
walkthrough is done by physically walking through the worksite and noting as
many hazards as possible. (Appendix D describes possible hazard categories) The walkthrough group members should
observe the work processes, methods and practices, engineering and
administrative controls in place and personal protective equipment used.
Checklists can be useful to facilitate a systematic and comprehensive survey
approach.
During
the walkthrough the survey team should ask the supervisors and employees to
ask any additional questions that may arise. Examples of questions that may
be helpful are as follows:
- Have
common safety or health problems been noticed among the workers?
- Do any
hazards exist that are not on the checklist?
- Do the
employees have any questions about occupational safety and health?
- Are there
any additional safety and health concerns or suggestions?
A
diagram of each department should be developed to include the number and
location of employees and the sources of potential exposure to hazards.
Hazard Analysis
When
indicated, a hazard analysis should be done after the walkthrough to further
assess the hazards of specific jobs, processes, and/or phases of work. A
hazard analysis is an orderly process for locating and evaluating hazards
that are most probable and have the severest consequences. This is
information essential for establishing effective control measures. The hazard
analysis involves selecting the jobs or processes to be analyzed, carefully
studying and recording each step, identifying existing or potential hazards
(both safety and health), and recommending changes to eliminate or reduce the
hazards. Recommendations following a hazard analysis could include, among
others, substitution of a less hazardous chemical, facility alterations,
equipment and materials selections, or redesign of the job tasks.
Ideally,
a hazard analysis should be conducted on all jobs or processes in all
departments and should consider the following:
- Frequency
of accidents or illnesses
- Potential
for injuries or illnesses
- Severity
of injuries or illnesses
- New or
altered equipment, processes or operations
To
be effective, a hazard analysis must be reviewed and updated periodically,
perhaps annually. If an accident, injury, or illness is associated with a
specific job or process, the hazard analysis should be reviewed immediately
to determine whether changes are needed.
Exposure Monitoring
When
the comprehensive work analysis identifies existing and potential health
hazards, exposure monitoring is used to evaluate the employee's level of
exposure. It is important to recognize that exposures must be measured while
work is occurring. There are several methods of monitoring occupational
exposures:
- Environmental
monitoring is a program of observation and measurement used to determine
levels of exposure to a specific substance in a worksite.
- Area
sampling monitoring is done by measuring the contaminants in the air of
the employee's work area.
- Personal
samples are used to measure air contaminants in the employee's breathing
zone.
- Biological
monitoring is the measurement of a chemical, its metabolite, or a
non-adverse biochemical effect in a person to assess exposure.
Program Elements
Accident and Record
Analysis
An effective program will analyze injury and illness records for
indications of sources and locations of hazards, and jobs that experience
higher numbers of injuries. By analyzing injury and illness trends over time,
patterns with common causes can be identified and prevented. In addition, an
effective recordkeeping program will provide for investigation of accidents
and "near miss" incidents, so that their causes, and the means for
their prevention, are identified.
OSHA 200 Log
The
OSH Act of 1970 requires employers with 11 or more employees to collect and
maintain injury and illness records for their own employees at each of their
establishments. The U.S. Department of Labor's publication, Recordkeeping
Guidelines for Occupational Injuries and Illness, is the OSHA document that
explains how cases are to recorded on the OSHA 200
log (See Appendix E). To correctly complete the OSHA 200 log,
employers must follow the guidelines carefully.
Every
OSHA recordable injury and illness must be recorded on an OSHA log 200 (or
equivalent) within six working days from the time the employer learns of the
injury or illness. This log is maintained on a calendar year basis and must
be retained for five years at the establishment.
Each
year the employer must post the annual summary of the previous calendar
year's occupational injuries and illnesses for the nursing home. Although the
summary is defined as a copy of the year's totals from the OSHA 200, it is,
for the most part, the right-hand side of the OSHA 200 (a dotted line divides
the OSHA 200). The employer must post the OSHA 200 Summary in a conspicuous
place or places where notices to employees are customarily placed. The
employer must post this by February 1 and it must must remain posted until at least March 1.
Recordable Injuries
and Illnesses
When
determining whether to record a case on the OSHA 200 log, noting that the
recordkeeping guidelines classify injuries and illnesses differently is
important.
- An
occupational injury is an injury such as a cut, puncture wound,
fracture, sprain or strain, which results from a work accident or from
an exposure involving a single incident in the work environment.
Injuries are always the result of instantaneous events.
- An
occupational illness is any abnormal condition or disorder, other than
one resulting from an occupational injury, caused by exposure to
environmental factors associated with employment .
An example is tuberculosis. Illnesses are always the result of
exposures over time.
- All
occupational deaths and nonfatal illnesses are recordable. Nonfatal
occupational injuries are recordable only if they involve one or more of
the following:
- loss of
consciousness
- restriction
of work or motion
- transfer
to another job
- medical treatment, beyond first aid.
Analysis of Trends
OSHA
recommends that injury and illness trends be analyzed over time, so that
patterns with common causes can be identified and prevented. Two procedures
for doing this are passive surveillance and active surveillance.
Passive Surveillance
Passive surveillance
utilizes existing data (i.e., OSHA 200 log) to describe past trends.
Documentation that is collected through recordkeeping provides data for
analysis of trends.
The
availability and access to these records will depend on the nursing home's
policy and log limitations such as access to employee's medical records. The
person accessing and reviewing these records must be cognizant of the
limitations of access to this, and all, information.
Active Surveillance
Active surveillance involves collecting data (i.e., laboratory data) that is not
currently documented. This surveillance creates data to describe current
trends and identify problem areas. The data can be obtained from sources such
as questionnaires, screening, or surveys. An example of this type of
surveillance is a symptom survey that could be given to employees in a
department with a suspected occupational hazard. This survey can be used with
other surveillance techniques to determine if a problem exists.
Special Recordkeeping
Issues
There
are several recordkeeping topics of special interest in the nursing home
environment. It is the recordkeeper's
responsibility to decide if the occupational injuries and illnesses meet the recordability criteria for entry on the log. These
special recording issues include:
- Bloodborne pathogen exposure incidents - typically,
occupational bloodborne pathogen exposure
incidents are classified as injuries since they are generally the result
of instantaneous events, for example, needlesticks,
blood splashes to mucous membranes, etc.
Medical treatment recommendations which make
exposure incidents recordable include:
The incident results in the administration or
recommendation of medical treatment beyond first aid, for example, gamma
globulin, hepatitis B immune globulin, hepatitis B vaccine, zidovudine, or other prescription medications, and/or the
incident results in a diagnosis of seroconversion.
- Another
special recordkeeping issue is the recordability
of employee exposures to tuberculosis (TB). An employee may have a
positive reaction to TB skin test (TB infection) or may become ill with
tuberculosis (TB disease). These cases would be recorded as illnesses
(column 7(c), respiratory agents due to toxic agents) because they are
the result of workplace exposures to TB-containing droplet nuclei over a
period of time.
A case of tuberculosis infection or disease
in a nursing home worker is presumed to be work related because the Centers
for Disease Control and Prevention has identified long-term care facilities
as high risk workplaces for exposure to tuberculosis. All documented TB
infections and TB diseases are recordable.
An exception to this presumption of
work-relatedness occurs when an employer has documentation that the employee
was infected before employment at the nursing home. For instance, if an
employee's pre-assignment TB skin test (within two weeks of his or her start
date) is read as "positive" the case does not need to be recorded
on the OSHA 200 log. This exception is allowed because it is unlikely that a
workplace exposure for the hiring facility would have caused the positive
test result in that time period. (The minimum incubation period for TB is 2
weeks to 3 months.)
If, however, the positive TB skin test
results occur more than two weeks from the employee's start date, the case is
presumed work-related and must be recorded on the OSHA 200 log. Additionally,
any subsequent evidence of TB infection or TB disease is recordable.
- Resident
handling - of special concern to nursing homes is the recordabilty of sprains and strains resulting from
resident handling. On the OSHA 200 log, these instantaneous events are
always recorded as injuries. Typical medical treatment provided for such
cases, which is considered medical treatment beyond first aid, involves
a recommendation of more than a single dose of prescription drugs, a
series (two or more) of physical therapy or chiropractic treatments, use
of splints or braces.
- Acts of
violence - Injuries resulting from acts of violence that are
work-related are generally recordable as injuries because they are the
result of instantaneous events. These cases are to be evaluated for recordability just like any other injury. Depending
on the injury to the employee, medical treatment, restricted time and
days away from work can vary significantly.
Temporary Employees
A
common practice in nursing homes is hiring temporary employees. Injuries and
illnesses experienced by temporary employees should be recorded on the Log of
the firm responsible for the daily direction of the temporary employee's
activities. A temporary employee works for an agency, but is usually
supervised on a day-to-day basis by the nursing home. If this holds true,
when one of these employees sustains a recordable injury or illness, it is to
be recorded on the OSHA 200 log of the nursing home where the injury or when
the illness occurred.
