Framework for a Comprehensive
Health and Safety Program
in Nursing Homes
Table of Contents
Introduction Purpose Program Elements
Management Leadership and Employee
Participation
Written Program
Multidisciplinary Team Approach
Workplace Analysis
Literature Review
Identification of Hazard Categories
Worksite Survey
Walkthrough
Hazard Analysis
Exposure Monitoring
Accident and Record Analysis
OSHA 200 Log
Recordable Injuries and Illnesses
Analysis of Trends
Passive Surveillance
Active Surveillance
Special Recordkeeping Issues
Temporary Employees
OSHA Form 101 or Equivalent
Incident or Accident Reports
Access to Employee Medical and Exposure Records
Employee Medical Records
Employee Exposure Records
Confidentiality of Records
Hazard Prevention and Control
Engineering Controls
Work Practice Controls
Administrative Controls
Personal Protective Equipment
Medical Program
Maintenance
Emergency Response
Safety and Health Training
Identifying Training Needs
Periodic Safety Training
Evaluations
Sources of Assistance
Management Training
Supervisor Training
Employee Training
Regular Program Review and Evaluation Conclusion
Appendix A: Resources
Appendix B: Ordering Information
Appendix C: Safety and Health Program Assessment Worksheet
Program Evaluation Profile
Appendix D: Occupational Hazards by Location in the Nursing Home
Anatomy of a Nursing Home with
Potential Hazards
Hazard Categories of Agents
Found in the Nursing Home
Setting
Appendix E: OSHA 101 Form
OSHA 200 Form
Appendix F: Identifying Risk Factors for Occupational
Injuries and Illnesses in
Nursing Homes
Appendix G: Examples of OSHA Standards Requiring Training
Appendix H: References
Appendix I: List of OSHA Regional Offices
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Introduction
The Occupational Safety and Health (OSH) Act of 1970 strives to "assure safe and
healthful working conditions for working men and women..." and mandates that
"each employer shall furnish to each of his employees employment and a place of
employment which are free from recognized hazards that are causing or are likely to cause
death or serious physical harm to his employees."
Numerous occupational health and safety hazards are potentially present throughout a
nursing home. Traditionally, the nursing home's focus of health care has been oriented to
the resident, but over the last few years there has been an increased public awareness of
the hazards facing nursing home workers. This heightened awareness can provide an
opportune time for developing a comprehensive occupational health and safety program in
the nursing home which will promote recognition, evaluation and control of hazards found
in nursing homes.
Table 1: Occupational injuries and illnesses data*
|
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.
__________
Footnote(1) The 29 CFR Volumes are available at cost from the U.S.
Government Printing Office. See Appendices A and B of this document for further
information.
Purpose
This document provides a framework for a comprehensive occupational health and safety
program in the nursing home setting. It can be used by nursing home occupational health
and safety professionals charged with the responsibility of developing a health and safety
program, or by those evaluating an existing program. Once the framework of a comprehensive
program is established, the resources and references listed in the appendices can be
helpful in meeting any special needs, and in tailoring the program.
This training and outreach document will serve, along with other available reference
materials, as a resource to assist employers in the nursing home industry to reduce the
number and severity of occupational injuries and illnesses in their facilities through the
development of a safety and health program.
Examples and statements presented in the reference material will not be the only means
of achieving the goal of a safe and healthful workplace. An employer who wishes to further
enhance his/her program may undertake additional measures designed to reduce injuries and
illnesses of the staff.
This is a training resource document only and is not a substitute for any of the
provisions of the Occupational Safety and Health Act of 1970 or for any standards issued
by the U.S. Department of Labor's Occupational Safety and Health Administration. This
framework may be applicable to most nursing homes because it is based on the many
similarities in program needs for health and safety in all types and sizes of nursing
homes.
An effective safety and health program is comprised of many elements, including
management leadership and employee participation, workplace analysis, accident and record
analysis, hazard prevention and control, emergency response, and safety and health
training. These elements are discussed briefly in the following paragraphs.
Program Elements
Management Leadership and Employee Participation
Visible management leadership provides an essential foundation for an effective
health and safety program. Employee participation is also a vital part of an effective
safety and health program.
Top management must demonstrate its commitment by following all safety rules and giving
visible support to the safety and health efforts of others. Management should convey
leadership which:
- Includes commitment to provide safe and healthful work and working conditions in the
nursing home's mission statement, establishing this as an organizational priority.
- Develops clear goals for the health and safety program and an action plan for meeting
these goals.
- Ensures that the goal and the action plan are communicated to all members of the
organization, so that all members of the organization understand the results desired and
the action plan for achieving them.
- Endorses and supports the program by providing implementation tools such as budget,
information, personnel with assigned responsibility and adequate expertise and authority,
line accountability, and program review procedures. (See Appendix C for Safety and
Health Program Assessment).
- Assigns the responsibility for development and management of the comprehensive program
to a person or team with expertise in hazard recognition and applicable OSHA requirements.
Ensures that this person or team keeps or has access to applicable OSHA standards at the
facility and seeks appropriate guidance information for interpretation of OSHA standards.
Also, ensures that this person or team has the authority to order/purchase safety and
health equipment.
- Ensures that performance evaluations for all line managers and supervisors include
specific criteria relating to safety and health protection.
- Ensures that the designated program manager protects all personnel in the facility
including employees of contractors, subcontractors, and temporary employees. This person
or team should also have the authority to monitor contractor safety and health practices
and have the authority to stop contractor practices that expose contractor employees to
hazards. Management must also inform contractors and employees of hazards present at the
facility and encourage them to report hazards that they may encounter or may result from
their work at the facility.
- Establishes, communicates, and enforces a disciplinary system that applies equally to
all employees (managers, supervisors, and staff) who break or disregard safety rules, safe
work practices, proper material handling and emergency procedures.
Employee participation provides the means through which employees identity hazards,
recommend and monitor abatement, and otherwise participate in their own protection.
Participation in the decision making process empowers and motivates employees to
actively participate in achieving program objectives and goals.
Because employees possess first-hand knowledge of the workplace, their input should be
a basic component of the health and safety program. The following mechanisms can
facilitate employee involvement:
- Designate employees for assignments in the health and safety program, based on
employees' special interest and/or expertise.
- Ensure that employees and their representatives are involved in the inspection of the
work area, and are permitted to observe the monitoring and that they receive the results.
Also, ensure that employees and their representatives have right of access to information
and that they understand this right of access.
- Establish a documented procedure that encourages employees to promptly and accurately
report complaints of hazards or discrimination, unsafe work practices and occupational
injuries and illness without fear of reprisal.
- Ensure that there there is documentation of employee participation, for example,
employee inspection reports, minutes of employee-management or employee committee
meetings.
- Provide employees who have expressed health and safety suggestions or concerns with a
timely response or follow-up.
- Inform employees about the provisions of the Occupational Safety and Health Act of 1970.
OSHA also requires the employers to post a Job Safety and Health Protection poster
(OSHA Publication 2203) in a conspicuous place where notices to employees are customarily
posted [29 CFR 1903.2].
Written Program
The nursing home safety and health program should be in writing in order to be
effectively implemented and communicated.
The written program must be tailored to the nursing home's mission and goals. It should
establish clear objectives and have an action plan. It should communicate the nursing home
health and safety policies, procedures and protocols, and assign responsibility for the
program. The written program should be reviewed, updated, and revised as needed.
Multi-disciplinary Team(1) Approach
__________
Footnote(1) Note: Two recent decisions of the National Labor Relations
Board (NLRB) in the cases of Electromation and Dupont have imposed certain
limitations on an employer's role in the formation and administration of employee
participation programs such as joint health and safety committees. In the wake of these
two decisions, an employer should ensure that it structures such programs to fit the safe
havens expressed therein by the NLRB.
A multi-disciplinary or employee safety and health team approach is recommended to meet
the diverse and numerous needs of a comprehensive health and safety program. The leader of
this team must have expertise in occupational health and safety with an understanding of
occupational illnesses and injuries, toxicology, epidemiology, ergonomics, and policy
development sufficient to recognize areas which require evaluation and control. The team
leader must also have management abilities in order to plan, develop and maintain an
effective program.
The team should examine the conditions of the workplace to determine existing hazards.
Representatives of all jobs in the nursing home can contribute valuable insights to the
identification of the hazards. Many hazards can be corrected with management and employees
working together.
Depending upon the expertise of the team members, however, it may be necessary to
consult outside experts to recommend controls for occupational safety and health hazards.
Program Elements
Workplace Analysis
An effective, proactive safety and health program will seek to identify and analyze all hazards.
Workplace analysis describes how management will collect information on current and
potential hazards. It consists of a literature review, identification of hazard
categories, workplace surveys, and an analysis of trends. The purpose of a workplace
analysis is to recognize existing and potential hazards, to identify employees at risk,
and to establish and subsequently to evaluate the control measures. The multi-disciplinary
team should conduct the workplace analysis.
