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Nursing Home Initiative Inspections Policy and Procedures



February 10, 1998

 

Memorandum For: Regional Administrators

From: John B. Miles, Jr.
Director, Compliance Programs

Subject: Nursing Home Initiative Inspections Policy and Procedures

The Secretary's Nursing Home Initiative in the seven affected states is being terminated and absorbed into the new OSHA-wide targeting procedures. Effective immediately, the enforcement policies adopted by previous memoranda for the Initiative will be superseded and replaced with the guidance of OSHA Instruction CPL 2-0.119, OSHA High Injury/Illness RateTargeting and Cooperative Compliance Programs. Many of the specific case development and litigation decisions on cases involving ergonomics will still be decided by ongoing consultation during the life of the inspection(s) between the Regional Ergonomics Coordinators and the Directorate of Compliance Programs' Ergonomics Coordinator, Dr. Graciela Perez. In addition, the IMIS recording procedures outlined for the for the Initiative will be carried over for all nursing home inspections in Federal enforcement states.

The IMIS recording guidance and Appendices from the original Initiative memorandum are attached for informational purposes.

IMIS Recording

The guidance below shall be followed for completing enforcement forms OSHA-1, OSHA-7, OSHA-36, and OSHA-90 and Consultation Request Form-20 and Visit Form-30 when recording all activities conducted in the SIC Codes, 8051, 8052, 8059.

  1. The OSHA-1 Form for any programmed inspection conducted in the SIC Codes, 8051, 8052, 8059 shall be marked "PLANNED" (Item 24h) and "SPECIAL EMPHASIS PROGRAM" (Item 25d). Record NURSING in the space in item 25d.

  2. The OSHA-1 Form for any unprogrammed inspection conducted in the SIC Codes, 8051, 8052, 8059 shall be marked as unprogrammed (Item 24a. through g. as appropriate). In addition, it shall be marked "SPECIAL EMPHASIS PROGRAM" (Item 25d). Record NURSING in the space in Item 25d.

  3. For focused inspections conducted under this SEP, Item 42 (Optional Information) of the OSHA 1 Form shall be completed as follows:
  4. TYPE ID VALUE
    R 16 FOCUS
  1. Whenever an OSHA-7 is completed by a Federal office and the applicable complaint applies to a nursing home, complete the OSHA-7 in the normal manner, but include the following in "Optional Information" Item No. 46:
  2. TYPE ID VALUE
    N 16 NURSING
  1. Whenever an OSHA-36 is completed by a Federal office and the inspecting compliance officer(s) is/are able to identify the site of the fatality/catastrophe as a nursing home, complete the OSHA-36 in the normal manner, but include the following in "Optional Information" Item No. 35:
  2. TYPE ID VALUE
    N 16 NURSING
  1. When an OSHA-90 is completed by a Federal office and the applicable referral case is a nursing home, complete the OSHA-90 in the normal manner and enter the following in "Optional Information" Item No. 26:
  2. TYPE ID VALUE
    N 16 NURSING

Whenever a visit is made in response to this SEP, Consultation Request, and/or Visit forms are to be completed as follows:

  1. Complete the Request Form-20 in the normal manner and enter the following in "Optional Information", Item No. 26:
  2. TYPE ID VALUE
    N 16 NURSING
  1. Complete the Visit Form-30 in the normal manner and enter the following in Optional Information", Item No. 34, when a visit has been made in response to the SEP:
  2. TYPE ID VALUE
    N 16 NURSING

 

Appendix A

Nursing Home Industry Background Information

The nursing home industry is one of America's fastest growing industries. Employee population in the industry grew by nearly 50% in the decade between 1982 and 1992. Today nursing homes and personal care facilities employ approximately 1.6 million workers at 21,000 work sites. By the year 2005, industry employment levels will rise to an estimated 2.4 million workers. Nursing homes with an employee population between 50-99 employ a total of more than 400,000 employees, while homes with an employee population between 100-249 account for more than 800,000.Approximately 10% of the employees are represented by unions. The two largest employee representatives are Service Employees International Union and the United Food and Commercial Workers Union with approximately 100,000 and 25,000 workers in the industry, respectively.

According to the Bureau of Labor Statistics, in 1994 nursing and personal care facilities reported 221,200 nonfatal occupational injuries and illnesses to their personnel. Among U.S. industries with 100,000 or more nonfatal injury or illness cases, nursing homes have the third highest rate--16.8 injuries and illnesses per 100 full-time workers. Only meat products processing (at 26.5) and motor vehicle/equipment manufacturing (at 25.4) have higher incidence rates. Nursing home workers suffer most of their injuries (51.2 percent) when handling residents. Fifty-eight percent of their injuries are strains and sprains. While back injuries account for 27 percent of all injuries in the private sector, in nursing homes they account for 42 percent of all injuries. According to BLS data for 1993, more than 28,000 lost workday incidents were related to lifting, almost 5,000 injuries were the result of assaults, and approximately 16,000 were due to slips, trips and falls. Of the 10 occupations with the largest number of injuries and illnesses, nursing aides and orderlies are exceeded only by truck drivers and nonconstruction laborers.