OSHA Form 101 or equivalent
A
supplementary form, OSHA form 101 (see Appendix E), must also be
completed when an OSHA recordable injury or illness occurs. This
supplementary record also must be completed within six working days from the
time that the employer learns of the work-related injury or illness. If
workers' compensation reports, such as the First Report of Injury, insurance
reports, or other reports contain the information required by the OSHA 101
form then they may be used as a substitute.
Incident or Accident Reports
Incident
or accident reports may be designed by the nursing home and may be used to
obtain information about the cause of accidents and "near miss"
incidents and to identify hazardous areas or practices. Supervisors should
complete an incident or accident report for each accident even when only a
minor injury or no injury occurs. Supervisors and employees must understand
the importance of completing these forms and their responsibility to do so.
Access to Employee Medical and Exposure Records
OSHA's Access to Employee Medical and Exposure
Records Standard, 29 CFR 1910.20, requires employers to maintain certain
employee medical and exposure records. The standard is limited to medical and
exposure records produced because of an employee's exposure to toxic
substances and harmful physical agents. Employees, or their designated
representatives, have a right to review their individual employee medical
records and records describing employee exposures. Access by other persons
(such as supervisors or other agency representatives) is prohibited.
Employee Medical Records
An
employee medical record is one concerning the health status of an employee,
which is made or maintained by a physician, registered nurse, or the health
care professional or technician. Each employee medical record must be
maintained for the duration of employment plus 30 years, unless a specific
occupational safety and health standard requires a different period. In addition,
the medical records of employees who have worked for less than one year for
the employer need not be retained if they are provided to the employee upon
the end of employment. Laboratory reports and worksheets need to be kept for
only one year. Examples of medical records are records concerning HIV/HBV
status and Mantoux skin testing for TB infection.
These records are considered confidential and access to them is strictly
limited.
Employee Exposure Records
An
employee exposure record is a record containing the information about
employee exposure, such as the following:
- Environmental
monitoring, specific sampling results, the collection methodology, a
description of the analytical and mathematical methods used, and a
summary of other background data relevant to interpretation of the
results obtained.
- Biological
monitoring results that directly assess the absorption of a hazard.
- Material
safety data sheets or a hazard inventory that describes chemicals and
identifies where and when they are used.
Each
employee exposure record must be maintained for at least 30 years, unless a
specific occupational safety and health standard requires a different period.
Confidentiality of Records
OSHA
is sensitive to the issue of personal privacy. While employee medical and
exposure records are subject to the strict confidentiality requirements of
the Access to Employee Medical and Exposure Records Standard, 29 CFR 1910.20,
the OSHA 200 log is not considered a medical record. The use of coded
personal identifiers on the OSHA 200 or the OSHA 101 form is not permissible.
All cases on the log must contain the employee's name.
Program Elements
Hazard Prevention and Control
Work force exposure to all current and potential hazards should be
prevented or controlled by using engineering controls wherever feasible and
appropriate, work practices and administrative controls, and personal
protective equipment.
Nursing
home policies and procedures should be written to describe the use of
appropriate methods of control such as engineering, work practice, and
administrative controls, and appropriate personal protective equipment. These
methods are sometimes organized into a "hierarchy of controls" to
indicate that some methods of controls are preferred over others.
Engineering Controls
Engineering
controls are the preferred method for controlling hazards in the nursing
home. Engineering controls involve physical changes to the work station,
equipment, facility, or any other relevant aspect of the work environment.
Some examples of engineering controls in nursing homes include using
electrically adjustable beds as a substitute for manually adjustable beds; needleless systems to prevent needlesticks,
puncture resistant sharps containers, resuscitation bags, and negative
pressure isolation rooms.
Another
example of an engineering control in the nursing home is the assist device.
Assist devices have been commonly used to reduce or eliminate forces on the
back and arm of the employee. (see Appendix F for
Identifying Risk Factors in Nursing Homes.) Assist devices also
contribute to comfort and security of the resident. An assist device can be
mechanical where human strength is supplemented with mechanical power, or a
device that improves posture, or a device that allows more people to assist.
The condition of the facility and the resident needs to be assessed in order
to select an appropriate assist device.
Nursing
personnel have been reluctant to use mechanical assist devices for a variety
of reasons such as: too time consuming to use the device; the resident was
fearful of the device; the device was broken or otherwise unsafe; the device
was not available or was stored too far away; the accessories for the lift
device, such as slings, were not available; and the staff was not adequately
trained to use the device. In most cases, reluctance to use assist devices
has been overcome with encouragement from management in the selection of
appropriate equipment, training, and adequate equipment maintenance.
Assist
devices that involve resident handling can be placed in several categories:
controls for lateral transfers; controls to move between sitting and
standing; controls to reposition; controls to transfer a resident; and
controls for toileting and bathing.
Controls for lateral transfers involve transferring a resident from one
horizontal position to another horizontal position (e.g., bed to gurney).
Examples of this type of controls include: lift sheets; roller board/roller
mat; slide board; flat gurneys with transfer aids; transfer mats;
Controls to move between sitting and standing include chairs that lift; lift
cushions; gait belts or walking belts with handles; wheelchairs with
removable armrests; resident transfer slings; pivot discs; and sit/stand hoists.
To use these controls, the resident must be cooperative and be able to bear
weight.
Controls to reposition include slide boards; hand blocks; push up
bars; and trapezes. To use these controls, resident must have upper body
strength.
Controls to transfer a resident include a variety of hoists to lift the
resident. The hoists are activated with a hand pump or crank. These controls
are used when the resident is heavy, not cooperative, or cannot bear weight.
A device that can be used with the hoists is a ramp or hoist scale. This
device eliminates the need to transfer the resident to/from a scale.
Controls for toileting and bathing include hip lifters; bath boards;
toileting/shower chairs; shower carts; and height adjustable baths.
Assist
devices need to be stored and in some cases the batteries recharged. The
storage area should be located within close proximity to the resident
handling tasks. The assist device and accessories need to be inspected
periodically to ensure they are in good working order. Equipment that is in
need of repair should be tagged as out of service.
Moving
a resident, either manually or with an assist device, requires space.
Particular attention needs to be given to the toilet, bathing area, and area
around the bed. There are codes that govern the requirements for room
dimensions, doorways, and halls.
Engineering
controls also involve other changes in the nursing home facility including
floor, lighting, work surfaces and shower facilities.
Floors
need to be even, so that the assist devices can be rolled without suddenly
stopping or getting stuck. Floors around the bed, toilet and bathing area
need to be dry with a non-slip surface.
Lighting
in the halls needs to be bright enough to allow employees to see tripping
hazards and obstacles. At night employees should have easy access to
flashlights for entrance into dark rooms.
Work
surfaces should be adjustable, so that the hands are near waist height. Jobs
that require an employee to stand in one place for one hour or more should
have anti-fatigue mats.
Changes
to shower facilities may also be needed. Appropriate shower rooms are needed
to accommodate shower chairs and carts.
Work Practice Controls
Work
practice controls, another preferred control method, reduces the likelihood
of exposure to occupational hazards by altering the manner in which a task is
performed. An example of a work practice control is prohibiting the recapping
of needles by a two-handed technique, hand washing when gloves are removed or
as soon as possible after contact with body fluids, and restricting eating,
drinking, smoking, etc. in areas where infectious materials are found.
Administrative Controls
Administrative
controls are procedures which significantly limit daily exposure by control
or manipulation of the work schedule or manner in which work is performed.
Administrative controls do not eliminate or limit the hazard. Consequently,
the controls must be consistently used and enforced. Examples of
administrative controls include good housekeeping policies that eliminate
obstacles from the work area and remove tripping hazards, providing adequate
rest between shifts, and lift teams trained to lift/transfer together with
enough people for the task.
Personal Protective Equipment
Personal
protective equipment is specialized clothing or equipment worn by an employee
for protection against a hazard. Personal protective equipment typically is
used when other engineering and work practice controls are not feasible or
until other controls can be implemented. Traditionally, personal protective
equipment serves as a supplement to minimize employee exposure, not as a
primary source of control. Examples of personal protective equipment include,
but are not limited to, rubber boots, gloves, gowns, face shields or masks,
and eye protection. Personal protective equipment must be accessible and
provided in appropriate sizes at no cost to the employee .
The employer also must ensure that protective equipment is properly used,
cleaned, laundered, repaired or replaced, as needed or discarded.
Medical Program
In
addition to other control measures listed under hazard prevention and
control, a medical program and maintenance of equipment and facilities are
also recommended.
An
effective safety and health program in the nursing home should include a
suitable medical program which should be appropriate for the size and nature
of the nursing home.
The
medical program should include medical surveillance, monitoring, removal and
reporting requirements which comply with OSHA standards.
Employees
must report early signs/symptoms of job-related injuries or illnesses and
receive appropriate treatment.
Maintenance
An
effective safety and health program in the nursing home will also provide for
facility and equipment maintenance, so that hazardous breakdowns are
prevented. A preventive maintenance schedule should be implemented for areas
in the nursing home where it is most needed under normal circumstances. All
manufacturers' and industry recommendations and consensus standards for
maintenance frequency should be compiled with. In addition, repairs for
safety-related items should be expedited and safety device checks should be
documented.