Initially, the workplace analysis will establish a baseline. Then it must become a
continuous and ongoing process to recognize, identify, and control occupational hazards.
The frequency of workplace analyses depends on the specific characteristics of the hazards
and the work environment.
The workplace analysis may be performed on a specific area or problem or it may be done
on a regularly scheduled basis in an area where a hazard has been identified. Workplace
analyses also should be conducted when there are changes in procedures, equipment, or
processes.
Literature Review
To facilitate the workplace analysis, a literature review may be helpful. This review
should include current publications that describe potential nursing home hazards and
effective control strategies. The review enables personnel involved in the analysis to
develop an understanding of potential hazards.
Identification of Hazard Categories
Based upon information gleaned from the literature, potential hazards can be
anticipated. Potential health and safety hazards in the nursing home environment can be
categorized as follows: biological, ergonomic, chemical, environmental, mechanical,
psychosocial, and physical (See Appendix D). An inventory of these
hazards should be maintained and used to develop and manage appropriate programs and to
anticipate potential emergency situations.
Worksite Surveys
With a working knowledge of the potential health and safety hazards in the nursing home
environment, the next step is to perform a worksite survey, comprised of a walkthrough
survey, job hazard analysis and exposure monitoring.
The purpose of the worksite survey is to identify and evaluate actual and potential
hazards in a specific workplace. OSHA recommends comprehensive worksite surveys to
establish safety and health hazard inventories. The surveys should be updated periodically
as expert understanding of hazards and the methods of control in the nursing home change.
Walkthrough
Regular site safety and health inspections, or walkthroughs, are recommended so that
new or previously unrecognized hazards and failures in hazard controls are identified. A
walkthrough of the worksite should begin with discussions with the managerial staff,
employees, and union representatives, when appropriate. During this discussion, the leader
of the group assigned to perform the walkthrough should explain the process and purpose of
the activity. Departmental representatives should provide an explanation of activities and
present any departmental health or safety concerns. These discussions are likely to reveal
problems that are not easily detected by visual inspection alone.
The walkthrough is done by physically walking through the worksite and noting as many
hazards as possible. (Appendix D describes possible hazard categories.)
The walkthrough group members should observe the work processes, methods and practices,
engineering and administrative controls in place and personal protective equipment used.
Checklists can be useful to facilitate a systematic and comprehensive
survey approach.
During the walkthrough the survey team should ask the supervisors and employees to ask
any additional questions that may arise. Examples of questions that may be helpful are as
follows:
- Have common safety or health problems been noticed among the workers?
- Do any hazards exist that are not on the checklist?
- Do the employees have any questions about occupational safety and health?
- Are there any additional safety and health concerns or suggestions?
A diagram of each department should be developed to include the number and location of
employees and the sources of potential exposure to hazards.
Hazard Analysis
When indicated, a hazard analysis should be done after the walkthrough to further
assess the hazards of specific jobs, processes, and/or phases of work. A hazard analysis
is an orderly process for locating and evaluating hazards that are most probable and have
the severest consequences. This is information essential for establishing effective
control measures. The hazard analysis involves selecting the jobs or processes to be
analyzed, carefully studying and recording each step, identifying existing or potential
hazards (both safety and health), and recommending changes to eliminate or reduce the
hazards. Recommendations following a hazard analysis could include, among others,
substitution of a less hazardous chemical, facility alterations, equipment and materials
selections, or redesign of the job tasks.
Ideally, a hazard analysis should be conducted on all jobs or processes in all
departments and should consider the following:
- Frequency of accidents or illnesses
- Potential for injuries or illnesses
- Severity of injuries or illnesses
- New or altered equipment, processes or operations
To be effective, a hazard analysis must be reviewed and updated periodically, perhaps
annually. If an accident, injury, or illness is associated with a specific job or process,
the hazard analysis should be reviewed immediately to determine whether changes are
needed.
Exposure Monitoring
When the comprehensive work analysis identifies existing and potential health hazards,
exposure monitoring is used to evaluate the employee's level of exposure. It is important
to recognize that exposures must be measured while work is occurring. There are several
methods of monitoring occupational exposures:
- Environmental monitoring is a program of observation and measurement used to determine
levels of exposure to a specific substance in a worksite.
- Area sampling monitoring is done by measuring the contaminants in the air of the
employee's work area.
- Personal samples are used to measure air contaminants in the employee's breathing zone.
- Biological monitoring is the measurement of a chemical, its metabolite, or a non-adverse
biochemical effect in a person to assess exposure.
Program Elements
Accident and Record Analysis
An effective program will analyze injury and illness records for indications of
sources and locations of hazards, and jobs that experience higher numbers of injuries. By
analyzing injury and illness trends over time, patterns with common causes can be
identified and prevented. In addition, an effective recordkeeping program will provide for
investigation of accidents and "near miss" incidents, so that their causes, and
the means for their prevention, are identified.
OSHA 200 Log
The OSH Act of 1970 requires employers with 11 or more employees to collect and
maintain injury and illness records for their own employees at each of their
establishments. The U.S. Department of Labor's publication, Recordkeeping Guidelines for
Occupational Injuries and Illness, is the OSHA document that explains how cases are to
recorded on the OSHA 200 log (See Appendix E). To correctly complete the
OSHA 200 log, employers must follow the guidelines carefully.
Every OSHA recordable injury and illness must be recorded on an OSHA log 200 (or
equivalent) within six working days from the time the employer learns of the injury or
illness. This log is maintained on a calendar year basis and must be retained for five
years at the establishment.
Each year the employer must post the annual summary of the previous calendar year's
occupational injuries and illnesses for the nursing home. Although the summary is defined
as a copy of the year's totals from the OSHA 200, it is, for the most part, the right-hand
side of the OSHA 200 (a dotted line divides the OSHA 200). The employer must post the OSHA
200 Summary in a conspicuous place or places where notices to employees are customarily
placed. The employer must post this by February 1 and it must must remain posted until at
least March 1.
Recordable Injuries and Illnesses
When determining whether to record a case on the OSHA 200 log, noting that the
recordkeeping guidelines classify injuries and illnesses differently is important.
- An occupational injury is an injury such as a cut, puncture wound, fracture, sprain or
strain, which results from a work accident or from an exposure involving a single incident
in the work environment. Injuries are always the result of instantaneous
events.
- An occupational illness is any abnormal condition or disorder, other than one resulting
from an occupational injury, caused by exposure to environmental factors associated with
employment . An example is tuberculosis. Illnesses are always the result of
exposures over time.
- All occupational deaths and nonfatal illnesses are recordable. Nonfatal occupational
injuries are recordable only if they involve one or more of the following:
- loss of consciousness
- restriction of work or motion
- transfer to another job
- medical treatment, beyond first aid.
Analysis of Trends
OSHA recommends that injury and illness trends be analyzed over time, so that patterns
with common causes can be identified and prevented. Two procedures for doing this are
passive surveillance and active surveillance.
Passive Surveillance
Passive surveillance utilizes existing data (i.e., OSHA 200
log) to describe past trends. Documentation that is collected through recordkeeping
provides data for analysis of trends.
The availability and access to these records will depend on the nursing home's policy
and log limitations such as access to employee's medical records. The person accessing and
reviewing these records must be cognizant of the limitations of access to this, and all,
information.
Active Surveillance
Active surveillance involves collecting data (i.e.,
laboratory data) that is not currently documented. This surveillance creates data to
describe current trends and identify problem areas. The data can be obtained from sources
such as questionnaires, screening, or surveys. An example of this type of surveillance is
a symptom survey that could be given to employees in a department with a suspected
occupational hazard. This survey can be used with other surveillance techniques to
determine if a problem exists.
Special Recordkeeping Issues
There are several recordkeeping topics of special interest in the nursing home
environment. It is the recordkeeper's responsibility to decide if the occupational
injuries and illnesses meet the recordability criteria for entry on the log. These special
recording issues include:
- Bloodborne pathogen exposure incidents - typically, occupational bloodborne pathogen
exposure incidents are classified as injuries since they are generally the result of
instantaneous events, for example, needlesticks, blood splashes to mucous membranes, etc.
Medical
treatment recommendations which make exposure incidents recordable include:
The incident results in the administration or recommendation of medical treatment
beyond first aid, for example, gamma globulin, hepatitis B immune globulin, hepatitis B
vaccine, zidovudine, or other prescription medications, and/or the incident results in a
diagnosis of seroconversion.
- Another special recordkeeping issue is the recordability of employee exposures to
tuberculosis (TB). An employee may have a positive reaction to TB skin test (TB infection)
or may become ill with tuberculosis (TB disease). These cases would be recorded as
illnesses (column 7(c), respiratory agents due to toxic agents) because they are the
result of workplace exposures to TB-containing droplet nuclei over a period of time.