A significant concern with the industry is the level of regulation under which the industry operates. Governments at all levels exercise regulatory authority over nursing homes. Local governments may have jurisdiction over issues of fire safety, egress, and food service sanitation as these issues pertain to residents. State and local governments may also regulate the industry for licensing and Medicare and Medicaid certification purposes on a yearly basis. Agencies also may respond to residents' complaints with unannounced inspections over patient's rights, patient safety issues, or other conditions in the facility. While it is necessary to be aware of the regulatory concerns of the industry, most of the regulations do not overlap the jurisdiction or issues addressed under OSHA standards. OSHA regulations may address some of the same conditions covered by other Agencies but only as far as they pertain to employee safety and health.

The Omnibus Budget Reconciliation Bill of 1987 (OBRA) and many regulations of the Health Care Financing Administration assure residents a level of privacy similar to that which they would enjoy in their homes. Evaluations of workplace safety issues in the nursing homes generally involve some injuries related to the employees' handling residents. The resident handling activities may take place in resident rooms, restrooms, shower and bathing areas. Documenting these actual activities by witnessing, videotaping, and photography requires the resident's consent. Family members or guardians may give consent for residents who are incapable of giving consent. Residents are often approached during other agencies inspections and questioned about issues including residents rights and privacy. The privacy issue should be treated with a high degree of concern and tact during any evaluation of safety and health hazards. Unresolvable conflicts between adequate hazard exposure documentation and resident privacy concerns should be discussed with supervisors, solicitors, and the nursing home initiative coordinators.

The daily activity profile for each resident may identify situations which are particularly problematic and make suggestions for specific steps which reduce the potential of injury to the employees and the residents. Many residents are totally dependent on the staff to provide for the activities of daily living such as dressing, bathing, feeding, and toileting. Each of these activities may require multiple interactions with a resident. Typical situations involving employee/resident interaction include transferring between bed and wheelchair, wheelchair to toilet or shower chair, and weighing of residents. Working conditions that may contribute to the risk of accidents include reduced lighting in resident rooms during sleeping hours, solo transfers of non-ambulatory residents without lift assist devices, broken equipment, wet floors, cramped working spaces and staffing levels inadequate to deal with the workload during high activity periods. An additional area of concern which should be addressed on the profile is the problem of combative residents who strike out at employees during interactions.

Many nursing home employers already have learned that working safely is a good way to not only help protect their employees, but also affect the bottom line. When one nursing home employer implemented a program to address safe resident handling, worker's compensation premium dropped from $750,000 to $184,000. A similar resident handling program at another nursing home led to a striking reduction in lost workdays --from 2,200 in 1993 to only 31 in 1996.

Commonly used terms in to the industry are as follows:

Ambulate - walk or help to walk

Gait, transfer, or walking belt - a wide belt placed around resident's waist to allow staff member a handhold on resident during transfer operations or walking.

Hoyer Lift - mechanical lift assist device used to lift heavy or dependent residents. Many manufacturers currently make similar devices.

Sliding board - a slick board used under resident to reduce the friction during transfers of resident from bed to chair or changing position in bed.

Geri chair - geriactic chair is a recliner chair used for dependent residents

Trapeze lift - a bar device suspended above bed which allows residents with upper muscle strength to reposition themselves.

Care plan or Activities of Daily Living (ADL) - written document kept by staff that gives detailed description of residents needs. It should also contain information on degree of assistance required by resident.

 

Appendix B

PROGRAM TO ADDRESS RESIDENT HANDLING
INJURIES IN NURSING HOMES

If the review of the safety and health program using the general guidance provided by OSHA Instruction 2, Program Evaluation Profile, shows a high rate of musculoskeletal injuries and illnesses, then the tool below may be used to evaluate the resident handling aspects of the facility's program. This evaluation tool has been derived from one developed by the Technical Support Section of OSHA's Region III. It is intended as an example of a safety and health program to address resident handling injuries in nursing homes. While the program is not specific to any one facility, it does address the major elements of an effective program.

MANAGEMENT LEADERSHIP AND EMPLOYEE PARTICIPATION. Commitment and involvement are essential elements of a sound safety and health program. Commitment by management provides organizational resources and motivating force necessary to deal effectively with resident handling hazards.

  1. Management demonstrates involvement by placing a priority on reducing or eliminating resident handling hazards.

  2. Management commitment is demonstrated by assigning and communicating responsibility for the resident handling program to all managers, supervisors and employees. Accountability mechanisms are in place.

  3. An effective written program for job safety, health and ergonomics is in place, outlining the nursing homes goals, and is communicated to all employees. All managers, supervisors, and employees involved know what is expected of them. This program should include policies and procedures about:

    1.  

    2. orientation of employees which includes education in injury prevention
    3. continuing injury prevention education
    4. methods of transfers and lifts to be used by all staff
    5. modified (light duty) work, and post injury return to work programs
    6. compliance with transfer and lift procedures
    7. procedures for reporting of early signs and symptoms of back pain and other musculoskeletal injuries.

    The written program should be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect worker exposure to ergonomic hazards.