Program Elements
Emergency Response
There should be appropriate planning, training/drills, and equipment
for response to emergencies. In addition, first aid/emergency care from
trained staff should be readily available to minimize harm if an injury or
illness occurs.
Planning
and preparing for emergencies are essential parts of the safety and health
program. All employees should know exactly what they must do in each type of
emergency situation. It is important that nursing homes plan and prepare for
emergencies, including weather and fire, [29 CFR 1910.38] and emergency
response operations to handle releases of hazardous substances [29 CFR
1910.120]. Training drills are needed so that in crisis situations the
responses become automatic. Appropriate alarm systems must be installed to
notify employees of an emergency.
Emergency
response plans for dealing with hazardous substances should be prepared by
persons with specific training. Planning must extend to how to handle spills
and incidents involving chemicals in routine use, including cleaning supplies
and disinfectants. Adequate supplies of spill control and personal protective
equipment appropriate to the particular hazards onsite must be available. In
some cases the employer's plan for dealing with hazardous chemical spills may
be to evacuate and call the fire department or other hazardous materials
organization.
Program Elements
Safety and Health Training
Safety and health training should cover the safety and health
responsibilities of all personnel who work at the nursing home. It is most
effective when it is incorporated into other training about performance
requirements and job practices. It should include all subjects and areas
necessary to address the hazards in the nursing home.
OSHA
considers safety and health training vital to every workplace and it is an
important component of a comprehensive program. Training helps employees
develop the knowledge and skills they need to understand workplace hazards
and how to handle them in order to prevent or minimize their own exposure.
Before
training begins, be sure that the company policy clearly states the company's
commitment to health and safety and to the training program. This commitment
must include paid work time for training. The training should be in the
language that the employee understands and at a level of understanding
appropriate for the individuals being trained. Both management and employees
should be involved in the development and delivery of the program.
Documentation
of training must be maintained where such training is required by a standard.
OSHA requires that such documentation be available for review by compliance
officers in the event of an inspection. See Appendix G for examples of
standards applicable to the nursing home environment that require
documentation of training. Documentation of training assures that initial or
periodic training is accomplished within established time frames.
Identifying Training Needs
New
employees need to be trained not only to do the job, but also to recognize,
understand and avoid potential hazards to themselves and others in the
workplace. Contract workers also need training to recognize the hazards of
the workplace. Experienced workers will need training if new equipment is
installed or a process changes. Employees needing to wear personal protective
equipment and persons working in high risk situations will need special
training.
Periodic Safety and Health Training
Some
worksites experience fairly frequent occupational injuries and illnesses. At
such sites, it is especially important that employees receive periodic safety
and health training to refresh their memories and to teach new methods of
control. New training also may be necessary when OSHA or industry standards
require it or industry practices are revised.
One-on-one
training is often the most effective training method. The supervisor
periodically spends some time watching an individual employee work. Then the
supervisor meets with the employee to discuss safe work practices, bestow
credit for safe work, and provide additional instruction to counteract any
observed unsafe practices. One-on-one training is most effective when applied
to all employees under supervision and not just those with whom there appears
to be a problem. Positive feedback given for safe work practices is a very powerful
tool. It helps employees establish safe behavior patterns and recognizes and
thereby reinforces the desired behavior.
Evaluations
Evaluations
help to determine whether the training you have provided has achieved its
goal of improving your employees' safety performance. Some ways that one can
evaluate a training program include:
- Before
training begins, determine what areas need improvement by observing
employees and soliciting their opinions. When training ends, test for
improvement. Ask employees to explain their jobs' hazards, protective
measures, and test new skills and knowledge.
- Keep
track of employee attendance at training.
- At the
end of training, ask participants to rate the course and the trainer.
- Compare
pre- and post-training injury and accident rates, near misses and
percent safe behavior exhibited.
Sources of Assistance
Additional
help in developing training programs and identifying training resources can
often be obtained from insurance carriers, corporate staff, or personal
protective equipment suppliers. OSHA-funded consultation projects for small
business can also provide some resources for training.
Addresses
and telephone numbers for the consultation services in each state may be
obtained by calling the OSHA Regional Office (see Appendix I) or by
requesting OSHA publication 3047, Consultation Services for the Employer
(Appendix A).
Management Training
Managers,
such as the nursing home administrator, should receive training and education
to ensure continuing support and understanding of the safety and health
program. It is the managers' responsibility to communicate the programs goal
and objectives to their employees, as well as to assign safety and health
responsibilities and to hold subordinates accountable. In addition to the
general orientation training outlined below, management should receive
information from the safety and health committee about the current components
of the program, the program's effectiveness and recommendations for
improvements.
Supervisor Training
Supervisors
may need additional training in hazard detection, accident investigation, their role in ensuring maintenance of controls, emergency
response and use of personal protective equipment. Supervisors should
reinforce employee training through continual performance feedback, and
through enforcement of safe work practices.
Employee Training
Employees
must be trained so that they understand the hazards to which they may be
exposed and how to prevent harm to themselves and others from exposure to
these hazards. The Health Care Financing Administration (HCFA), under U.S.
Department of Health and Human Services (HHS), enforces the requirement for
nurse's aides to receive supervised training and competence evaluation in
order for the nursing home to receive Medicaid and Medicare funding. While
this training is mostly focused on delivery of resident care, the training
addresses issues that mesh with OSHA's concerns for
safety and health in the workplace. For instance, nurse aide training
includes body mechanics regarding lifting and transfer of residents,
infection control, techniques for addressing the unique needs and behaviors
of individuals with dementia (Alzheimer's and others), and dealing with
cognitively impaired residents.
After
initial work assignments are made, employees should receive a general
orientation on nursing home safety and health hazards and the elements of the
safety and health program and procedures. This general training should
include an explanation of the following:
- the
health and safety program, policies and procedures;
- relevant
safety and health regulations;
- hazardous
materials (including housekeeping or maintenance chemicals, oxygen, and
resident recreational supplies and materials) and how to handle, store,
manage and dispose of them;
- regulated
waste and infectious materials (including bloodborne
pathogens and tuberculosis) and how to handle, manage, and dispose of
them;
- electrical
safety and hazard prevention;
- walking
and working surfaces (including wet floors in kitchens or hallways);
- back-injury
prevention and other ergonomic issues (including resident lifting and
transfer, food handling, laundry and maintenance tasks);
- fire
prevention and protection;
- workplace
violence prevention (including avoiding injuries from residents);
- accident
and illness reporting procedures (including reporting unsafe conditions
such as frayed electrical, slippery floors from spills or malfunctioning
equipment, etc.);
- infection
control precautions;
- material
safety data sheets (MSDSs) and other
information resources for chemicals;
- disaster
preparedness and response; and
- job and hazard specific training (such as specific
procedures for lock-out or tag-out of machinery prior to maintenance or
repair work).
Regular Program
Review and Evaluation
With
all of the safety and health program elements in place, a formal program
review and evaluation should be completed to measure the achievement of
established goals and to evaluate program outcomes.
OSHA
recommends that program operations be reviewed at least annually to evaluate
their success in meeting stated goals.
Members
of the multi-disciplinary team, including employee representatives should
conduct the program review and evaluation. The program review and evaluation
should measure outcomes, such as the attainment of goals and objectives,
trend analysis, and program effectiveness. These outcomes can be evaluated by
using employee interviews and testing, and by observing work practices to
determine whether employees understand the health and safety policies, procedures,
and training. Program effectiveness also may be evaluated by observing both
overall and unit trends in occupational injuries and illnesses.
For
example, if one of the safety and health committee's goals is "to
complete the training for bloodborne pathogens
compliance for all exposed employees before (a certain date)," then the
program review and evaluation should measure the attainment of this goal. The
evaluation might include interviews with employees, a review of training
records, and a walkthrough of areas where exposed employees work to observe
implementation.
In
reviewing and evaluating the nursing home safety and health program, data
should be compiled from activities related to the worksite analysis, hazard
prevention and control, training and education, and recordkeeping. The
information gathered from this process should be communicated to all members
of the nursing home community, including senior management, through the
safety and health committee. The program review and evaluation should be used
to determine any program elements that need to be altered to continually
improve the overall effectiveness.
Conclusion
This
document provides a framework for a comprehensive occupational health and
safety program for the nursing home environment. This guide will be helpful
to personnel responsible for developing and evaluating a comprehensive
occupational health and safety program for the nursing home setting. The
management commitment and employee involvement and the program elements
described in this document are the foundation for a comprehensive program.
These components can be expanded on by using the references and resources in
the appendices.
The
development of an occupational health and safety program in the nursing home
setting is a challenging endeavor; but most importantly, a worthwhile one.
With time, commitment and resources a successful program can be developed.
Appendix A: Resources
The following is a list of some of the OSHA standards (Title 29 of the
Code of Federal Regulations), recommended programs, and resources applicable
to nursing homes. The list provides further sources of information that may
be helpful. The footnote numbers refer to the resource information listed in
Appendix B: Ordering Information.