A case of tuberculosis infection or disease in a nursing home worker is presumed to be work
related because the Centers for Disease Control and Prevention has identified long-term
care facilities as high risk workplaces for exposure to tuberculosis. All documented TB
infections and TB diseases are recordable.
An exception to this presumption of work-relatedness occurs when an employer has
documentation that the employee was infected before employment at the nursing home. For
instance, if an employee's pre-assignment TB skin test (within two weeks of his or her
start date) is read as "positive" the case does not need to be recorded on the
OSHA 200 log. This exception is allowed because it is unlikely that a workplace exposure
for the hiring facility would have caused the positive test result in that time period.
(The minimum incubation period for TB is 2 weeks to 3 months.)
If, however, the positive TB skin test results occur more than two weeks from the
employee's start date, the case is presumed work-related and must be recorded on the OSHA
200 log. Additionally, any subsequent evidence of TB infection or TB disease is
recordable.
- Resident handling - of special concern to nursing homes is the recordabilty of sprains
and strains resulting from resident handling. On the OSHA 200 log, these instantaneous
events are always recorded as injuries. Typical medical treatment provided for such cases,
which is considered medical treatment beyond first aid, involves a recommendation of more
than a single dose of prescription drugs, a series (two or more) of physical therapy or
chiropractic treatments, use of splints or braces.
- Acts of violence - Injuries resulting from acts of violence that are work-related are
generally recordable as injuries because they are the result of instantaneous events.
These cases are to be evaluated for recordability just like any other injury. Depending on
the injury to the employee, medical treatment, restricted time and days away from work can
vary significantly.
Temporary Employees
A common practice in nursing homes is hiring temporary employees. Injuries and illnesses experienced by temporary employees should be recorded on the Log of the firm responsible for the daily direction of the temporary employee's activities. A temporary employee works for an agency, but is usually supervised on a day-to-day basis by the nursing home. If this holds true, when one of these employees sustains a recordable injury or illness, it is to be recorded on the OSHA 200 log of the nursing home where the injury or when the illness occurred.
OSHA Form 101 or equivalent
A supplementary form, OSHA form 101 (see Appendix E), must also be
completed when an OSHA recordable injury or illness occurs. This supplementary record also
must be completed within six working days from the time that the employer learns of the
work-related injury or illness. If workers' compensation reports, such as the First Report
of Injury, insurance reports, or other reports contain the information required by the
OSHA 101 form then they may be used as a substitute.
Incident or Accident Reports
Incident or accident reports may be designed by the nursing home and may be used to
obtain information about the cause of accidents and "near miss" incidents and to
identify hazardous areas or practices. Supervisors should complete an incident or accident
report for each accident even when only a minor injury or no injury occurs. Supervisors
and employees must understand the importance of completing these forms and their
responsibility to do so.
Access to Employee Medical and Exposure Records
OSHA's Access to Employee Medical and Exposure Records Standard, 29 CFR 1910.20,
requires employers to maintain certain employee medical and exposure records. The standard
is limited to medical and exposure records produced because of an employee's exposure to
toxic substances and harmful physical agents. Employees, or their designated
representatives, have a right to review their individual employee medical records and
records describing employee exposures. Access by other persons (such as supervisors or
other agency representatives) is prohibited.
Employee Medical Records
An employee medical record is one concerning the health status of an employee, which is
made or maintained by a physician, registered nurse, or the health care professional or
technician. Each employee medical record must be maintained for the duration of employment
plus 30 years, unless a specific occupational safety and health standard requires a
different period. In addition, the medical records of employees who have worked for less
than one year for the employer need not be retained if they are provided to the employee
upon the end of employment. Laboratory reports and worksheets need to be kept for only one
year. Examples of medical records are records concerning HIV/HBV status and Mantoux skin
testing for TB infection. These records are considered confidential and access to them is
strictly limited.
Employee Exposure Records
An employee exposure record is a record containing the information about employee
exposure, such as the following:
- Environmental monitoring, specific sampling results, the collection methodology, a
description of the analytical and mathematical methods used, and a summary of other
background data relevant to interpretation of the results obtained.
- Biological monitoring results that directly assess the absorption of a hazard.
- Material safety data sheets or a hazard inventory that describes chemicals and
identifies where and when they are used.
Each employee exposure record must be maintained for at least 30 years, unless a
specific occupational safety and health standard requires a different period.
Confidentiality of Records
OSHA is sensitive to the issue of personal privacy. While employee medical and exposure
records are subject to the strict confidentiality requirements of the Access to Employee
Medical and Exposure Records Standard, 29 CFR 1910.20, the OSHA 200 log is not considered
a medical record. The use of coded personal identifiers on the OSHA 200 or the OSHA 101
form is not permissible. All cases on the log must contain the employee's name.
Program Elements
Hazard Prevention and Control
Work force exposure to all current and potential hazards should be prevented or
controlled by using engineering controls wherever feasible and appropriate, work practices
and administrative controls, and personal protective equipment.
Nursing home policies and procedures should be written to describe the use of
appropriate methods of control such as engineering, work practice, and administrative
controls, and appropriate personal protective equipment. These methods are sometimes
organized into a "hierarchy of controls" to indicate that some methods of
controls are preferred over others.
Engineering Controls
Engineering controls are the preferred method for controlling hazards in the nursing
home. Engineering controls involve physical changes to the work station, equipment,
facility, or any other relevant aspect of the work environment. Some examples of
engineering controls in nursing homes include using electrically adjustable beds as a
substitute for manually adjustable beds; needleless systems to prevent needlesticks,
puncture resistant sharps containers, resuscitation bags, and negative pressure isolation
rooms.
Another example of an engineering control in the nursing home is the assist device.
Assist devices have been commonly used to reduce or eliminate forces on the back and arm
of the employee. (see Appendix F for Identifying Risk Factors in
Nursing Homes.) Assist devices also contribute to comfort and security of the
resident. An assist device can be mechanical where human strength is supplemented with
mechanical power, or a device that improves posture, or a device that allows more people
to assist. The condition of the facility and the resident needs to be assessed in order to
select an appropriate assist device.
Nursing personnel have been reluctant to use mechanical assist devices for a variety of
reasons such as: too time consuming to use the device; the resident was fearful of the
device; the device was broken or otherwise unsafe; the device was not available or was
stored too far away; the accessories for the lift device, such as slings, were not
available; and the staff was not adequately trained to use the device. In most cases,
reluctance to use assist devices has been overcome with encouragement from management in
the selection of appropriate equipment, training, and adequate equipment maintenance.
Assist devices that involve resident handling can be placed in several categories:
controls for lateral transfers; controls to move between sitting and standing; controls to
reposition; controls to transfer a resident; and controls for toileting and bathing.
Controls for lateral transfers involve transferring a
resident from one horizontal position to another horizontal position (e.g., bed to
gurney). Examples of this type of controls include: lift sheets; roller board/roller mat;
slide board; flat gurneys with transfer aids; transfer mats; 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.
Program Elements
Emergency Response
There should be appropriate planning, training/drills, and equipment for response
to emergencies. In addition, first aid/emergency care from trained staff should be readily
available to minimize harm if an injury or illness occurs.
Planning and preparing for emergencies are essential parts of the safety and health
program. All employees should know exactly what they must do in each type of emergency
situation. It is important that nursing homes plan and prepare for emergencies, including
weather and fire, [29 CFR 1910.38] and emergency response operations to handle releases of
hazardous substances [29 CFR 1910.120]. Training drills are needed so that in crisis
situations the responses become automatic. Appropriate alarm systems must be installed to
notify employees of an emergency.
Emergency response plans for dealing with hazardous substances should be prepared by
persons with specific training. Planning must extend to how to handle spills and incidents
involving chemicals in routine use, including cleaning supplies and disinfectants.
Adequate supplies of spill control and personal protective equipment appropriate to the
particular hazards onsite must be available. In some cases the employer's plan for dealing
with hazardous chemical spills may be to evacuate and call the fire department or other
hazardous materials organization.
Program Elements
Safety and Health Training
Safety and health training should cover the safety and health responsibilities of
all personnel who work at the nursing home. It is most effective when it is incorporated
into other training about performance requirements and job practices. It should include
all subjects and areas necessary to address the hazards in the nursing home.
OSHA considers safety and health training vital to every workplace and it is an
important component of a comprehensive program. Training helps employees develop the
knowledge and skills they need to understand workplace hazards and how to handle them in
order to prevent or minimize their own exposure.
Before training begins, be sure that the company policy clearly states the company's
commitment to health and safety and to the training program. This commitment must include
paid work time for training. The training should be in the language that the employee
understands and at a level of understanding appropriate for the individuals being trained.
Both management and employees should be involved in the development and delivery of the
program.