  4. Employee involvement in the resident handling program is encouraged through a complaint/suggestion program, prompt and accurate reporting of injuries, establishment of safety and health committees, and training of employees in the skills necessary to analyze jobs for ergonomic stress.

  5. Procedures are implemented to regularly evaluate the effectiveness of the resident handling program, and to monitor success in meeting goals and objectives. This process includes review of recorded OSHA 200 injuries, workers' compensation and insurance reports, and reports from employees of unsafe working conditions. Also included maybe regular (monthly) walk-around inspections, and employee surveys regarding worksite changes.

WORKPLACE ANALYSIS. Workplace analysis identifies existing and potential hazards. It consists of a literature review, identification of hazard categories, workplace surveys and an analysis of trends. This should identify conditions and work habits which create hazards, and areas where hazards may develop. The objective of workplace analysis is to recognize, identify, and correct resident handling hazards.

  1. The nursing home gathers relevant information on ergonomic solutions to resident handling problems.

  2. Baseline screening surveys using a checklist are conducted to evaluate ergonomic risk factors and determine which tasks are most stressful and need improvement.

  3. Job analysis is performed by persons skilled in evaluating ergonomic risk factors associated with resident handling requirements. Evaluation is conducted during peak lifting and transferring times.

  4. Changes are implemented to avoid the most stressful resident transfers.

  5. Periodic surveys and follow-ups are conducted to evaluate changes
  6. Screening surveys / checklists are utilized to evaluate workplace stressors.

  7. After each resident handling injury, a determination is made if a task can be modified to reduce future risk.

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, all accidents and near miss incidents should be investigated so that their causes and the means for prevention are identified.

  1. Incident investigations are performed by knowledgeable people on all accidents, incidents and near miss incidents involving musculoskeletal injury or illness,
  2. A system is in place to resolve all recommendations resulting from an incident investigation.

  3. OSHA 200 logs, OSHA 101 forms, and workers' compensation or insurance records are scrutinized on a periodic basis for trends or patterns.

HAZARD PREVENTION AND CONTROL. Resident handling injuries are prevented primarily by proper selection of equipment, effective use of assistive devices, and by implementation of proper work practices. The equipment must be available in sufficient quantities, convenient for use, and properly maintained.

RESIDENT HANDLING (ASSISTIVE) DEVICES

  1. Resident chairs allow nurse to place feet under chair; chair back is low enough to permit lifting access.

  2. Mobile chairs, wheelchairs, and commodes have functional brakes, mobile arms, and footrests which do not obstruct movement.

  3. Transfer surfaces are approximately at the same level, for example, toilet seats are raised so that the heights of the wheelchair and toilet seat are the same. Bath stretchers are height adjustable to allow horizontal transfers.

  4. Hoists are selected based on nurse and resident evaluation of ease of use, comfort, and safety. Hoists are routinely maintained, are conveniently located and available, with suitable lifting attachments and/or slings, such as:

    1. fixed hoists, often used in bathrooms due to limited space.

    2. hoists on a track, which can also be operated by residents.

    3. mobile hoists.
  5. An adequate number of hoists are available for the transfer of residents who are dependent or can only provide minimal assistance in the transfer.

    1. At least one portable resident hoist with a maximum capacity is available for extremely heavy residents. A backup hoist is available when the primary lift is out of service.

    2. One hoist with an adequate number of slings is easily accessible.

    3. At least one of the portable hoists in the nursing home should have the functional capacity for lifting a resident from the floor.

    4. A digital scale is attached to one mechanical hoist to allow the weighing of dependent residents during routine transfers.

  6. Guidelines have been developed to instruct nurses in which type of hoist or sling would be appropriate for particular residents.

  7. Nursing supervisors are trained so that they understand the importance of using resident handling devices and the techniques for using them.

  8. "Sliding boards" are used to ease transfer from wheelchair to bed and bed to wheelchair when the resident has the cognitive and upper body strength to assist.

  9. Transfer belts are used where appropriate.

  10. Resident transfers are minimized. Shower chairs are utilized, which are also compatible with toileting facilities. Weighing stations allow residents to remain in their chairs while being weighed on a wheelchair ramp.

  11. Good bed design is evident through convenient location of controls, adjustable bed height to wheelchair, and sufficient foot clearance.

WORK PRACTICES / ADMINISTRATIVE CONTROLS.

  1. Supervisors are familiar with resident handling guidelines and enforce company rules.

  2. Injuries are accurately recorded on the OSHA 101 form.

  3. Care plans are specific in assessing resident handling requirements, and are communicated to affected employees prior to resident handling. A practical system for communicating changing assessment results is developed, and special attention is given for residents who have special handling needs, such as residents who have weakness on one side from a stroke.

  4. Resident clothing is selected which aids transfers where feasible (non-slippery; clothing handles for unconscious residents; adaptive clothing for ease of changing; absorbent pads for incontinent residents).

  5. Proper resident transfer techniques are utilized (resident is properly positioned prior to transfer; resident handling slings or transfer belts are utilized; resident clothing is never adjusted while transferring).