Access to Medical and
Exposure Records
Access to Employee
Exposure and Medical Records 29 CFR 1910.20. In: Title 29 Code of Federal Regulations, Parts
1901.1 to 1910.999. July 1995. GPO Order No. 869-022-00111-6. $33.00.4
Access to Medical and
Exposure Records
(OSHA 3110).1
Asbestos
Asbestos Standards for
Construction (OSHA
3096).1
Asbestos Standards for
General Industry (OSHA
3095).1
Asbestos 29 CFR
1910.1001. In:
Title 29 Code of Federal Regulations, Parts 1910.1000 to End. July 1995.
GPO Order No. 869-022-00112-4. $21.00.4
Electrical Hazards
Control of Hazardous
Energy (Lockout/Tagout) (OSHA 3120).1
Controlling Electrical
Hazards (OSHA
3075). GPO Order No. 029-016-00126-3. $1.00.4
Electrical Protective
Devices 29 CFR 1910.137. In: Title 29 Code of Federal Regulations, Parts 1910.1 to 1910.999.
July 1995. GPO Order No. 369-022-00111-6. $33.00.4
Subpart S - Electrical
29 CFR 1910.301 to .399. In: Title 29 Code of Federal Regulations,
Parts 1910.1 to 1910.999. July 1995. GPO Order No. 869-022-00111-6.
$33.00.4
The Control of
Hazardous Energy (Lockout/Tagout) 29 CFR 1910.147. In: Title 29 Code of Federal
Regulations, Parts 1910.1 to 1910.999. July 1995. GPO Order No.
869-022-00111-6. $33.00.4
Emergency Response
Program
How to Prepare for
Workplace Emergencies (OSHA 3088).1
Subpart E - Means of
Egress 29 CFR 1910; Subpart L - Fire Protection 29
CFR 1910; Employee Emergency Plans and Fire Prevention Plans 29
CFR 1910.38; and Hazardous Waste Operations and Emergency Response
Standard 29 CFR 1910.120. In: Title 29 Code of Federal
Regulations, Parts 1910.1 to 1910.999. July 1995. GPO Order No.
869-022-00111-6. $33.00.4
Principal Emergency
Response and Preparedness Requirements in OSHA Standards and Guidance for
Safety and Health Programs (OSHA 3122). GPO Order No. 029-016-00136-1. $2.50.4
Ergonomics
Ergonomics Program
Management Guidelines For Meatpacking Plants (OSHA 3123).1
Ergonomics: The Study of Work (OSHA 3125). GPO Order No. 029-016-00124-7. $1.00.4
Glazner, Linda. "Shiftwork:
Its effects on workers." AAOHN Journal, 39(9).
Hales, Thomas R., and Bertsche, Patricia K. "Management of Upper Extremity
Cumulative Trauma Disorders." AAOHN Journal, 40(3):118-127, March
1992.
Formaldehyde
Formaldehyde Standard
29 CFR 1910.1048. In:
Title 29 Code of Federal Regulations, Parts 1910.1000 to End, July 1995.
GPO Order No. 869-022-00112-4, $21.00.4
Hazard Communication
Hazard Communication
Standard 29 CFR
1910.1200. In: Title 29 Code of Federal Regulations, Parts 1910.1000 to
End. July
1995. GPO Order No.
869-022-00112-4. $21.00.4
Hazard Communication - A
Compliance Kit. GPO Order No 029-016-00147-6. $18.00.4
Hazard Communication
Guidelines for Compliance. GPO Order No. 029-016-00127-1. $1.004
Chemical Hazard
Communication (OSHA
3084).1
Hazardous Waste
Program
Hazardous Waste and Emergency
Response (OSHA
3114).1
Hazardous Waste
Operations and Emergency Response Standard 29 CFR 1910.120. In: Title 29 Code of Federal
Regulations, Parts 1910.1 to 1910.999.
July 1995. GPO Order No.
869-022-00111-6. $33.00.4
Infectious Diseases
Occupational Exposure
to Bloodborne Pathogens Standard 29 CFR 1910.1030. In: Title 29 Code of Federal
Regulations, Parts 1910.1000 to End. July 1995. GPO Order No.
869-022-00112-4. $21.00.4
Bloodborne Facts, factsheets
provided by OSHA entitled, "Reporting Exposure Incidents;"
"Protect Yourself When Handling Sharps;" "Hepatitis B
Vaccination Protection for You;" and "Personal Protective Equipment
Cuts Risk;" and "Holding the line on Contamination."1
Occupational Exposure
to Bloodborne Pathogens and Long-Term Healthcare
Workers (OSHA
3131).1
Occupational Exposure
to Bloodborne Pathogens (OSHA 3127).1
Care Workers."
Division of Immunization, Center for Prevention Services.
[Note: The Centers for
Disease Control and Prevention publish a weekly report, called Morbidity
and Mortality Weekly Report (MMWR), which provides current information
about the status and control of infectious disease.]
_________. Centers for
Disease Control. "Protections Against Viral Hepatitis Recommendations of
the Immunization Practices Advisory Committee (ACIP)." MMWR 39(RR-2).
_________.
"Guidelines for Preventing the Transmission of Tuberculosis in
Health-Care Settings, with Special Focus on HIV-Related Issues." MMWR 39
(RR17),
Ionizing Radiation
Gauvin, J.P. "Radiation Protection
in Hospitals." In: W. Chaney and J. Schimer.
Essentials of
Ionizing Radiation 29 CFR 1910.96. In: Title
29 Code of Federal Regulations, Parts 1910.1 to 1910.999. July 1995. GPO
Order No. 869-0017-00109-1. $29.00.4
OSHA Information
OSHA Act (OSHA 2001).1
OSHA Publications and
Audiovisual Programs (OSHA 2019 ).1
All About OSHA (OSHA 2056 ).1
OSHA Act (Spanish) (OSHA 2069).1
OSHA Inspections (OSHA 2098).1
OSHA Poster (Spanish) (OSHA 2200).1
OSHA Poster (OSHA 2203).1
Employer Rights and Responsibilities Following an
OSHA Inspection (OSHA 3000).1
Employee Workplace Rights (OSHA 3021).1
Consultation Services
for the Employer
(OSHA 3047).1
Handbook for Small
Business (OSHA
2209). GPO Order No. 029-016-00144-1. $4.00.4
OSHA Regulations,
Documents and Technical Information on CD-ROM. GPO Order No. 729-13-00000-5. $79.00 annually
(4 discs quarterly). $28.00 for a single copy.4
Respiratory Protection
Personal Protective
Equipment (OSHA
3077).1
Respiratory Protection 29 CFR 1910.134. In: Title
29 Code of Federal Regulations, Parts 1910.1 to 1910.999. June 1995. GPO
Order No. 869-022-00111-6. $33.00.1
Respiratory Protection (OSHA 3079).1
Recordkeeping
Recording and
Reporting Occupational Injuries and Illnesses 29 CFR 1904. In: Title 29 Code of Federal
Regulations, Parts 1901.1 to 1910.1 to 1910.999. July 1995. GPO Order No.
869-017-00109. $29.00.4
Recordkeeping
Guidelines for Occupational Injuries and Illnesses. GPO Order No. 029-016-00165-4.
$6.004
Training
Training Requirements
in OSHA Standards and Training Guidelines (OSHA 2254). GPO Order No. 029-016-00137-9.
$4.25.4
Worksite Analysis
Job Hazard Analysis (OSHA 3071). GPO Order No.
029-016-00142-5. $1.00.4
Workplace Violence
Guidelines for
Preventing Workplace Violence for Healthcare and Social Service Workers (OSHA 3148). GPO Order No.
029-016-00172-7. $3.254
Other Resources
Center for Healthcare
Environmental Managers. Healthcare Hazardous Materials Management.
Finkle, B.S.; Blank, R.V,; and Walsh, J.M. Technical, Scientific, and
Procedural Issues of Employee Drug Testing.
Appendix B: Ordering
Information
1U.S. Department of Labor - OSHA
Publications Office, Room N3101
200 Constitution Ave., NW
Telephone: (202) 219-4667
FAX: (202) 219-9266
2National Technical Information
Service (NTIS)
Telephone: (703) 487-4650
FAX: (703) 321-8547
3National Institute for
Occupational Safety and Health
Publication Dissemination, DSDTT
Telephone: (513) 533-8287
4Superintendent of Documents
Telephone: (202) 783-3238
5Technical
Centers for Disease Control and Prevention
6Centers for Disease Control and
Division of Viral Diseases
Appendix C: Safety and
Health Program Assessment Worksheet; Program Evaluation Profile
OSHA
Form 33 (Safety and Health Program Assessment Worksheet) is introduced
at the opening conference of the Consultation visit. It acquaints employers
and employee representatives with OSHA guidelines and its indicators
graphically provide a score of each main program element. This allows the
employer and the consultant to visualize the employer's status in meeting
each of these elements. OSHA Form 33 serves to reinforce efforts employers
and their employees may have already made, and will suggest achievable next
steps in the facility's program improvement.