Documentation of training must be maintained where such training is required by a
standard. OSHA requires that such documentation be available for review by compliance
officers in the event of an inspection. See Appendix G for examples of
standards applicable to the nursing home environment that require documentation of
training. Documentation of training assures that initial or periodic training is
accomplished within established time frames.
Identifying Training Needs
New employees need to be trained not only to do the job, but also to recognize,
understand and avoid potential hazards to themselves and others in the workplace. Contract
workers also need training to recognize the hazards of the workplace. Experienced workers
will need training if new equipment is installed or a process changes. Employees needing
to wear personal protective equipment and persons working in high risk situations will
need special training.
Periodic Safety and Health Training
Some worksites experience fairly frequent occupational injuries and illnesses. At such
sites, it is especially important that employees receive periodic safety and health
training to refresh their memories and to teach new methods of control. New training also
may be necessary when OSHA or industry standards require it or industry practices are
revised.
One-on-one training is often the most effective training method. The supervisor
periodically spends some time watching an individual employee work. Then the supervisor
meets with the employee to discuss safe work practices, bestow credit for safe work, and
provide additional instruction to counteract any observed unsafe practices. One-on-one
training is most effective when applied to all employees under supervision and not just
those with whom there appears to be a problem. Positive feedback given for safe work
practices is a very powerful tool. It helps employees establish safe behavior patterns and
recognizes and thereby reinforces the desired behavior.
Evaluations
Evaluations help to determine whether the training you have provided has achieved its
goal of improving your employees' safety performance. Some ways that one can evaluate a
training program include:
- Before training begins, determine what areas need improvement by observing employees and
soliciting their opinions. When training ends, test for improvement. Ask employees to
explain their jobs' hazards, protective measures, and test new skills and knowledge.
- Keep track of employee attendance at training.
- At the end of training, ask participants to rate the course and the trainer.
- Compare pre- and post-training injury and accident rates, near misses and percent safe
behavior exhibited.
Sources of Assistance
Additional help in developing training programs and identifying training resources can
often be obtained from insurance carriers, corporate staff, or personal protective
equipment suppliers. OSHA-funded consultation projects for small business can also provide
some resources for training.
Addresses and telephone numbers for the consultation services in each state may be
obtained by calling the OSHA Regional Office (see Appendix I) or by
requesting OSHA publication 3047, Consultation Services for the Employer (Appendix A).
Management Training
Managers, such as the nursing home administrator, should receive training and education
to ensure continuing support and understanding of the safety and health program. It is the
managers' responsibility to communicate the programs goal and objectives to their
employees, as well as to assign safety and health responsibilities and to hold
subordinates accountable. In addition to the general orientation training outlined below,
management should receive information from the safety and health committee about the
current components of the program, the program's effectiveness and recommendations for
improvements.
Supervisor Training
Supervisors may need additional training in hazard detection, accident investigation,
their role in ensuring maintenance of controls, emergency response and use of personal
protective equipment. Supervisors should reinforce employee training through continual
performance feedback, and through enforcement of safe work practices.
Employee Training
Employees must be trained so that they understand the hazards to which they may be
exposed and how to prevent harm to themselves and others from exposure to these hazards.
The Health Care Financing Administration (HCFA), under U.S. Department of Health and Human
Services (HHS), enforces the requirement for nurse's aides to receive supervised training
and competence evaluation in order for the nursing home to receive Medicaid and Medicare
funding. While this training is mostly focused on delivery of resident care, the training
addresses issues that mesh with OSHA's concerns for safety and health in the workplace.
For instance, nurse aide training includes body mechanics regarding lifting and transfer
of residents, infection control, techniques for addressing the unique needs and behaviors
of individuals with dementia (Alzheimer's and others), and dealing with cognitively
impaired residents.
After initial work assignments are made, employees should receive a general orientation
on nursing home safety and health hazards and the elements of the safety and health
program and procedures. This general training should include an explanation of the
following:
- the health and safety program, policies and procedures;
- relevant safety and health regulations;
- hazardous materials (including housekeeping or maintenance chemicals, oxygen, and
resident recreational supplies and materials) and how to handle, store, manage and dispose
of them;
- regulated waste and infectious materials (including bloodborne pathogens and
tuberculosis) and how to handle, manage, and dispose of them;
- electrical safety and hazard prevention;
- walking and working surfaces (including wet floors in kitchens or hallways);
- back-injury prevention and other ergonomic issues (including resident lifting and
transfer, food handling, laundry and maintenance tasks);
- fire prevention and protection;
- workplace violence prevention (including avoiding injuries from residents);
- accident and illness reporting procedures (including reporting unsafe conditions such as
frayed electrical, slippery floors from spills or malfunctioning equipment, etc.);
- infection control precautions;
- material safety data sheets (MSDSs) and other information resources for chemicals;
- disaster preparedness and response; and
- job and hazard specific training (such as specific procedures for lock-out or tag-out of
machinery prior to maintenance or repair work).
Regular Program Review and Evaluation
With all of the safety and health program elements in place, a formal program review
and evaluation should be completed to measure the achievement of established goals and to
evaluate program outcomes.
OSHA recommends that program operations be reviewed at least annually to evaluate their
success in meeting stated goals.
Members of the multi-disciplinary team, including employee representatives should
conduct the program review and evaluation. The program review and evaluation should
measure outcomes, such as the attainment of goals and objectives, trend analysis, and
program effectiveness. These outcomes can be evaluated by using employee interviews and
testing, and by observing work practices to determine whether employees understand the
health and safety policies, procedures, and training. Program effectiveness also may be
evaluated by observing both overall and unit trends in occupational injuries and
illnesses.
For example, if one of the safety and health committee's goals is "to complete the
training for bloodborne pathogens compliance for all exposed employees before (a certain
date)," then the program review and evaluation should measure the attainment of this
goal. The evaluation might include interviews with employees, a review of training
records, and a walkthrough of areas where exposed employees work to observe
implementation.
In reviewing and evaluating the nursing home safety and health program, data should be
compiled from activities related to the worksite analysis, hazard prevention and control,
training and education, and recordkeeping. The information gathered from this process
should be communicated to all members of the nursing home community, including senior
management, through the safety and health committee. The program review and evaluation
should be used to determine any program elements that need to be altered to continually
improve the overall effectiveness.
Conclusion
This document provides a framework for a comprehensive occupational health and safety
program for the nursing home environment. This guide will be helpful to personnel
responsible for developing and evaluating a comprehensive occupational health and safety
program for the nursing home setting. The management commitment and employee involvement
and the program elements described in this document are the foundation for a comprehensive
program. These components can be expanded on by using the references and resources in the
appendices.
The development of an occupational health and safety program in the nursing home
setting is a challenging endeavor; but most importantly, a worthwhile one. With time,
commitment and resources a successful program can be developed.
Appendix A: Resources
The following is a list of some of the OSHA standards (Title 29 of the Code of
Federal Regulations), recommended programs, and resources applicable to nursing homes. The
list provides further sources of information that may be helpful. The footnote numbers
refer to the resource information listed in Appendix B: Ordering Information.
Access to Medical and Exposure Records
Access to Employee Exposure and Medical Records 29 CFR 1910.20. In: Title
29 Code of Federal Regulations, Parts 1901.1 to 1910.999. July 1995. GPO Order No.
869-022-00111-6. $33.00.4
Access to Medical and Exposure Records (OSHA 3110).1
Asbestos
Asbestos Standards for Construction (OSHA 3096).1
Asbestos Standards for General Industry (OSHA 3095).1
Asbestos 29 CFR 1910.1001. In: Title 29 Code of Federal Regulations, Parts
1910.1000 to End. July 1995. GPO Order No. 869-022-00112-4. $21.00.4
Electrical Hazards
Control of Hazardous Energy (Lockout/Tagout) (OSHA 3120).1
Controlling Electrical Hazards (OSHA 3075). GPO Order No. 029-016-00126-3.
$1.00.4
Electrical Protective Devices 29 CFR 1910.137. In: Title 29 Code of
Federal Regulations, Parts 1910.1 to 1910.999. July 1995. GPO Order No.
369-022-00111-6. $33.00.4
Subpart S - Electrical 29 CFR 1910.301 to .399. In: Title 29 Code of
Federal Regulations, Parts 1910.1 to 1910.999. July 1995. GPO Order No.
869-022-00111-6. $33.00.4
The Control of Hazardous Energy (Lockout/Tagout) 29 CFR 1910.147. In:
Title 29 Code of Federal Regulations, Parts 1910.1 to 1910.999. July 1995. GPO Order
No. 869-022-00111-6. $33.00.4
Emergency Response Program
How to Prepare for Workplace Emergencies (OSHA 3088).1
Subpart E - Means of Egress 29 CFR 1910; Subpart L -
Fire Protection 29 CFR 1910; Employee Emergency Plans and Fire
Prevention Plans 29 CFR 1910.38; and Hazardous Waste Operations and
Emergency Response Standard 29 CFR 1910.120. In: Title 29 Code of
Federal Regulations, Parts 1910.1 to 1910.999. July 1995. GPO Order No.