  6. Slips and trips are minimized by eliminating uneven floor surfaces where possible, using large wheels on transport equipment, creating non-slip surfaces in toilet/shower areas, and enforcing a policy of immediately cleaning up fluids spilled on a floor.

  7. A policy exists which ensures that resident handling help is provided to a nurse anytime it is requested.

  8. Restricted "light duty employees" are not involved in transferring residents.

  9. An effective program for facility and equipment maintenance is implemented which minimizes resident handling hazards and includes:

    1. a preventive maintenance program for resident handling devices.

    2. maintenance whenever employees report problems; sufficient spares exist for out of service equipment.

    3. implementation of housekeeping programs which minimize slippery work surfaces and slip/fall hazards.

MEDICAL MANAGEMENT. Proper medical management is necessary both to eliminate or reduce the risk of resident handling injuries through early identification and treatment, and to prevent future problems through rehabilitation and training. Health care providers must be part of the injury prevention team, and after on-site review, regularly interact and exchange information with the management.

  1. The program is supervised by a person trained in the prevention of musculoskeletal disorders. The program is periodically evaluated and may include:

    1. accurate injury and illness recording.

    2. early recognition and reporting.

    3. conservative treatment with specific transferring restrictions during recovery.

    4. for disabling injuries, early (eg. 2 days) referral to specialist in physical medicine and rehabilitation.

    5. systematic monitoring - return to work only after transferring skills have been re-assessed.

    6. baseline health assessment for comparing changes in health status, and preplacement evaluation of resident handling skills.

    7. medical management participation in the development of a list of light-duty jobs, to assist management in assigning light or restricted duty jobs.

SAFETY AND HEALTH TRAINING. The purpose of training and education is to ensure that managers, supervisors, and healthcare providers are sufficiently informed about the ergonomic hazards to which they may be exposed and thus are able to participate actively in their own protection.

Training programs should be designed and implemented by qualified persons. The program should include an overview of the potential risk of back and other musculoskeletal injuries, their causes and early symptoms, and means of prevention and treatment. Appropriate "train the trainer" instruction is required for personnel responsible for providing training. Training should be presented in a language, and at a level of understanding, appropriate for the individuals being trained, and should include opportunities for interactive questions and answers with the trainer.

  1. The orientation/new employee program includes job site evaluation of transferring technique by a person skilled in the art and science of transferring residents. Feedback is provided. Basic training in handling residents has been given. Supervising nurses have been trained to develop policies and procedures for their units and to train their nursing staff:

    1. never transfer residents when off balance.

    2. avoid heavy work with spine rotated.

    3. lift loads close to the body.

    4. avoid vertical "dead-lift".

    5. never risk over exertion with a resident that is resistant; use assistance.

    6. use team lifts and mechanical devices where necessary (residents over 150 pounds are always considered "heavy").

    7. properly place and adjust equipment used to handle residents.

    8. always bring resident toward you, never away.

    9. don't lift fallen residents alone, consider mechanical assistance.

  2. Employees (nurse assistants, licensed practical nurses, and registered nurses, as appropriate) are also provided:

    1. proper training for assisting walking residents (stand on weaker side, close to resident, take load on hip rather than back).

    2. training in appropriate transfers and lift techniques in confined spaces, such as shower stalls and toilet areas.

    3. training in when and how to use mechanical hoists (eg. for residents over 150 pounds who cannot support their own weight).

    4. initial and periodic (eg., monthly) programs on back care and transferring techniques.

    5. training on the appropriate resident handling devices to use with particular residents and the proper use of this equipment.

  3. Training in emergency resident handling is given, such as for residents who have fallen, have spasms, are combative or exhibit any unpredictable behavior.

  4. Training and feedback is provided on use of resident handling devices.

  5. Annual refresher training is provided and addresses specific needs. Provisions are made to train absent employees.

  6. Staff physical fitness is encouraged.

  7. Training on early identification, reporting and conservative treatment of musculoskeletal disorders is provided to all workers, supervisors and management on an annual basis.

 

Appendix C

Incidence and Severity

The minimum information required for calculating incidence and severity rates includes the total number of new cases; the date each case was reported; the number of workers in the same risk group; the number of workers in the entire facility, the number of days of restricted or alternative work duty, and the number of days away from work. Incidence and severity for job types or hazards should be calculated per year from at least three years data when the injuries are identified during the record review.

 

A yearly total incidence rate normalized to 100 workers is calculated according to the formula below.

IR = (# of specific type of injury or incident per year)(200,000 hours)
                   Total hours worked per year

The 200,000 hours represents the average annual hours of 100 full-time workers and allows for comparisons between different groups of workers. If the actual number of hours worked by the subject group is unavailable, than the number of workers in the group may be multiplied by 2000 hours for an estimate. Note that the above rate may calculated either for the Lost Workdays Incident Rate (LWDI) or for total rate. An incident rate should be calculated for the entire facility and specific groups of workers within the facility when the job requirements and injury stressors are similar.

Severity comparisons may be used between groups to identify the groups which need the most attention in a facility. One measure of the severity of the hazard can be calculated from the formula below.