OSHA
-195 form (Program Evaluation Profile) is being piloted by OSHA
Compliance staff on assessing employer safety and health programs in general
industry workplaces. This form is a draft form and may be revised.
Safety and Health
Program Assessment Worksheet
|
Visit Number |
|
Employer |
|
|
Consultant |
|
Contact |
|
|
Open Conf Dt |
|
SIC Code |
|
Nr Emp In Ext |
|
|
Facility LWDI: |
|
TOTAL IR: |
|
|
Facility LWDI: |
|
TOTAL IR: |
|
|
I. MANAGEMENT LEADERSHIP AND EMPLOYEE
PARTICIPATION Comments: What
evidence helped identify/verify adequacy? What improvement action is
needed? |
|
A. Clear Worksite Safety and Health Policy |
1. (4) Workforce accepts, can explain, and fully understands,
S&H policy (3) Majority of
personnel can explain policy (2) Some personnel can
explain policy (1) There is a written
(or oral, where appropriate) policy (0) There is no policy |
|
Comments: |
|
|
B. Clear Goals and Objectives, Set and Communicated |
2. (4) Workforce involved in goal development, all personnel can
explain desired results and measures (3) Majority of
personnel can explain desired results and measures for achieving them (2) Some personnel can
explain desired results and measures for achieving them (1) There are written
(or oral, where appropriate) goals and objectives (0) There are no safety
and health goals and objectives |
|
Comments: |
|
|
C-1. Management Leadership |
3. (4) All personnel acknowledge that top management provides essential
safety and health leadership (3) Majority of
personnel see top management as active safety and health leaders and
participants (2) Top management is
visible through safety and health videos, training, and documents (1) Evidence exists
that top management is committed to safety and health (0) Safety and health
does not appear to be a top management priority |
|
Comments: |
|
|
C-2. Management Example |
4. (4) All personnel acknowledge that top management always sets positive
safety and health examples (3) Majority of
personnel credit top management for setting positive examples for safety
and health (2) Top management can
generally be seen modeling positive safety and health behavior (1) Evidence exists
that top management generally says and does the right things in support of
safety (0) Top management does
not appear to follow the basic safety and health rules set for others |
|
Comments: |
|
|
D. Employee Involvement |
5. (4) All personnel responsible for actively identifying and
resolving S&H issues (3) Majority of
personnel feel they have a positive impact on identifying and resolving
S&H issues (2) Some personnel feel
they have a positive impact on S&H (1) Employees generally
feel that their S&H input will be considered by supervision (0) Employee
involvement in safety and health issues is not encouraged or rewarded |
|
Comments: |
|
|
E. Assigned Safety and Health Responsibilities |
6. (4) All personnel
can explain what performance (including S&H) is expected of them (2) Some personnel can
explain what performance is expected of them (1) Performance
expectations, including S&H elements, are spelled out for all (0) Specific job
S&H responsibilities and performance expectations are generally unknown
or hard to find |
|
Comments: |
|
|
F. Authority and Resources for Safety and Health |
7. (4) All personnel believe they have the necessary authority and resources
to meet their responsibilities (3) Majority of
personnel believe they have the necessary authority and resources to do
their job (2) Authority and
resources are spelled out for all; but there is often a reluctance to use
them (1) Authority and resources
exists, but most are still controlled by supervisors (0) All authority and
resources come from supervisors and are not delegated |
|
Comments: |
|
|
G. Accountability |
8. (4) Safety and health performance for all is measured against goals,
clearly displayed , and rewarded (3) Personnel are held
accountable for safe performance with appropriate rewards and consequences (2) Accountability
systems are in place; but rewards & consequences do not always follow
performance (1) Personnel generally
held accountable, but consequences tend to be negative rather than positive (0) Accountability is
generally hit or miss and prompted by serious negative events |
|
Comments: |
|
|
H. Program Review (Quality Assurance) |
9. (4) In addition to a comprehensive review, a process is used
which drives continuous correction (3) A comprehensive
review is conducted at least annually and drives appropriate program
modification (2) A program review is
conducted, but does not appear to drive all necessary program changes (1) Changes in programs
are driven by events such as accidents or compliance activity (0) There is no
evidence of any program review process |
|
Comments: |
|
|
II. WORKPLACE ANALYSIS |
|
A-1. Hazard Identification (Expert Survey) |
10. (4) In addition to corrective action, regular expert surveys
result in updated hazard inventories (3) Comprehensive
expert surveys are conducted periodically and drive appropriate corrective
action (2) Comprehensive
expert surveys are conducted, but updates and corrective action sometimes
lag (1) Qualified safety or
health experts survey in response to accidents, complaints, or compliance
activity (0) There is no evidence
of any comprehensive expert hazard survey having been conducted |
|
Comments: |
|
|
A-2. Hazard Identification (Change Analysis) |
11. (4) Every planned/new facility, process, material, or equipment
is fully reviewed by competent personnel (3) A hazard review of
all planned/new facility, process, material, or equipment is conducted by
experts (2) Planned.new
facility, process, material, or equipment considered high hazard are
reviewed (1) Hazard reviews of
planned/new facility, process, material, or equipment are problem driven (0) No system or
requirement exists for hazard review of planned/new operations |
|
Comments: |
|
|
A-3. Hazard Identification (Job and Process Analysis) |
12. (4) Employees are involved in the development of current hazard
analysis on their jobs. (3) A current hazard
analysis exists for appropriate jobs and processes and is understood by
affected employees (2) A hazard analysis
program exists for appropriate jobs and processes and is understood by
affected employees (1) A hazard analysis
program exists; but few employees are involved and most are not aware of
results (0) There is no routine
hazard analysis system in place at this facility |
|
Comments: |
|
|
A-4. Hazard Identification (Self-Inspection) |
13. (4) Employees and supervisors are trained, conduct routine joint
inspections, and all items are corrected (3) All employees are
trained in inspection techniques and all routinely participate in workplace
inspections (2) Routine inspections
are conducted by selected personnel which drive appropriate corrective
action (1) An inspection
program exists; but few are employees involved and coverage and corrective
action are not complete (0) There is no routine
inspection program in place at this facility |
|
Comments: |
|
|
B. Hazard Reporting System |
14. (4) Employees are empowered to correct any hazards identified on
their own initiative (3) A comprehensive
system for gathering information exists; is positive, rewarding and
effective (2) A system exists for
hazard reporting; employees feel they can use it; but it may be slow to
respond (1) A system exists for
hazard reporting; but employees may find it unresponsive or be unclear on
its use (0) No hazard reporting
system exists and/or employees do not appear comfortable reporting hazards |
|
Comments: |
|
|
C. Accident/Incidents Investigation |
15. (4) All loss-producing incidents and "near misses" are
investigated for root cause with effective prevention (3) All OSHA-reportable
incidents are investigated and effective prevention is implemented (2) OSHA-reportable
incidents are generally investigated; cause identification/correction may
be inadequate (1) Some investigation
of incidents takes place, but root cause is seldom identified, correction
is spotty (0) Incidents are
either not investigated or investigation is limited to report writing
required for compliance |
|
Comments: |
|
|
D. Injury/Illness Analysis |
16. (4) All employees are fully aware of incident trends, causes,
and means of prevention (3) Trends fully
analyzed & displayed, common causes communicated, management ensures
prevention (2) Data is collected
and analyzed centrally, common causes communicated to concerned supervisors (1) Data is centrally
collected and analyzed; but not widely communicated for prevention (0) Little or no effort
is made to analyze data for trends, causes, and prevention |
|
Comments: |
|
|
III. HAZARD PREVENTION |
|
A. Timely Hazard Control |
17. (4) Hazard controls fully in place, known to workforce, with
concentration on engineering controls and reinforced/enforced safe work
procedures (3) Hazard controls
fully in place with priority to engineering controls, safe work procedures,
administrative controls, and personal protective equipment (in that order) (2) Hazard controls
fully in place; but order of priority variable (1) Hazard controls are
generally in place; but priority and completeness varies (0) Hazard control is
not considered complete, effective and appropriate in this workplace |
|
Comments: |
|
|
B. Facility/Equipment Maintenance |
18. (4) Operators are trained to recognize maintenance needs and
perform/order timely maintenance (3) An effective
preventive maintenance schedule is in place and applicable to all equipment (2) A preventive
maintenance schedule is in place and is usually followed except for higher
priorities (1) A preventive
maintenance schedule is in place; but is often allowed to slide (0) Little effort is
made to prepare for emergencies |
|
Comments: |
|
|
C-1. Emergency Planning and Preparation |
19. (4) All personnel know immediately how to respond as a result of
effective planning, training, and drills (3) Most employees have
a good understanding of responsibilities as a result of plans, training,
& drills (2) There is an
effective emergency response team; but others may be uncertain of their
responsibilities (1) There is an
effective emergency response plan; but training and drills are weak and
roles ma y be unclear (0) Little effort is