869-022-00111-6. $33.00.4
Principal Emergency Response and Preparedness Requirements in OSHA Standards and
Guidance for Safety and Health Programs (OSHA 3122). GPO Order No. 029-016-00136-1.
$2.50.4
Ergonomics
Ergonomics Program Management Guidelines For Meatpacking Plants (OSHA 3123).1
Ergonomics: The Study of Work (OSHA 3125). GPO Order No. 029-016-00124-7.
$1.00.4
Glazner, Linda. "Shiftwork: Its effects on workers." AAOHN Journal,
39(9).
Hales, Thomas R., and Bertsche, Patricia K. "Management of Upper Extremity
Cumulative Trauma Disorders." AAOHN Journal, 40(3):118-127, March 1992.
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 Bloodborne 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 of 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.
Appendix B: Ordering Information
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
Appendix C: Safety and Health Program Assessment Worksheet;
Program Evaluation Profile
OSHA Form 33 (Safety and Health Program Assessment Worksheet) is introduced at
the opening conference of the Consultation visit. It acquaints employers and employee
representatives with OSHA guidelines and its indicators graphically provide a score of
each main program element. This allows the employer and the consultant to visualize the
employer's status in meeting each of these elements. OSHA Form 33 serves to reinforce
efforts employers and their employees may have already made, and will suggest achievable
next steps in the facility's program improvement.
OSHA -195 form (Program Evaluation Profile) is being piloted by OSHA
Compliance staff on assessing employer safety and health programs in general industry
workplaces. This form is a draft form and may be revised.
Safety and Health Program Assessment Worksheet
Visit Number |
|
Employer |
|
Consultant |
|
Contact |
|
Open Conf Dt |
|
SIC Code |
|
Nr Emp In Ext |
|
Facility LWDI: |
|
TOTAL IR: |
|
Facility LWDI: |
|
TOTAL IR: |
|
I. MANAGEMENT LEADERSHIP AND EMPLOYEE PARTICIPATION
Comments: What evidence helped identify/verify adequacy? What improvement action is needed? |
A. Clear Worksite Safety and Health Policy |
1. (4) Workforce accepts, can explain, and fully understands, S&H
policy (3) Majority of personnel can explain policy
(2) Some personnel can explain policy
(1) There is a written (or oral, where appropriate) policy
(0) There is no policy |
Comments: |
|
B. Clear Goals and Objectives, Set and Communicated |
2. (4) Workforce involved in goal development, all personnel can explain
desired results and measures (3) Majority of personnel can explain desired results and
measures for achieving them
(2) Some personnel can explain desired results and measures for achieving them
(1) There are written (or oral, where appropriate) goals and objectives
(0) There are no safety and health goals and objectives |
Comments: |
|
C-1. Management Leadership |
3. (4) All personnel acknowledge that top management provides essential
safety and health leadership (3) Majority of personnel see top management as active
safety and health leaders and participants
(2) Top management is visible through safety and health videos, training, and documents
(1) Evidence exists that top management is committed to safety and health
(0) Safety and health does not appear to be a top management priority |
Comments: |
|
C-2. Management Example |
4. (4) All personnel acknowledge that top management always sets positive
safety and health examples (3) Majority of personnel credit top management for setting
positive examples for safety and health
(2) Top management can generally be seen modeling positive safety and health behavior
(1) Evidence exists that top management generally says and does the right things in
support of safety
(0) Top management does not appear to follow the basic safety and health rules set for others |
Comments: |
|
D. Employee Involvement |
5. (4) All personnel responsible for actively identifying and resolving
S&H issues (3) Majority of personnel feel they have a positive impact on
identifying and resolving S&H issues
(2) Some personnel feel they have a positive impact on S&H
(1) Employees generally feel that their S&H input will be considered by supervision
(0) Employee involvement in safety and health issues is not encouraged or rewarded |
Comments: |
|
E. Assigned Safety and Health Responsibilities |
6. (4) All personnel can explain what performance (including S&H) is
expected of them (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. Accountability |
8. (4) Safety and health performance for all is measured against goals,
clearly displayed , and rewarded (3) Personnel are held accountable for safe
performance with appropriate rewards and consequences
(2) Accountability systems are in place; but rewards & consequences do not always
follow performance
(1) Personnel generally held accountable, but consequences tend to be negative rather
than positive
(0) Accountability is generally hit or miss and prompted by serious negative events |
Comments: |
|
H. Program Review (Quality Assurance) |
9. (4) In addition to a comprehensive review, a process is used which
drives continuous correction (3) A comprehensive review is conducted at least annually
and drives appropriate program modification
(2) A program review is conducted, but does not appear to drive all necessary program
changes
(1) Changes in programs are driven by events such as accidents or compliance activity
(0) There is no evidence of any program review process |
Comments: |
|
A-1. Hazard Identification (Expert Survey) |
10. (4) In addition to corrective action, regular expert surveys result
in updated hazard inventories (3) Comprehensive expert surveys are conducted
periodically and drive appropriate corrective action
(2) Comprehensive expert surveys are conducted, but updates and corrective action
sometimes lag
(1) Qualified safety or health experts survey in response to accidents, complaints, or
compliance activity
(0) There is no evidence of any comprehensive expert hazard survey having been conducted |
Comments: |
|
A-2. Hazard Identification (Change Analysis) |
11. (4) Every planned/new facility, process, material, or equipment is
fully reviewed by competent personnel (3) A hazard review of all planned/new facility,
process, material, or equipment is conducted by experts
(2) Planned.new facility, process, material, or equipment considered high hazard are reviewed
(1) Hazard reviews of planned/new facility, process, material, or equipment are problem driven
(0) No system or requirement exists for hazard review of planned/new operations |
Comments: |
|
A-3. Hazard Identification (Job and Process Analysis) |
12. (4) Employees are involved in the development of current hazard
analysis on their jobs. (3) A current hazard analysis exists for appropriate jobs and
processes and is understood by affected employees
(2) A hazard analysis program exists for appropriate jobs and processes and is
understood by affected employees
(1) A hazard analysis program exists; but few employees are involved and most are not
aware of results
(0) There is no routine hazard analysis system in place at this facility |
Comments: |
|
A-4. Hazard Identification (Self-Inspection) |
13. (4) Employees and supervisors are trained, conduct routine joint
inspections, and all items are corrected (3) All employees are trained in inspection
techniques and all routinely participate in workplace inspections
(2) Routine inspections are conducted by selected personnel which drive appropriate
corrective action
(1) An inspection program exists; but few are employees involved and coverage and
corrective action are not complete
(0) There is no routine inspection program in place at this facility |
Comments: |
|
B. Hazard Reporting System |
14. (4) Employees are empowered to correct any hazards identified on
their own initiative (3) A comprehensive system for gathering information exists; is
positive, rewarding and effective
(2) A system exists for hazard reporting; employees feel they can use it; but it may be
slow to respond
(1) A system exists for hazard reporting; but employees may find it unresponsive or be
unclear on its use
(0) No hazard reporting system exists and/or employees do not appear comfortable
reporting hazards |
Comments: |
|
C. Accident/Incidents Investigation |
15. (4) All loss-producing incidents and "near misses" are
investigated for root cause with effective prevention (3) All OSHA-reportable incidents
are investigated and effective prevention is implemented
(2) OSHA-reportable incidents are generally investigated; cause
identification/correction may be inadequate
(1) Some investigation of incidents takes place, but root cause is seldom identified,
correction is spotty
(0) Incidents are either not investigated or investigation is limited to report writing
required for compliance |
Comments: |
|
D. Injury/Illness Analysis |
16. (4) All employees are fully aware of incident trends, causes, and
means of prevention (3) Trends fully analyzed & displayed, common causes
communicated, management ensures prevention
(2) Data is collected and analyzed centrally, common causes communicated to concerned
supervisors
(1) Data is centrally collected and analyzed; but not widely communicated for
prevention
(0) Little or no effort is made to analyze data for trends, causes, and prevention |
Comments: |
|
A. Timely Hazard Control |
17. (4) Hazard controls fully in place, known to workforce, with
concentration on engineering controls and reinforced/enforced safe work procedures (3)
Hazard controls fully in place with priority to engineering controls, safe work
procedures, administrative controls, and personal protective equipment (in that order)
(2) Hazard controls fully in place; but order of priority variable
(1) Hazard controls are generally in place; but priority and completeness varies
(0) Hazard control is not considered complete, effective and appropriate in this workplace |
Comments: |
|
B. Facility/Equipment Maintenance |
18. (4) Operators are trained to recognize maintenance needs and