S = (Number of Lost Workdays)(200,000 hours)
              Total # of hours worked per year

Care should be taken with interpreting the severity statistic as one injury resulting in a large number of days off may give a high rate for the facility.

The analysis of trends with these statistics should be done so that a decision is based upon the trends of both rather than the either individually. A hazard may exist where where there are increased incidence of similar injuries between the employees in question and a control group, usually an unexposed group of workers at the same facility. However, if the severity of the injuries is decreasing, an increase in incidence may represent an early intervention policy.

 

Appendix D

STANDARD AVD LANGUAGE FOR RESIDENT TRANSFER HAZARDS

Section 5(a)(1) of the Occupational Safety and Health Act: The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were required to perform certain resident transfer tasks resulting in stresses that had caused, were causing, or were likely to cause musculoskeletal injuries:

  1. Location - Describe the Task e.g. Nurses aides were required to perform solo or two-person manual lifts of residents who cannot assist the aide significantly with the lift from beds, wheelchairs, toilets. The employer did not implement an effective control strategy to reduce or eliminate such tasks. The injury and illness records for 19--, 19--, and 19-- document a pattern of musculoskeletal injuries from such tasks.

Among other methods, one feasible and acceptable abatement method to correct this hazard is the implementation of a resident handling program consisting of the following elements.

1) Management commitment and employee involvement - Top management must demonstrate its commitment by following all safety rules and giving visible support to the safety and health efforts of others. Employee participation provides the means through which employees identify 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.

2) Workplace analysis - 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. 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.

3) 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 record keeping program will provide for investigation of accidents and "near miss" incidents, so that their causes, and the means for their prevention, are identified.

4) 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 and to indicate that some methods of controls are preferred over others. Engineering controls include the use of resident lifting hoists, sliding sheets/boards, and inflatable cushions. Administrative controls include the implementation of a "No Unassisted Lift" policy for all non-weight bearing residents. Work practice controls include proper work techniques, new employee conditioning, use of walking and transfer belts with weight bearing residents. The program should include a medical management component which addresses the recognition, evaluation, treatment and referral of resident handling injury cases.

5) 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. 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.

6) 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.

Step 1 - Implementation of an resident handling program which meets the requirements detailed above.

Step 2 - Submit to the Area Director a written, detailed plan of abatement outlining a schedule for the implementation of the engineering, administrative and work practice controls selected for the control of the hazards.

Step 3 - Implementation of engineering, administrative and work practice controls.

 

Appendix E

SAMPLE 5(a)(1) LETTER FOR RESIDENT TRANSFER TASKS

Dear Employer

During the Occupational Safety and Health Administration's recent inspection of your facility, the Compliance Officer noted a number of musculoskeletal injuries on the OSHA 200 log associated with resident transfer tasks. While we believe the exposures documented during our investigation do not constitute a violation of the Occupational Safety and Health Act, we have typically found that such injuries are associated with potentially hazardous resident lifting and transfer procedures. The implementation of a resident transfer program should serve to reduce the potential for injury to your staff. Such programs generally include the following elements:

 

1) Management commitment and employee involvement - Top management must demonstrate its commitment by following all safety rules and giving visible support to the safety and health efforts of others. Employee participation provides the means through which employees identify 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.

2) Workplace analysis - 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. 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.

3) 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.

4) 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 and to indicate that some methods of controls are preferred over others. Engineering controls include the use of resident lifting hoists, sliding sheets/boards, and inflatable cushions. Administrative controls include the implementation of a "No Unassisted Lift" policy for all non-weight bearing residents. Work practice controls include proper work techniques, new employee conditioning, use of walking and transfer belts with weight bearing residents. The program should include a medical management component which addresses the recognition, evaluation, treatment and referral of resident handling injury cases.

5) 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.

6) 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.

Our office can provide you with assistance as you develop your program to provide greater safety and health for your employees. If you desire further information on this subject, please feel free to contact us.

Sincerely



Area Director

 

Appendix F

VIDEO GUIDELINES FOR ERGONOMIC EVALUATIONS

Obtaining good video documentation for ergonomic evaluations can be difficult as the tasks are often performed in inaccessible areas with poor lighting conditions and a lot of extraneous movement taking place. This guide presents suggestions for capturing effective video documentation of potential ergonomic hazards.

PREPARATION

Use the OSHA Form 200 logs and 101s, complaint information, and interviews to help prioritize areas for taping. It is desirable to have at least a two person team when performing an evaluation. One person can operate the video camera while the other can record task and employee information.

The equipment needed for an ergonomic inspection will generally include:

  • Video Camera with extra tapes and charged batteries
  • Tape measure
  • Small Notebook
  • Fanny pack
  • Small scale
  • Bungee cord or small piece of rope
  • Questionnaires for employee interviews concerning ergonomic factors.

Other useful items may include:

  • Stop watch
  • Lens cleaning paper
  • Extra batteries for internal clock
  • Skylight UV filter. This is a must in dirty environment if you do not have a protective case.

The following are general suggestions on camera usage which if reviewed prior to going on-site will provide the best video documentation for the analyst and will ensure that all pertinent information is obtained and documented.