made to prepare for emergencies |
|
Comments: |
|
|
C-2. Emergency Planning and Preparation |
20. (4) Facility is fully equipped for emergencies, all systems and
equipment in place and regularly tested, all personnel know how to use
equipment and communicate during emergencies (3) Well equipped with appropriate
emergency phones and directions, most people know what to do (2) Emergency phones,
directions, and equipment in place; but only emergency teams know what to
do (1) Emergency phones,
directions, and equipment in place; but employees show little awareness (0) There is little
evidence of an effective effort at providing emergency equipment and
information |
|
Comments: |
|
|
D-1. Medical Surveillance Program (as required) |
21. (4) Occupational health providers available on-site, fully
involved in hazard identification and training (3) Occupational health
providers there when needed and generally involved in assessment and
training (2) Occupational health
providers are frequently consulted about significant health concerns (1) Occupational health
providers available; but normally concentrate on clinical issues (0) Occupational health
providers assistance is rarely requested or provided |
|
Comments: |
|
|
D-2. Medical Treatment Availability |
22. (4) Personnel fully trained in emergency medicine are always
available on-site (3) Personnel with
basic first aid skills are always available on-site and emergency care is
close by (2) Personnel with
basic first aid skills are usually available with community assistance
near-by (1) Either on-site or
near-by community aid is always available (0) On-site and/or
community aid can not be ensured at all times |
|
Comments: |
|
|
IV. SAFETY AND HEALTH TRAINING |
|
A. Employees learn hazards, how to protect themselves and others |
23. (4) Employees involved in hazard assessment, help develop and
deliver training, all are trained (3) Facility committed
to high quality employee hazard training, ensures all participate, regular
updates (2) Facility provides
legally required training, makes effort to include all personnel (1) Training is
provided when need is apparent, experienced personnel assumed to know
material (0) Facility depends on
experienced and informal peer training to meet needs |
|
Comments: |
|
|
B-1. Supervisors learn responsibilities and underlying reasons |
24. (4) All supervisors assist in worksite analysis, ensure physical
protections, reinforce training, enforce discipline, and can explain work procedures
(3) Most supervisors
assist in worksite analysis, ensure physical protections, reinforce
training, enforce discipline, and can explain work procedures (2) Supervisors have
received basic training, appear to understand and demonstrate importance of
worksite analysis, physical protections, training reinforcement,
discipline, knowledge of procedures (1) Supervisors make
reasonable effort to meet S&H responsibilities; but have limited
training (0) There is no formal
effort to train supervisors in safety and health responsibilities |
|
Comments: |
|
|
B-2. Managers learn safety and health program management |
25. (4) All managers have received formal training in S&H
management and demonstrate full understanding (3) All managers follow,
and can explain, their roles in S&H program management (2) Managers generally
show a good understanding of their S&H management role and usually
model it (1) Managers are
generally able to describe their S&H role; but often have trouble
modeling it (0) Managers generally
show little understanding of their S&H management responsibilities |
|
Comments: |
|
|
Safety & Health Program Element |
Possible
Score |
Actual Score |
|
Management Leadership |
36 |
|
|
Workplace Analysis |
28 |
|
|
Hazard Prevention and Control |
24 |
|
|
Safety and Health Training |
12 |
|
|
TOTALS |
100 |
|
|
PEP Program Evaluation Profile |
Management Leadership and Employee Participation |
Workplace Analysis |
Accident and Record Analysis |
Hazard Prevention and Control |
Emergency Response |
Safety and Health Training |
|
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Employer: Inspection No.: Date: CSHO ID: |
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Outstanding |
5 |
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5 |
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4 |
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4 |
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Basic |
3 |
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3 |
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Develop- |
2 |
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2 |
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Absent or Ineffective |
1 |
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1 |
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Score for element |
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Overall Score |
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OSHA-195 (3/96)
Appendix D:
Occupational Hazards by Location in the Nursing Home
Central supply
Biological/infectious wastes
Broken/malfunctioning equipment
Disinfectants/sterilizing agents
Ergonomic hazards: i.e., lifting, pushing/pulling
Latex allergy
Soaps, detergents
Corridors
Blocked or locked egress routes
Double door problems with travel paths
Loose electrical outlets
Loose safety rails
Slipping hazards from spills or broken or torn flooring
Environmental
Services
Biological/infectious wastes
Cleaners/solvents
Climbing
Disinfectants/glutaraldehyde
Electrical
Ergonomic hazards: i.e., lifting, pushing/pulling, twisting
Hazardous wastes
Latex allergy
Sharps (needles, broken glass, etc.)
Soaps/detergents
Wet surfaces
Food service
Ammonia, chlorine
Cleaners (equipment)
Cold/heat stress
Drain cleaners
Disinfectants
Electrical
Ergonomic hazards: i.e., lifting, pushing/pulling, twisting, awkward
positions
Egress hazards
Housekeeping
Lack of machine guards on food processing equipment
Latex allergy
Nonionizing radiation (microwaves)
Oven cleaners
Pesticides
Sanitation
Sharp objects: i.e., broken glass and dishes, knives, meat slicers
Soaps/detergents
Steam
Thermal burns
Wet floors/surfaces
Laboratory
Biological/infectious hazards
Latex allergy
Sharps: i.e., needles, lancets
Toxic chemicals: i.e., formaldehyde
Ventilation/hoods
Laundry
Biological/infectious hazards
Bleach
Detergents
Ergonomic hazards: i.e., pulling/pushing, lifting, folding, twisting
Egress hazards
Falls
Hazardous wastes
Heat stress
Latex allergy
Needle punctures
Unguarded belts and pulleys
Wet floors
Maintenance and
Engineering
Climbing
Cold/heat stress
Compressed gases
Confined space
Cylinder storage
Electrical
Ergonomic hazards: i.e., lifting, pulling
Flammable liquids
Hazardous wastes
Noise
Steam
Tools, machinery
Toxic/hazardous substances: i.e., asbestos, carbon monoxide, additives of
adhesives/paints, freons, solvents, water treatment
chemicals
Unguarded saws and grinders
Welding fumes
Office areas
Cleaning chemicals
Ergonomic hazards: i.e., static postures, repetitive motion
Trip hazards such as file drawers and electrical wires
Video display terminals
Patient care
Aerosolized medication
Aggression/violence
Biological/infectious hazards
Electrical
Ergonomic hazards: i.e., patient handling, lifting, pushing/pulling
Hazardous drugs
Latex allergy
Needle punctures
Radiation (x-rays)
Trip hazards
Wet floors
Pharmacy
Ergonomic hazards: i.e., static postures
Hazardous drugs
Latex allergy
Wet floors
Radiology
Biological/infectious hazards
Ergonomic hazards: i.e., patient handling, lifting, pulling
Latex allergy
Radiation - darkroom chemicals
Ventilation
Therapy services
Aggression/violence
Biological/infectious hazards
Ergonomic hazards: i.e., patient handling, lifting, pushing/pulling
Toxic substances from craft materials
Construction/Renovation
area
Climbing (where applicable)
Confined space
Electrical
Elevated work surfaces
Fall hazards
Indoor air quality
Noise
Toxic/hazardous substances: i.e., asbestos, solvents, paint additives
Trip hazards
Vibration hazards
Note: This list demonstrates the
variety of hazards that can be found in nursing homes and should be used as a
reference. It is not all inclusive. Stress can occur in any area and is not
included in the separate listings.
Appendix D
Hazard Categories of
Agents Found in the Nursing Home Setting.
|
Hazard Categories |
Definition |
Examples Found in the Nursing home Setting |
|
Biological/Infectious |
Agents, such as viruses, bacteria,
parasites, or fungi, which may be transmitted via contact with infected
patients or contaminated body secretions/fluids to other individuals ( |
Hepatitis B virus, hepatitis C virus, human
immunodeficiency virus (HIV) influenza tuberculosis methicillin-resistant staphylococcus aureus
(MRSA) vancomycin-resistant enterococci
(VRE) scabies,
lice |
|
Chemical |
Various forms of chemicals such as
medications, aerosols, vapors, particulates, and solutions, that are potentially toxic or irritating to a body
system ( |
Cleaning agents/solvents disinfectants/sterilizing
agents (bleach, glutaraldehyde) hazardous
drugs latex
allergy |
|
Environmental/ Mechanical |
"Factors encountered in the work
environment that cause or potentiate accidents,
injuries, strain, or discomfort" (Rogers, 1994, p.96). |
Tripping hazards (cords, hoses) unsafe/unguarded
equipment (wheelchair, bed, ladder, mixer) air
quality slippery
floors confined
spaces cluttered
or obstructed work areas/passageways |
|
Ergonomic |
"Ergonomics is the design or
modification of the workplace to match human characteristics and
capabilities" (Sluchak, 1992, p. 105). |
Patient handling lifting awkward
positions poor
lighting |
|
Physical |
Agents in the work environment that can
cause tissue trauma ( |
Aggression/violence (resulting from
resistive/combative patient or family member) cold/heat
stress electrical
shock fire radiation noise (engineering,
mechanical) sharps
(broken glass, needles, razors, kitchen equipment) |
|
Psychosocial |
"Factors and situations encountered
or associated with one's job or work environment that create or potentiate stress, emotional strain, and/or
interpersonal problems" (Rogers, 1994, p.96). |
Aggression/violence shift
work emotional
stress |
* This list should
serve as a reference only; it is not meant to be all inclusive.