perform/order timely maintenance (3) An effective preventive maintenance schedule is in
place and applicable to all equipment
(2) A preventive maintenance schedule is in place and is usually followed except for
higher priorities
(1) A preventive maintenance schedule is in place; but is often allowed to slide
(0) Little effort is made to prepare for emergencies |
Comments: |
|
C-1. Emergency Planning and Preparation |
19. (4) All personnel know immediately how to respond as a result of
effective planning, training, and drills (3) Most employees have a good understanding
of responsibilities as a result of plans, training, & drills
(2) There is an effective emergency response team; but others may be uncertain of their
responsibilities
(1) There is an effective emergency response plan; but training and drills are weak and
roles ma y be unclear
(0) Little effort is made to prepare for emergencies |
Comments: |
|
C-2. Emergency Planning and Preparation |
20. (4) Facility is fully equipped for emergencies, all systems and
equipment in place and regularly tested, all personnel know how to use equipment and
communicate during emergencies (3) Well equipped with appropriate emergency phones and
directions, most people know what to do
(2) Emergency phones, directions, and equipment in place; but only emergency teams know
what to do
(1) Emergency phones, directions, and equipment in place; but employees show little
awareness
(0) There is little evidence of an effective effort at providing emergency equipment
and information |
Comments: |
|
D-1. Medical Surveillance Program (as required) |
21. (4) Occupational health providers available on-site, fully involved
in hazard identification and training (3) Occupational health providers there when
needed and generally involved in assessment and training
(2) Occupational health providers are frequently consulted about significant health concerns
(1) Occupational health providers available; but normally concentrate on clinical issues
(0) Occupational health providers assistance is rarely requested or provided |
Comments: |
|
D-2. Medical Treatment Availability |
22. (4) Personnel fully trained in emergency medicine are always
available on-site (3) Personnel with basic first aid skills are always available
on-site and emergency care is close by
(2) Personnel with basic first aid skills are usually available with community assistance near-by
(1) Either on-site or near-by community aid is always available
(0) On-site and/or community aid can not be ensured at all times |
Comments: |
|
IV. SAFETY AND HEALTH TRAINING |
A. Employees learn hazards, how to protect themselves and others |
23. (4) Employees involved in hazard assessment, help develop and deliver
training, all are trained (3) Facility committed to high quality employee hazard
training, ensures all participate, regular updates
(2) Facility provides legally required training, makes effort to include all personnel
(1) Training is provided when need is apparent, experienced personnel assumed to know
material
(0) Facility depends on experienced and informal peer training to meet needs |
Comments: |
|
B-1. Supervisors learn responsibilities and underlying reasons |
24. (4) All supervisors assist in worksite analysis, ensure physical
protections, reinforce training, enforce discipline, and can explain work procedures (3)
Most supervisors assist in worksite analysis, ensure physical protections, reinforce
training, enforce discipline, and can explain work procedures
(2) Supervisors have received basic training, appear to understand and demonstrate
importance of worksite analysis, physical protections, training reinforcement, discipline,
knowledge of procedures
(1) Supervisors make reasonable effort to meet S&H responsibilities; but have
limited training
(0) There is no formal effort to train supervisors in safety and health
responsibilities |
Comments: |
|
B-2. Managers learn safety and health program management |
25. (4) All managers have received formal training in S&H management
and demonstrate full understanding (3) All managers follow, and can explain, their
roles in S&H program management
(2) Managers generally show a good understanding of their S&H management role and usually model it
(1) Managers are generally able to describe their S&H role; but often have trouble modeling it
(0) Managers generally show little understanding of their S&H management responsibilities |
Comments: |
|
Safety & Health Program Element |
Possible Score |
Actual Score |
Management Leadership |
36 |
|
Workplace Analysis |
28 |
|
Hazard Prevention and Control |
24 |
|
Safety and Health Training |
12 |
|
TOTALS |
100 |
|
PEP Program Evaluation Profile |
Management Leadership and Employee Participation |
Workplace Analysis |
Accident and Record Analysis |
Hazard Prevention and Control |
Emergency Response |
Safety and Health Training |
|
Outstanding |
5 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5 |
Superior |
4 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
4 |
Basic |
3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
3 |
Developmental |
2 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2 |
Absent or Ineffective |
1 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1 |
Score for element |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Overall Score |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
OSHA-195 (3/96)
Appendix D: Occupational Hazards by Location in the Nursing Home
Central supply
Biological/infectious wastes
Broken/malfunctioning equipment
Disinfectants/sterilizing agents
Ergonomic hazards: i.e., lifting, pushing/pulling
Latex allergy
Soaps, detergents
Corridors
Blocked or locked egress routes
Double door problems with travel paths
Loose electrical outlets
Loose safety rails
Slipping hazards from spills or broken or torn flooring
Environmental Services
Biological/infectious wastes
Cleaners/solvents
Climbing
Disinfectants/glutaraldehyde
Electrical
Ergonomic hazards: i.e., lifting, pushing/pulling, twisting
Hazardous wastes
Latex allergy
Sharps (needles, broken glass, etc.)
Soaps/detergents
Wet surfaces
Food service
Ammonia, chlorine
Cleaners (equipment)
Cold/heat stress
Drain cleaners
Disinfectants
Electrical
Ergonomic hazards: i.e., lifting, pushing/pulling, twisting, awkward positions
Egress hazards
Housekeeping
Lack of machine guards on food processing equipment
Latex allergy
Nonionizing radiation (microwaves)
Oven cleaners
Pesticides
Sanitation
Sharp objects: i.e., broken glass and dishes, knives, meat slicers
Soaps/detergents
Steam
Thermal burns
Wet floors/surfaces
Laboratory
Biological/infectious hazards
Latex allergy
Sharps: i.e., needles, lancets
Toxic chemicals: i.e., formaldehyde
Ventilation/hoods
Laundry
Biological/infectious hazards
Bleach
Detergents
Ergonomic hazards: i.e., pulling/pushing, lifting, folding, twisting
Egress hazards
Falls
Hazardous wastes
Heat stress
Latex allergy
Needle punctures
Unguarded belts and pulleys
Wet floors
Maintenance and Engineering
Climbing
Cold/heat stress
Compressed gases
Confined space
Cylinder storage
Electrical
Ergonomic hazards: i.e., lifting, pulling
Flammable liquids
Hazardous wastes
Noise
Steam
Tools, machinery
Toxic/hazardous substances: i.e., asbestos, carbon monoxide, additives of
adhesives/paints, freons, solvents, water treatment chemicals
Unguarded saws and grinders
Welding fumes
Office areas
Cleaning chemicals
Ergonomic hazards: i.e., static postures, repetitive motion
Trip hazards such as file drawers and electrical wires
Video display terminals
Patient care
Aerosolized medication
Aggression/violence
Biological/infectious hazards
Electrical
Ergonomic hazards: i.e., patient handling, lifting, pushing/pulling
Hazardous drugs
Latex allergy
Needle punctures
Radiation (x-rays)
Trip hazards
Wet floors
Pharmacy
Ergonomic hazards: i.e., static postures
Hazardous drugs
Latex allergy
Wet floors
Radiology
Biological/infectious hazards
Ergonomic hazards: i.e., patient handling, lifting, pulling
Latex allergy
Radiation - darkroom chemicals
Ventilation
Therapy services
Aggression/violence
Biological/infectious hazards
Ergonomic hazards: i.e., patient handling, lifting, pushing/pulling
Toxic substances from craft materials
Construction/Renovation area
Climbing (where applicable)
Confined space
Electrical
Elevated work surfaces
Fall hazards
Indoor air quality
Noise
Toxic/hazardous substances: i.e., asbestos, solvents, paint additives
Trip hazards
Vibration hazards
Note: This list demonstrates the variety of hazards that can be
found in nursing homes and should be used as a reference. It is not all inclusive. Stress
can occur in any area and is not included in the separate listings.

Appendix D
Hazard Categories of Agents Found in the Nursing Home Setting.
Hazard Categories |
Definition |
Examples Found in the Nursing home Setting |
Biological/Infectious |
Agents, such as viruses, bacteria, parasites, or fungi,
which may be transmitted via contact with infected patients or contaminated body
secretions/fluids to other individuals (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 (OSHA No. 101) may be used or the necessary facts can
be listed on a separate plain sheet of paper. These records must also be available in the
establishment without delay and at reasonable times for examination by representatives of
the Department of Labor and the Department of Health and Human Services, and States
accorded jurisdiction under the Act. The records must be maintained for a period of not
less than five years following the end of the calendar year to which they relate.
Such records must contain at least the following facts:
1) About the employer - name, mail address, and locations if different from mail address
2) About the injured or ill employee - name, social security number, home address, age, sex, occupation, and department.
3) About the accident or exposure to occupational illness -
place of accident or exposure, whether it was on employer's premises, what the employee
was doing when injured, and how the accident occurred.