  • Become familiar with the camera and read the operators manual. Shoot some test footage so you are familiar with all the functions of the camera.

  • Always activate the date and time mechanism on the camera so this information is displayed on the video during the entire taping series. This will provide additional reference points with which to correlate written information with the video tape footage. Be aware of the position of the date and time printout on the video footage such that it is not superimposed over the top of important features of the video documentation.

  • For operations with extraneous movement it may be necessary to use the manual focus to avoid the camera refocusing on irrelevant moving objects. Determine where the focus point is for the camera you are using. It may not be in the center of the viewfinder. To make this determination place the camera on auto focus and try to focus on a small item such as a hanging pendant which has nothing else in the same plane. Hang the item from a doorway and try to focus by moving the item back and forth in the field of the viewfinder. You have found the focus point when the camera focuses on the item.

  • If the camera has a high speed shutter, turn it off and use the auto shutter. High speed requires too much light for most industrial tasks. If you are taping a worker with dark clothes against a light background (window, white wall), activate the "back lit" capability on the camera.

  • Practice visual slating of information. This should be done by filming a piece of paper with information clearly written on it just prior to or directly after, video taping the task. Use a marker or dark pen which can be clearly seen. The macro-zoom on your camera will permit use of a small notebook or journal to be used as a slate. A small notebook is easy to carry and any pertinent notes for can be recorded on the slate sheet for easy correlation and future reference. Macro-zoom is also helpful for documentation of small informational areas such as labels.

  • If visual slating is absolutely not possible, cover the lens with your hand and record the information verbally before the actual job taping begins. Be aware that you will need to speak directly into the camera microphone to be clearly understood. Use of an external microphone can aid in audio slating.

  • Hold the camera as still as possible or use a tripod if available. Don't walk with the camera unless absolutely necessary to record the task. When you change location, move slowly and minimize camera movement. Use the zoom instead of walking whenever possible. Use the manual focus whenever there is extraneous movement in the frame of action to ensure the focus will be on the items of interest.

VIDEOTAPING TASKS

The following items outline the procedures used for obtaining useful video documentation.

  • If possible tape the operation in the order of production. Do the beginning of the production process first and proceed through all tasks of interest.

  • Visually SLATE at least the name of the task just prior to or directly after, video taping the task.

  • Tape 5-10 minutes for all jobs including approximately 10 cycles. A cycle is considered to be a set of repeated motions during which one part or assembly is processed. Jobs which have relatively long cycle times in excess of 30-60 seconds may require fewer than 10 cycles if all aspects of the job are recorded at least 3-4 times.

  • Begin each task with a whole-body view of the worker from the side including the chair and/or the floor. Hold this view for 2-3 cycles and then zoom the camera in for a closer view of the area of principle interest. Tape from a variety of angles to allow a determination of wrist deviation, arm postures, back angles, etc. Tape from both sides and the front if possible. The total footage may be distributed between these different angles.

  • Video the operation from a distance to give perspective to the analyst about workstation layout.

  • Find an entity of known dimension in the frame of the picture and measure it for reference purposes. The employees forearm from the wrist to the elbow is a convenient landmark since it is in most frames and is measurable on the television screen. Record the reference dimensions either by visually slating the information or verbally recording the data. If using a ruler or tape measure, ensure that the increments are clearly visible.

  • Obtain video footage of tools or machinery which are used on the job. Videotape labels from hand tools, machinery, weight from boxes, etc.

ANALYSIS OF VIDEO TAPES

It is usually best to contact the Salt Lake Technical Center before you submit a videotape for analysis. This will allow us to provide you with a time frame for analysis completion and to make any pertinent inquiries concerning the nature of the request. Send a copy of the tape rather than the original since we keep all materials for our files, and any written documentation which was obtained about the inspection. Allow plenty of time for analysis as there is generally significant backlog.

There is information which can not be readily obtained by visual inspection of the video documentation. The following information should be recorded on the video tape slate at the beginning of the taping sequence or be provided in the written "Request For Tape Evaluation" accompanying the tape.(example attached)

  • Name, SIC code, and location of the facility being inspected.

  • Date of inspection.

  • Name of Compliance Officer(s), and OSHA office performing the inspection.

Additionally, the following information should be visually slated at the beginning of each individual task or recorded in a written Supplemental Factors Checklist.(example attached) Written information should be referenced to the video documentation and must accompany the video tape when submitted for analysis.

  • The name of the task and employee.

  • Anthropometry (height) of the employee.
  • Ambient conditions when working in extreme areas (freezers, furnaces, etc).

  • Clothing and PPE (materials, etc.)
  • The period of time in which the task is performed including work - rest schedules.

  • The nature of injuries as determined from the 200s, 101s, or interviews
  • Weight and dimension of loads lifted.

  • Dimensions of the work items seen in the shot (ie. pallets, tables, shelving units, etc.).

  • Vertical distance between origin and destination of lift. Horizontal distance the load is held from the body at the beginning and end of the lift. These distances can be estimated directly from the video documentation if measuring will significantly interfere with the operation. To do this there must be a clear view of the entire body and the work space, preferably in profile. Provide dimensional information on as many work items seen in the footage as possible.