Appendix E
Appendix E
SUPPLEMENTARY RECORD OF
OCCUPATIONAL
INJURIES AND ILLNESS
To
supplement the Log and Summary of Occupational Injuries and Illness (OSHA No.
200), each establishment must maintain a record of each recordable
occupational injury and illness. Worker's compensation, insurance, or other
reports are acceptable as records if they contain all facts listed below or
are supplemented to do so. If no suitable report is made for other purposes,
this form (OSHA No. 101) may be used or the necessary facts can be listed on
a separate plain sheet of paper. These records must also be available in the
establishment without delay and at reasonable times for examination by
representatives of the Department of Labor and the Department of Health and
Human Services, and States accorded jurisdiction under the Act. The records
must be maintained for a period of not less than five years following the end
of the calendar year to which they relate.
Such records must contain
at least the following facts:
1) About the
employer - name, mail address, and locations if different from
mail address
2) About the
injured or ill employee - name, social security number, home address,
age, sex, occupation, and department.
3) About the
accident or exposure to occupational illness - place of accident or
exposure, whether it was on employer's premises, what the employee was doing
when injured, and how the accident occurred.
4) About the occupational
injury or illness - description of the injury or illness, including
part of body affected, name of the object or substance which directly injured
the employee, and date of injury or diagnosis of illness.
5) Other -
name and address of physician, if hospitalized, name and address of hospital,
date of report, and name and position of person preparing the report.
SEE DEFINITIONS ON THE BACK OF OSHA FORM 200.
|
OMB DISCLOSURE STATEMENT We estimate that it will
take an average of 20 minutes to complete this form including time for
reviewing instructions; searching, gathering and maintaining the data
needed; and completing and reviewing the form. If you have any comments
regarding this estimate or any other aspect of this recordkeeping system,
send then to the Bureau of Labor Statistics, Division of Management Systems
(1220-0029), Washington, D.C. 20212 and to the Office of management and
Budget, Paperwork Reduction Project (1220-0029), Washington, D.C. 20503. |
Public
reporting burden for this collection of information is estimated to vary from
Instructions for OSHA
No. 200
I. Log and Summary of
Occupational Injuries and Illnesses
Each
employer who is subject to the recordkeeping requirements of the Occupational
Safety and Health Act of 1970 must maintain for each establishment a log of
all recordable occupational injuries and illnesses. This form (OSHA No. 200)
may be used for that purpose. A substitute for the OSHA No. 200 is acceptable
if it is as detailed, easily readable, and understandable as the OSHA No.
200.
Enter
each recordable case on the log within six (6) workdays after learning of its
occurrence. Although other records must be maintained at the establishment to
which they refer, it is possible to prepare and maintain the log at another
location, using data processing equipment if desired. If the log is prepared
elsewhere, a copy updated to within 45 calendar days must be present at all
times in the establishment.
Logs
must be maintained and retained for five (5) years following the end of the
calendar year to which they relate. Logs must be available (normally at the
establishment) for inspection and copying by representatives of the Department
of Labor, or the Department of Health and Human Services, or States accorded
jurisdiction under the Act. Access to the log is also provided to employees,
former employees and their representatives.
II. Changes in Extent
of or Outcome of Injury or Illness
If,
during the 5-year period the log must be retained, there is a change in an
extent and outcome of an injury or illness which affects entries in columns
1, 2, 6, 8, 9, or 13, the first entry should be lined out and a new entry
made. For example, if an injured employee at first required only medical
treatment but later lost workdays away from work, the check in column 6
should be lined out, and checks entered in columns 2 and 3 and the number of
lost workdays entered in column 4.
In
another example, if an employee with an occupational illness lost workdays,
returned to work, and then died of the illness, and entries in columns 9
through 12 should be lined out and the date of death entered in column 8.
The
entire entry for an injury or illness should be lined out if later found to
be nonrecordable. For example: an injury which is
later determined not to be work related, or which was initially through to
involve medical treatment but later was determined to have involved only
first aid.
III. Posting Requirements
A
copy of the totals and information following the fold line of the last page
for the year must be posted at each establishment in the place or places
where notices to employees are customarily posted. This copy must be posted
no later than February 1 and must remain in place until March 1.
Even
though there were no injuries or illnesses during the year, zeros must be
entered on the totals line, and the form posted.
The
person responsible for the annual summary totals shall certify
that the totals are true and completed by signing at the bottom of the form.
IV. Instructions for Completing Log and Summary of Occupational
Injuries and Illnesses
Column A - CASE OR FILE NUMBER. Self-explanatory.
Column B - DATE INJURY OR ONSET OF ILLNESS.
For
occupational injuries, enter the date of the work accident which resulted in
injury. For occupational illnesses, enter the date of initial diagnosis of
illness, or if absence from work occurred before diagnosis, enter the first
day of the absence attributable to the illness which was later diagnosed or
recognized.
Columns
C through F - Self explanatory.
Columns
1 and 8 - INJURY OR
ILLNESS-RELATED DEATHS. Self-explanatory.
Columns
2 and 9 - INJURIES OR
ILLNESSES WITH LOST WORKDAYS. Self-explanatory.
Any
injury which involves days away from work, or days of restricted work
activity, or both must be recorded since it always involves one or more of
the criteria for recordability.
Columns
3 and 10 - INJURIES OR ILLNESSES INVOLVING DAYS AWAY FROM WORK. Self-explanatory.
Columns
4 and 11 - LOST WORKDAYS--DAYS AWAY FROM WORK.
Enter
the number of workdays (consecutive or not) on which the employee would have
worked but could not because of occupational injury or illness. The number of
lost workdays should not include the day of injury or onset of illness or any
days on which the employee would not have worked even though able to work.
NOTE: For
employees not having a regularly scheduled shift, such as certain truck
drivers, construction workers, farm labor, casual labor, part-time employees,
etc., it may be necessary to estimate the number of lost workdays. Estimates
of lost workdays shall be based on prior work history of the employee AND
days worked by employees, not ill or injured, working in the department
and/or occupation of the ill or injured employee.
Columns
5 and 12 - LOST
WORKDAYS--DAYS OF RESTRICTED WORK ACTIVITY.
Enter
the number of workdays (consecutive or not) on which because of injury and
illness:
(1)
the employee was assigned to another job on a temporary basis, or
(2)
the employee worked at a permanent job less than full time, or
(3)
the employee worked at a permanently assigned job
but could not perform all duties normally connected with it.
The
number of lost workdays should not include the day of injury or onset of
illness or any days on which the employee would not have worked even though
able to work.
Columns
6 and 13 - INJURIES OR
ILLNESSES WITHOUT LOST WORKDAYS. Self-explanatory.
Columns 7a through 7g
- TYPE OF ILLNESS.
Enter a check in only one
column for each illness.
TERMINATION OR PERMANENT TRANSFER-Place an asterisk to the right of the entry
in columns 7a through 7g (type of illness) which represented a termination of
employment or permanent transfer.
V. Totals
Add
number of entries in columns 1 and 8.
Add
number of checks in columns 2, 3, 6, 7, 9, 10, and 13.
Add
number of days in columns 4, 5, 11, and 12.
Yearly
totals for each column (1-13) are required for posting. Running or page
totals may be generated at the discretion of the employer.
If
an employee's loss of workdays is continuing at the time the totals are
summarized, estimate that number of future workdays the employee will lose
and add that estimate to the workdays already lost and include this figure in
the annual totals. No further entries are to be made with respect to such
cases in the next year's log.
VI. Definitions
OCCUPATIONAL INJURY is any injury such as a cut, fracture, sprain, amputation, etc.,
which results from a work accident or from an exposure involving a single
incident in the work environment.
NOTE: Conditions
resulting from animal bites, such as insect or snake bites or from one-time
exposure to chemicals, are considered to be injuries.
OCCUPATIONAL ILLNESS of an employee is any abnormal condition or disorder, other than one
resulting from an occupational injury, caused by exposure to environmental
factors associated with employment. It includes acute and chronic illnesses
or diseases which may be caused by inhalation, absorption, ingestion, or
direct contact.
The
following listing gives the categories of occupational illnesses and
disorders that will be utilized for the purpose of classifying recordable
illnesses. For purposes of information, examples of each category are given.
These are typical examples, however, and are not to be considered the
complete listing of the types of illnesses and disorders that are to be
counted under each category.
7a. Occupational Skin Diseases or Disorders
Examples: Contact dermatitis, eczema, or rash caused by primary irritants and
sensitizers of poisonous plants; oil acne; chrome ulcers; chemical burns or
inflammations; etc.
7b. Dust Diseases of the Lungs (Pneumoconioses)
Examples: Silicosis, asbestosis and other asbestos-related diseases, coal
worker's pneumoconiosis, byssinosis, siderosis, and other pneumoconioses.