4) About the occupational injury or illness - description of
the injury or illness, including part of body affected, name of the object or substance
which directly injured the employee, and date of injury or diagnosis of illness.
5) Other - name and address of physician, if hospitalized,
name and address of hospital, date of report, and name and position of person preparing
the report.
SEE DEFINITIONS ON THE BACK OF OSHA FORM 200.
OMB DISCLOSURE STATEMENT
We estimate that it will take an average of 20 minutes to complete this form including
time for reviewing instructions; searching, gathering and maintaining the data needed; and
completing and reviewing the form. If you have any comments regarding this estimate or any
other aspect of this recordkeeping system, send then to the Bureau of Labor Statistics,
Division of Management Systems (1220-0029), Washington, D.C. 20212 and to the Office of
management and Budget, Paperwork Reduction Project (1220-0029), Washington, D.C. 20503. |
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
I. Log and Summary of Occupational Injuries and Illnesses
Each employer who is subject to the recordkeeping requirements of the Occupational
Safety and Health Act of 1970 must maintain for each establishment a log of all recordable
occupational injuries and illnesses. This form (OSHA No. 200) may be used for that
purpose. A substitute for the OSHA No. 200 is acceptable if it is as detailed, easily
readable, and understandable as the OSHA No. 200.
Enter each recordable case on the log within six (6) workdays after learning of its
occurrence. Although other records must be maintained at the establishment to which they
refer, it is possible to prepare and maintain the log at another location, using data
processing equipment if desired. If the log is prepared elsewhere, a copy updated to
within 45 calendar days must be present at all times in the establishment.
Logs must be maintained and retained for five (5) years following the end of the
calendar year to which they relate. Logs must be available (normally at the establishment)
for inspection and copying by representatives of the Department of Labor, or the
Department of Health and Human Services, or States accorded jurisdiction under the Act.
Access to the log is also provided to employees, former employees and their
representatives.
II. Changes in Extent of or Outcome of Injury or Illness
If, during the 5-year period the log must be retained, there is a change in an extent
and outcome of an injury or illness which affects entries in columns 1, 2, 6, 8, 9, or 13,
the first entry should be lined out and a new entry made. For example, if an injured
employee at first required only medical treatment but later lost workdays away from work,
the check in column 6 should be lined out, and checks entered in columns 2 and 3 and the
number of lost workdays entered in column 4.
In another example, if an employee with an occupational illness lost workdays, returned
to work, and then died of the illness, and entries in columns 9 through 12 should be lined
out and the date of death entered in column 8.
The entire entry for an injury or illness should be lined out if later found to be
nonrecordable. For example: an injury which is later determined not to be work related, or
which was initially through to involve medical treatment but later was determined to have
involved only first aid.
III. Posting Requirements
A copy of the totals and information following the fold line of the last page for the
year must be posted at each establishment in the place or places where notices to
employees are customarily posted. This copy must be posted no later than February
1 and must remain in place until March 1.
Even though there were no injuries or illnesses during the year, zeros must be entered
on the totals line, and the form posted.
The person responsible for the annual summary totals shall
certify that the totals are true and completed by signing at the bottom of the form.
IV. Instructions for Completing Log and Summary of Occupational Injuries and Illnesses
Column A - CASE OR FILE NUMBER. Self-explanatory.
Column B - DATE INJURY OR ONSET OF ILLNESS.
For occupational injuries, enter the date of the work accident which resulted in
injury. For occupational illnesses, enter the date of initial diagnosis of illness, or if
absence from work occurred before diagnosis, enter the first day of the absence
attributable to the illness which was later diagnosed or recognized.
Columns
C through F - Self explanatory.
Columns
1 and 8 - INJURY OR ILLNESS-RELATED DEATHS. Self-explanatory.
Columns
2 and 9 - INJURIES OR ILLNESSES WITH LOST WORKDAYS. Self-explanatory.
Any injury which involves days away from work, or days of restricted work activity, or
both must be recorded since it always involves one or more of the criteria for
recordability.
Columns
3 and 10 - INJURIES OR ILLNESSES INVOLVING DAYS AWAY FROM WORK. Self-explanatory.
Columns
4 and 11 - LOST WORKDAYS--DAYS AWAY FROM WORK.
Enter the number of workdays (consecutive or not) on which the employee would have
worked but could not because of occupational injury or illness. The number of lost
workdays should not include the day of injury or onset of illness or any days on which the
employee would not have worked even though able to work.
NOTE: For employees not having a regularly scheduled shift, such as
certain truck drivers, construction workers, farm labor, casual labor, part-time
employees, etc., it may be necessary to estimate the number of lost workdays. Estimates of
lost workdays shall be based on prior work history of the employee AND days worked by
employees, not ill or injured, working in the department and/or occupation of the ill or
injured employee.
Columns
5 and 12 - LOST WORKDAYS--DAYS OF RESTRICTED WORK ACTIVITY.
Enter the number of workdays (consecutive or not) on which because of injury and illness:
(1) the employee was assigned to another job on a temporary basis, or
(2) the employee worked at a permanent job less than full time, or
(3) the employee worked at a permanently assigned job but could not perform all duties normally connected with it.
The number of lost workdays should not include the day of injury or onset of illness or
any days on which the employee would not have worked even though able to work.
Columns
6 and 13 - INJURIES OR ILLNESSES WITHOUT LOST WORKDAYS. Self-explanatory.
Columns 7a through 7g - TYPE OF ILLNESS.
Enter a check in only one column for each illness.
TERMINATION OR PERMANENT TRANSFER-Place an asterisk to the right of
the entry in columns 7a through 7g (type of illness) which represented a termination of
employment or permanent transfer.
V. Totals
Add number of entries in columns 1 and 8.
Add number of checks in columns 2, 3, 6, 7, 9, 10, and 13.
Add number of days in columns 4, 5, 11, and 12.
Yearly totals for each column (1-13) are required for posting. Running or page totals
may be generated at the discretion of the employer.
If an employee's loss of workdays is continuing at the time the totals are summarized,
estimate that number of future workdays the employee will lose and add that estimate to
the workdays already lost and include this figure in the annual totals. No further entries
are to be made with respect to such cases in the next year's log.
VI. Definitions
OCCUPATIONAL INJURY is any injury such as a cut, fracture, sprain,
amputation, etc., which results from a work accident or from an exposure involving a
single incident in the work environment.
NOTE: Conditions resulting from animal bites, such as insect or snake
bites or from one-time exposure to chemicals, are considered to be injuries.
OCCUPATIONAL ILLNESS of an employee is any abnormal condition or
disorder, other than one resulting from an occupational injury, caused by exposure to
environmental factors associated with employment. It includes acute and chronic illnesses
or diseases which may be caused by inhalation, absorption, ingestion, or direct contact.
The following listing gives the categories of occupational illnesses and disorders that
will be utilized for the purpose of classifying recordable illnesses. For purposes of
information, examples of each category are given. These are typical examples, however, and
are not to be considered the complete listing of the types of illnesses and disorders that
are to be counted under each category.
7a. Occupational Skin Diseases or Disorders
Examples: Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers
of poisonous plants; oil acne; chrome ulcers; chemical burns or inflammations; etc.
7b. Dust Diseases of the Lungs (Pneumoconioses)
Examples: Silicosis, asbestosis and other asbestos-related diseases, coal worker's
pneumoconiosis, byssinosis, siderosis, and other pneumoconioses.
7c. Respiratory Conditions Due to Toxic Agents
Examples: Pneumonitis, pharyngitis, rhinitis or acute congestion due to chemical, dusts,
gases, or fumes; farmer's lung; etc.
7d. Poisoning (Systemic Effect of Toxic Materials)
Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals; poisoning by
carbon monoxide, hydrogen sulfide, or other gases; poisoning by benzol, carbon
tetrachloride, or other organic solvents; poisoning by insecticide sprays such as
parathion, lead arsenate; poisoning by other chemicals such as formaldehyde, plastics, and
resins; etc.
7e. Disorders Due to Physical Agents (Other than Toxic Materials)
Examples: Heatstroke, sunstroke, heat exhaustion, and other effects of environmental heat;
freezing, frostbite, and effects of exposure to low temperatures; caisson disease; effects
of ionizing radiation (isotopes, X-rays, radium); effects of nonionizing radiation
(welding flash, ultraviolet rays, microwaves, sunburn); etc.
7f. Disorders Associated With Repeated Trauma
Examples: Noise-induced hearing loss; synovitis, tenosynovitis, and bursitis; Raynaud's
phenomena; and other conditions due to repeated motion, vibration, or pressure.
7g. All Other Occupational Illnesses
Examples: Anthrax, brucellosis, infections hepatitis, malignant and benign tumors, food
poisoning, histoplasmosis, coccidioidomycosis, etc.