  • Distance loads must be carried.

  • Production data to aid in determining if the video segment is representative of normal activity.Conditions which might affect grip or traction (ie. sand on the floor, ice on boxes being lifted, etc).

REQUEST FOR TAPE EVALUATION OF ERGONOMIC FACTORS

Inspection #: _________________________
CSHO name and phone: _________________________
Area Office: _________________________
Date of Insp.: _________________________
Need results by: _________________________
Company Name & SIC: _________________________

 


 

Task name Injuries as determined from 101, interview, or complaint. Descriptions of employees or job taped. Reference to coordinate ergonomics checklist data to tape.

SUPPLEMENTAL FACTORS FOR ERGONOMIC TAPE EVALUATION

Worker Information:

Workers Name: ______________________________________

Workers Height: ____________________________________

Job Name: __________________________________________

   Location: _______________________________________

   Bldg & floor: ___________________________________

   Tape time of sequence: __________________________

Job Description (task frequency, cycle time, time on job):

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________



Number of employees on job: ________________________________________

Line speed; Self or machine paced; ( pieces/min): __________________

Break schedule: ____________________________________________________

Rotation schedule: ________________________________________________

___________________________________________________________________

Jobs in rotation: __________________________________________________

___________________________________________________________________

Past CTD problems: ________________________________________________

Medical problems: _________________________________________________

Previous histories: ________________________________________________

Non-occupational activities: ______________________________________

Workstation*

Adjustability (mechanism and range of motion, heights, dimensions):

Table: ___________________________________________________

__________________________________________________________

Chair: ___________________________________________________

__________________________________________________________

Can work surfaces be tilted or rotated: _____________________

What is the worker standing on (concrete, wood): _______________

Is it slippery: __________________________________________

Can work positions be changed (sit/stand): ___________________

Maximum reach distances:

Horizontal: _____________________________

Vertical: _______________________________

* Make a sketch of the workstation layout on separate sheet of paper or reference to area of tape which shows the entire work layout.

Tools*

Name of tool: ________________________________

Sketch of tool:

Type of tool: ________________________________

Torque: ___________________________________

Reciprocating or vibrating: _______________

Other: ____________________________________

Weight of tool: ______________________________

Handle: _______________________________

Span: __________________________________

Length: ________________________________

Material: ______________________________

Are gloves worn, What material: ___________________________________

Source of power: ___________________________________________________

Is tool counter balanced: __________________________________________

Noticeable vibration: _____________________________________________

If air powered, is the exhaust away from the hand: _________________

* Answer these questions and make a sketch or identify the tool on the video segment for each tool used. Use other sheets of paper if needed.

Miscellaneous

What other objects or materials are handled and their weight:

   Name: ____________________________________________

   Weight: ___________________________________________

Temperature of work environment: _________________________________

Personal protective equipment: ___________________________________

Can worker control line speed: ___________________________________

Are there opportunities for micro rest pauses: ___________________

How many seconds: _________________________________________________

Estimate exertion level: __________________________________________

1 = Low; hold coffee cup; to 5 = high; open large "Bulldog" paper clip

Job and Ergonomic Training

Given by Whom: ____________________________________________________

   Hands on or theoretical: ________________________________________

Time spent in training: ___________________________________________

Updates:

   How often: ______________________________________________________

   Last update: ____________________________________________________

   Update given by whom: ___________________________________________



Does the employee have an opinion concerning the nature of the

problem and possible corrective measures? _____________________

 

Appendix G

References

From "Frameworks for Safety and Health Program in Nursing Homes"

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Bowman, J. Play it safe in long-term care facilities: health care workers face may hazards, including back injuries and violence. Safety & Health, March: 64-67,1996.

Charney, W., Zimmerman, K., and Walara, E. The lifting team: a design method to reduce lost time back injury in nursing. AAOHN Journal, 39(5), 231-234, 1991.

Cohen-Mansfield, J., Culpepper, W.J. II & Carter, P. Nursing staff back injuries: prevalence and costs in long term care facilities. AAOHN Journal 44(1):9-17, 1996.

Engels, J.A., van der Gulden, J. W. J., Senden, T. F., Hertog, C. A. W. M., Kolk, J. J., & Binkhorst, R. A. Physical work load and its assessment among the nursing staff in nursing homes. JOM 36(3), 338-345, 1994.

Gagnon, M., Sicard, C. and Sirois, J.P. Evaluation of forces on the lumbo-sacral joint and assessment of work and energy transfers in nursing aides lifting patients. Ergonomics, 29(3), 407-421, 1986.

Garg, A., & Owen, B. Reducing back stress to nursing personnel: an ergonomic intervention in a nursing home. Ergonomics, 35(11), 1353-1375, 1992.

Garg, A., & Owen, B. An ergonomic evaluation of nursing assistants' jobs in a nursing home.

Ergonomics, 35(9), 979-995, 1992.

