Introduction

The Occupational Safety and Health (OSH) Act of 1970 strives to

assure safe and healthful working conditions for working men and women...

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^*

	Nursing home	Private Industry
Incidence rate of occupational injury and illness cases per 100 full-time workers (1994)	16.8	8.4
Incidence rate of lost workdays per 100 full-time nursing home workers (1994)	8.4	3.8
Number of employees in the nursing home industry	1,650,000

^* 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.

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 Team¹ Approach

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.

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.

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:

1. 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.

2. 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.

3. 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.

4. 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. A temporary employee works for an agency, but is supervised on a day-to-day basis by the nursing home. 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 occurred as well as the OSHA 200 log for the agency providing the temporary employees.

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.

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; jordan frame; and convertible wheelchairs.

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.

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.

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).

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),

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.

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.

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 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.

U.S. Department of Labor. Occupational Safety and Health Administration. "Ergonomic Safety and Health Management; Proposed Rule." Federal Register 57 (149): 34192-34200, August 3, 1992.¹

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 Bloodbone Pathogens (OSHA 3127).¹

U.S. Department of Health and Human Services. Centers for Disease Control. "Immunization Recommendations for Health Care Workers." Division of Immunization, Center for Prevention Services. Atlanta: April 1989.⁵

[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). February 9, 1990.

U.S. Department of Labor. Occupational Safety and Health Administration. "Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis. CPL 2.106." Office of Health Compliance Assistance. Washington, D.C.⁴

U.S. Department of Health and Human Services. Centers for Disease Control. "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Healthcare." Center for Infectious Disease. Division of Viral Diseases. Atlanta: October 1994.⁶

_________. "Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Settings, with Special Focus on HIV-Related Issues." MMWR 39 (RR17), December 7, 1990.

U.S. Department of Labor. Occupational Safety and Health Administration. "OSHA Instruction CPL 2-2.44C: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens Standard. Office of Compliance Assistance. Washington, DC: March 6, 1991.⁴

Ionizing Radiation

Gauvin, J.P. "Radiation Protection in Hospitals." In: W. Chaney and J. Schimer. Essentials fo Modern Hospital Safety. Chelsea, Michigan: Lewis Publishers, 1990.

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. Plymouth Meeting, PA: ECRI, 5200 Butler Pike.

Finkle, B.S.; Blank, R.V,; and Walsh, J.M. Technical, Scientific, and Procedural Issues of Employee Drug Testing.

¹U.S. Department of Labor - OSHA

Publications Office, Room N3101

200 Constitution Ave., NW

Washington, DC 20210

Telephone: (202) 219-4667

FAX: (202) 219-9266

²National Technical Information Service (NTIS)

U.S. Department of Commerce

5285 Port Royal Road

Springfield, Virginia 22161

Telephone: (703) 487-4650

FAX: (703) 321-8547

³National Institute for Occupational Safety and Health

Publication Dissemination, DSDTT

4676 Columbia Parkway

Cincinnati, Ohio 45226

Telephone: (513) 533-8287

⁴Superintendent of Documents

U.S. Government Printing Office

Washington, D.C. 20402

Telephone: (202) 783-3238

⁵Technical Information Services

Center for Prevention Services

Centers for Disease Control and Prevention

Atlanta, Georgia 30333

⁶Centers for Disease Control

and Prevention

Center for Infectious Disease

Division of Viral Diseases

Atlanta, Georgia 30333

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		Emloyer
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 (3) Majority of personnel can explain what performance 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. Accountablility	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) Accountablility 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 safetya or health experts survey in response to accidents, complaints, or compliance acitvity (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 reviewd (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; byt 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 initative (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 appeat 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 indidents 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 controlls fully in place, known to workforce, with concentration on engineering controls and reinforced/enforced safe work procedures (3) Hazard controls fully in palce 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 generaly 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 recognise maintenance needs and perform/order timely maintenance (3) An effective preventive maintenance schedule is in place and applicable to all ewuipment (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 equippment in place; but only energency teams know what to do (1) Emergency phones, directions, and equippment 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 aavailable 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, jelp develop and deliver training, all are trained (3) Facility commited 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 recieved 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 effot to train supervisors in safety and health responsibilities
Comments:
B-2. Managers learn safety and health program management	25. (4) All managers have recieved 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 Conotrol	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

Employer: Inspection No.: Date: CSHO ID:

Outstanding=5

Superior=4

Basic=3

Developmental=2

Absent or Ineffective=1

Score for element

Overall Score

OSHA-195 (3/96)

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

Santitation

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 bodysecretions/fluids to other individuals (Rogers,1994).	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 (Rogers, 1994).	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 (Rogers, 1994).	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 (OSAH 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 Hea;th 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 occured.

4) About the occupational injury or illness - description of the injury or illness, inculding 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 physican, 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.

U.S. GPO: 1989-241-374/08098

Public reporting burden for this collection of information is estimated to vary from 8 to 30 minutes per line entry, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Information Management, Department of Labor, Room N-1301, 200 Constitution Avenue, NW, Washington, DC 20210; and to the Office of Information and Regulatory Affairs, Office of management and Budget, Washington, DC 20503.

Instructions for OSHA No. 200

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 establishement.

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.

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.