7c. Respiratory Conditions Due to Toxic Agents
Examples: Pneumonitis, pharyngitis,
rhinitis or acute congestion due to chemical, dusts, gases, or fumes;
farmer's lung; etc.
7d. Poisoning (Systemic Effect of Toxic Materials)
Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals;
poisoning by carbon monoxide, hydrogen sulfide, or other gases; poisoning by benzol, carbon tetrachloride, or other organic solvents;
poisoning by insecticide sprays such as parathion, lead arsenate; poisoning
by other chemicals such as formaldehyde, plastics, and resins; etc.
7e. Disorders Due to Physical Agents (Other than Toxic Materials)
Examples: Heatstroke, sunstroke, heat exhaustion, and other effects of
environmental heat; freezing, frostbite, and effects of exposure to low
temperatures; caisson disease; effects of ionizing radiation (isotopes,
X-rays, radium); effects of nonionizing radiation
(welding flash, ultraviolet rays, microwaves, sunburn); etc.
7f. Disorders Associated With Repeated Trauma
Examples: Noise-induced hearing loss; synovitis, tenosynovitis, and bursitis; Raynaud's
phenomena; and other conditions due to repeated motion, vibration, or
pressure.
7g. All Other Occupational Illnesses
Examples: Anthrax, brucellosis, infections hepatitis, malignant and benign
tumors, food poisoning, histoplasmosis, coccidioidomycosis, etc.
MEDICAL TREATMENT includes treatment (other than first aid) administered by a physician
or by registered professional personnel under the standing orders of a
physician. Medical treatment does NOT include first-aid treatment(one-time
treatment and subsequent observation of minor scratches, cuts, burns,
splinters, and so forth, which do not ordinarily require medical care) even
though provided by a physician or registered professional personnel.
ESTABLISHMENT: A single physical location where business is conducted or where
services or industrial operations are performed (for example: a factory, mill,
store, hotel, restaurant, movie theater, farm, ranch, bank, sales office,
warehouse, or central administrative office.) Where distinctly separate
activities are performed at a single physical location, such as construction
activities operated from the same physical location as a lumber yard, each
activity shall be treated as a separate establishment.
For
firms engaged in activities which may be physically dispersed, such as
agriculture; construction; transportation; communications; and electric, gas,
and sanitary services, records may be maintained at a place to which
employees report each day.
Records
for personnel who do not primarily report or work at a single establishment,
such as traveling salesman, technicians, engineers, etc., shall be maintained
at the location from which they are paid or the base from which personnel
operate to carry out their activities.
WORK ENVIRONMENT is comprised of the physical location, equipment, materials processed
or used, and the kinds of operations performed in the course of an employee's
work, whether on or off the employer's premises.
Appendix F: Identifying Risk Factors for Occupational Injuries and
Illnesses In Nursing Homes
Underlying
an incident or a trend of occupational injuries or illnesses are risk factors
that contribute to their occurrence or development. A combination of risk
factors rather than any single risk factor may be responsible. Prevention of
the work-related injury or illness may be accomplished by controlling
employee exposure to the workplace risk factors that can cause them. Through
observation, environmental monitoring, and discussions with the workers all
the risk factors which may be present in the job should be identified. Then
controls that will eliminate or reduce the identified risk factors can be
selected.
The
first step in identifying risk factors is to examine injury and illness
records to determine any trends with regard to occupation, nature of
disabling condition, part of the body affected, event or exposure causing the
injury or illness, and the source directly producing the disability.
Example: Suppose that an analysis of the OSHA 200 and associated workers'
compensation records for a nursing home show a trend of nursing assistants
with low back pain associated with lifting or transferring residents. Low
back pain is a musculoskeletal disorder.
Moving residents is not the same as lifting in most industrial jobs.
Variables such as distance, force required, frequency and coupling (good
place to grasp) do not stay constant. In addition, the resident may actively
resist being moved.
A. Potential risk factors for resident handling back injuries include:
Weight
Moving
a person who has limited ability to assist has caused low back pain and
disability among health care workers. There are many reasons why the injury
occurs including overexertion, fitness, skill, work conditions, resident
condition, and moves per shift to name a few variables. An adult resident who has a limited ability to assist with a
transfer or lift, weighs enough to cause a back injury to the worker.
Distance
Weight
is important, but increasing the distance between the lower back and the
hands has the effect of multiplying the weight moved by the back. Therefore,
factors that separate the worker from the resident contribute to back
injuries. Some factors would include but are not limited to the following:
- IV bag stands
- Bed rails
- Wheel chairs without
moveable arms
- Geri-chairs
- Furniture near the
bed.
Activity
Moving
a resident can bring together the elements of weight, distance and awkward
posture that result in a back injury. The most common activities associated
with back injury include but are not limited to the following:
- Moving a
totally dependent resident
- Moving a
combative resident
- Transfer
from the floor
- Lateral
transfer - moving a resident from one horizontal position to another
- Bed to
chair or chair to bed transfer (i.e., to/from Clinitron
bed)
- Chair to
chair (i.e., to/from geri-chair, toilet)
- Bathing
- Repositioning
in bed or chair
- Weighing
a resident
- Positioning
a bed pan or changing incontinence pads
- Attempting
to stop a resident's fall.
Nursing
assistants who routinely move residents are well qualified to identify which
tasks they find most stressful to their backs. The easiest way to learn which
tasks are the most difficult is to ask the workers; this can be done
individually or at the debriefing session between shifts. Other elements that
increase the risk of injury when moving a resident include but are not
limited to the following:
- Floor conditions
[such as cluttered, uneven, wet/slippery (water, urine, etc.,)]
- Not
enough room to maneuver
- Carrying
for more than 3 feet a resident who can not bear much weight
- Poor
lighting
- Poorly
maintained equipment
- Poor grip
on the resident due to special medical conditions
- Fatigue
from handling residents more than a total of 20 times per shift
- Pushing
and pulling while repositioning, or moving wheelchairs or carts
- Pushing
or pulling a gel mattress
- Grasping
a lift sheet or sling without handles
- Grasping a gait belt
B. In
addition to the risk factors that relate directly to the lifting activity, awkward
postures, separately or in combination with forward exertions may
cause or contribute to an injury/illness of the back. To be considered a risk
factor, an awkward posture needs to last more than 1 hour continuously, or a
total of 4 hours in the workshift and occur during
three or more workshifts per week. Postures
determine which muscles are used in an activity and how forces are translated
from the muscles to the object being handled.
- More
muscular force is required when awkward postures are used because
muscles cannot perform efficiently;
- Fixed
awkward postures (i.e., holding the arm out straight for several
minutes) contribute to muscle and tendon fatigue, and joint soreness;
- Forces on
the spine increase when lifting, lowering or handling objects with the
back bent or twisted. This occurs because the muscles must handle the
body weight in addition to the load in the hands.
While
awkward postures can create risk factors it is important to allow flexible
joints like the back to move. A good rule of thumb for flexible
joints is to use them, or lose them, but don't abuse them. Therefore,
the combination of the risk factors needs to be considered.
Awkward
back postures include bending backward (hyperextension > 20, Figure 1),
mild forward bending (20 to 45 see Figure 2), severe forward bending (>45
back flexion, see Figure 3), bending to either side (lateral bending, see Figure
4), and twisting of the back (see Figure 5). Activities which can put the
back in an awkward postures include but are not limited to the following:
- lifting/lowering
- stooping
over to change sheets
- manually
adjusting the position of the bed
- bending to bath a resident.
Awkward Back Postures
Appendix G
Examples of OSHA
Standards Requiring Training
|
Standard |
When Required |
|
29 CFR 1910.1200 Hazard Communication |
Initially and when new chemicals are introduced |
|
29 CFR 1910.1030 Bloodborne Pathogens |
Initially and annually |
|
29 CFR 1910.147 Lock-out/Tag-out |
Initially and when equipment or processes change or periodic
inspection indicates |
|
29 CFR 1910.132 Personal Protective
Equipment |
Initially and when changes to workplace render previous training
obsolete or when employees show improper use or other inadequacies in use
of PPE |
|
29 CFR 1910.20 Access to Employee
Exposure and Medical Records |
Initially and annually |
|
29 CFR 1910.332 Electrical |
Initially |
|
29 CFR 1910.38 Employee Emergency
Plans and Fire Prevention Plans |
Initially and annually and whenever responsibilities or plan are
changed |
|
29 CFR 1926.1101 Asbestos |
1. Maintenance and repair operations that disturb asbestos
containing materials (repair or replace asbestos flanges, repair boilers or
piping with asbestos wrap) 2. Housekeeping and
custodial operations that contact asbestos-containing materials (vinyl
asbestos floors, clean-up of dust or debris from maintenance operations as
described above) |
Note: This list shows
examples of OSHA Standards requiring training. It is not meant to be all
inclusive.
Appendix H
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Cohen-Mansfield, J.,
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Electronic Revision Date: 29 May 2002