Garg, A., Owen, B., Beller, D., & Banaag, J. A biomechanical and ergonomic evaluation of patient transferring tasks: wheelchair to shower chair and shower chair to wheelchair. Erognomics, 34(4), 407-419, 1991.

Garg, A., Owen, B., Beller, D., & Banaag, J. A biomechanical and ergonomic evaluation of patient transferring tasks: Bed to wheelchair and wheelchair to bed. Ergonomics, 34(3), 289-312, 1991.

Gold, M.F. The ergonomic workplace: charting a course for long term care. Provider, 20(2), 20-26, 1991.

Halbur, Bernice T. Turnover among nursing personnel in nursing homes. UMI Research Press, 1982.

Jansen, R.C. Back injuries among nursing personnel related to exposure. Applied Occupational and Enviromental Hygiene 5(1), 38-45, 1990.

Kroll, B. B., and Lowewenhardt, P. M. Staff involvement critical in enhancing a safe environment for care. The Florida Nurse, 43(10), 13-14, 1995.

Lusk, S.L. Violence experienced by nurses' aides in nursing homes: an exploratory study. AAOHN Journal 40(5), 237-241, 1992.

McCormack, J. Uplifting news for patients, worker safety, and financial returns. Association of Occupational Health Professionals, Jan-Feb. 1-8, 1996.

Merritt Company. Nursing home gets lifts. Merrit Workers' Comp News, May 15, 1995.

Nelson, M. L., and Olson, D. K. Health care worker incidents reported in a rural health care facility: a descriptive study. AAOHN Journal, 44(3), 115-122, 1996.

Nursing homes: What you need to know. Baltimore, Md: Maryland Attorney General's Office, 1990.

Forrest, M.B., Forrest, C.B., and Forrest R.

Nursing homes: the complete guide. Dallas, Tex.: Taylor Pub. Co., c1993.

Owen, B. D., and Garg, A. Reducing risk for back pain in nursing personnel. AAOHN Journal, 39(1), 24-33, 1991.

Owen, B. D., & Garg, A. Back stress isn't part of the job. American Journal of Nursing, 93(2), 30-37, 1993.

Patcher, Michael A. Excellence in nursing homes: care planning, quality assurance, and personnel management. New York: Springer Pub. Co., 1993.

Personick, M. E. Nursing home aides experience increase in serious injuries. Monthly Labor Review, 113(2): 30-37, 1990.

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Ramseyer, R. Handle with care. Maine Workplace, Spring: 20-24, 1995.

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Rogers, B. Occupational Health Nursing: Concepts and Practices. W. B. Saunders Co. Philadelphia, 1994.

Seifer Consultants. Handle with care. Maine Workplace, Spring: 20-24, 1995.

Sluchak, T.J. Erogonomics: Origins, focus, and implementation considerations. AAOHN Journal, 40(3), 105-112, 1992.

Spindel, M.P. (1995). Agency pushes for ergonomics rule. Provider, 21(2), 65.

Stubbs, D. A., Buckle, P.W., Hudson, M.P., and Rivers, P.M. Back pain in the nursing profession II: the effectiveness of training. Ergonomics, 26, 767-779, 1983.

Takala, E.P., & Kukkonen, R. The handling of patients on geriatric wards: a challenge for on-the-job training. Applied Ergonomics, 18(1), 17-22, 1987.

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Venning P. J. Back injury prevention among nursing personnel: the role of education. AAOHN Journal, 36(8), 327-333, 1988.

Venning P. J. Back injury prevention: instructional design features for program planning. AAOHN Journal, 36 98), 336-341, 1988.

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Strahan, Genevieve W. Mental illness in nursing homes. United States Public Health Service, Centers for Disease Control, National Center for Health Statistics, 1991.

Venning, P.J., Walter S.D., and Stitt L.W. Personal and Job-Related Factors As Determinants of Incidence of Back Injuries Among Nursing Personnel, Journal of Occupational Medicine, 29(10), 820-825, 1987.

Klein, B.P., Jensen, R.C. and Sandeson, L.M. Assessment of Worker's Compensation Claims for Back Strains/Sprains; RC Jensen ed., The Increasing Occupational Injury Rate in Nursing Homes, Advances in Industrial Ergonomics and Safety II (Biman Das Ed.), Taylor and Rancis, 1990.

Stobbe, T.J., Plummer, R.W., Jensen, R.C. and Attfield, M.D. Incidence of Low Back Injuries Among Nursing Personnel As A Function of Patient Lifting Frequency. Journal of Safety Research, 19, 21-28, 1988.

U.S. Equal Employment Opportunity Commission. U.S. Department of Justice and Civil Rights Division. The Americans with Disabilities Act Questions and Answers. Washington, D.C., July 1991.

U.S. Department of Health and Human Services. National Institute for Occupational Safety and Health. Guidelines for Protecting the Safety and Health of Health Care Workers. Washington, D.C.: U.S. Government Printing Office, September 1988.

U.S. Department of Labor. Occupational Safety and Health Administration. "Safety and Health Program Management Guidelines; Issuance of Voluntary Guidelines; Notice," Federal Register 54(16); 3904-3916. January 26, 1989.



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