MEDICAL TREATMENT includes treatment (other than first aid)
administered by a physician or by registered professional personnel under the standing
orders of a physician. Medical treatment does NOT include first-aid treatment(one-time
treatment and subsequent observation of minor scratches, cuts, burns, splinters, and so
forth, which do not ordinarily require medical care) even though provided by a physician
or registered professional personnel.
ESTABLISHMENT: A single physical location where business is conducted
or where services or industrial operations are performed (for example: a factory, mill,
store, hotel, restaurant, movie theater, farm, ranch, bank, sales office, warehouse, or
central administrative office.) Where distinctly separate activities are performed at a
single physical location, such as construction activities operated from the same physical
location as a lumber yard, each activity shall be treated as a separate establishment.
For firms engaged in activities which may be physically dispersed, such as agriculture;
construction; transportation; communications; and electric, gas, and sanitary services,
records may be maintained at a place to which employees report each day.
Records for personnel who do not primarily report or work at a single establishment,
such as traveling salesman, technicians, engineers, etc., shall be maintained at the
location from which they are paid or the base from which personnel operate to carry out
their activities.
WORK ENVIRONMENT is comprised of the physical location, equipment,
materials processed or used, and the kinds of operations performed in the course of an
employee's work, whether on or off the employer's premises.
Appendix F: Identifying Risk Factors for Occupational Injuries
and Illnesses In Nursing Homes
Underlying an incident or a trend of occupational injuries or illnesses are risk
factors that contribute to their occurrence or development. A combination of risk factors
rather than any single risk factor may be responsible. Prevention of the work-related
injury or illness may be accomplished by controlling employee exposure to the workplace
risk factors that can cause them. Through observation, environmental monitoring, and
discussions with the workers all the risk factors which may be present in the job should
be identified. Then controls that will eliminate or reduce the identified risk factors can
be selected.
The first step in identifying risk factors is to examine injury and illness records to
determine any trends with regard to occupation, nature of disabling condition, part of the
body affected, event or exposure causing the injury or illness, and the source directly
producing the disability.
Example: Suppose that an analysis of the OSHA 200
and associated workers' compensation records for a nursing home show a trend of nursing
assistants with low back pain associated with lifting or transferring residents. Low back
pain is a musculoskeletal disorder.
Moving residents is not the same as lifting in most industrial jobs. Variables such
as distance, force required, frequency and coupling (good place to grasp) do not stay
constant. In addition, the resident may actively resist being moved.
A. Potential risk factors for resident handling back injuries include:
Weight
Moving a person who has limited ability to assist has caused low back pain and
disability among health care workers. There are many reasons why the injury occurs
including overexertion, fitness, skill, work conditions, resident condition, and moves per
shift to name a few variables. An adult resident who has a limited ability to assist with
a transfer or lift, weighs enough to cause a back injury to the worker.
Distance
Weight is important, but increasing the distance between the lower back and the hands
has the effect of multiplying the weight moved by the back. Therefore, factors that
separate the worker from the resident contribute to back injuries. Some factors would
include but are not limited to the following:
- IV bag stands
- Bed rails
- Wheel chairs without moveable arms
- Geri-chairs
- Furniture near the bed.
Activity
Moving a resident can bring together the elements of weight, distance and awkward
posture that result in a back injury. The most common activities associated with back
injury include but are not limited to the following:
- Moving a totally dependent resident
- Moving a combative resident
- Transfer from the floor
- Lateral transfer - moving a resident from one horizontal position to another
- Bed to chair or chair to bed transfer (i.e., to/from Clinitron bed)
- Chair to chair (i.e., to/from geri-chair, toilet)
- Bathing
- Repositioning in bed or chair
- Weighing a resident
- Positioning a bed pan or changing incontinence pads
- Attempting to stop a resident's fall.
Nursing assistants who routinely move residents are well qualified to identify which
tasks they find most stressful to their backs. The easiest way to learn which tasks are
the most difficult is to ask the workers; this can be done individually or at the
debriefing session between shifts. Other elements that increase the risk of injury when
moving a resident include but are not limited to the following:
- Floor conditions [such as cluttered, uneven, wet/slippery (water, urine, etc.,)]
- Not enough room to maneuver
- Carrying for more than 3 feet a resident who can not bear much weight
- Poor lighting
- Poorly maintained equipment
- Poor grip on the resident due to special medical conditions
- Fatigue from handling residents more than a total of 20 times per shift
- Pushing and pulling while repositioning, or moving wheelchairs or carts
- Pushing or pulling a gel mattress
- Grasping a lift sheet or sling without handles
- Grasping a gait belt
B. In addition to the risk factors that relate directly to the lifting
activity, awkward postures, separately or in combination with
forward exertions may cause or contribute to an injury/illness of the back. To be
considered a risk factor, an awkward posture needs to last more than 1 hour continuously,
or a total of 4 hours in the workshift and occur during three or more workshifts per week.
Postures determine which muscles are used in an activity and how forces are translated
from the muscles to the object being handled.
- More muscular force is required when awkward postures are used because muscles cannot
perform efficiently;
- Fixed awkward postures (i.e., holding the arm out straight for several minutes)
contribute to muscle and tendon fatigue, and joint soreness;
- Forces on the spine increase when lifting, lowering or handling objects with the back
bent or twisted. This occurs because the muscles must handle the body weight in addition
to the load in the hands.
While awkward postures can create risk factors it is important to allow flexible joints
like the back to move. A good rule of thumb for flexible joints is to use them, or lose
them, but don't abuse them. Therefore, the combination of the risk factors needs to be
considered.
Awkward back postures include bending backward (hyperextension > 20, Figure 1), mild
forward bending (20 to 45 see Figure 2), severe forward bending (>45 back flexion, see
Figure 3), bending to either side (lateral bending, see Figure 4), and twisting of the
back (see Figure 5). Activities which can put the back in an awkward postures include but
are not limited to the following:
- lifting/lowering
- stooping over to change sheets
- manually adjusting the position of the bed
- bending to bath a resident.
Awkward Back Postures

Appendix G
Examples of OSHA Standards Requiring Training
Standard |
When Required |
29 CFR 1910.1200 Hazard Communication |
Initially and when new chemicals are introduced |
29 CFR 1910.1030 Bloodborne Pathogens |
Initially and annually |
29 CFR 1910.147 Lock-out/Tag-out |
Initially and when equipment or processes change or periodic inspection
indicates |
29 CFR 1910.132 Personal Protective Equipment |
Initially and when changes to workplace render previous training obsolete
or when employees show improper use or other inadequacies in use of PPE |
29 CFR 1910.20 Access to Employee Exposure and Medical Records |
Initially and annually |
29 CFR 1910.332 Electrical |
Initially |
29 CFR 1910.38 Employee Emergency Plans and Fire Prevention Plans |
Initially and annually and whenever responsibilities or plan are changed |
29 CFR 1926.1101 Asbestos |
1. Maintenance and repair operations that disturb asbestos containing
materials (repair or replace asbestos flanges, repair boilers or piping with asbestos
wrap) 2. Housekeeping and custodial operations that contact asbestos-containing
materials (vinyl asbestos floors, clean-up of dust or debris from maintenance operations
as described above) |
Note: This list shows examples of OSHA Standards requiring training. It is not meant to be all inclusive.
Appendix H
References
Ashford, Nicholas A. and Caldart, Charles C. Technology, Law and the Working
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Appendix I
U.S. Department of Labor
Occupational Safety and Health Administration
Regional Offices
Region I
(CT*,MA,ME,NH,RI,VT*)
JFK Federal Building
Room E-340
Boston, MA 02203
Telephone: (617) 565-9860
Region II
(NJ,NY*,PR*,VI*)
201 Varick Street
Room 670
New York, NY 10014
Telephone: (212) 337-2378
Region III
(DC,DE,MD*,PA,VA*,WV)
Gateway Building, Suite 2100
3535 Market Street
Philadelphia, PA 19104
Telephone: (215) 596-1201
Region IV
(AL,FL,GA,KY*,MS,NC*,SC*,TN*)
61 Forsyth Street, S.W.
Atlanta, GA 30303
Telephone (404) 562-2300
Region V
(IL,IN*,MI*,MN*,OH,WI)
230 South Dearborn Street
Room 3244
Chicago, IL 60604
Telephone: (312) 353-2220
Region VI
(AR,LA,NM*,OK,TX)
525 Griffin Street
Room 602
Dallas, TX 75202
Telephone: (214) 767-4731
Region VII
(IA*,KS,MO,NE)
City Center Square
1100 Main Street, Suite 800
Kansas City, MO 64105
Telephone: (816) 426-5861
Region VIII
(CO,MT,ND,SD,UT*,WY*)
Suite 1690
1999 Broadway
Denver, CO 80202-5716
Telephone: (303) 844-1600
Region IX
(American Samoa, AZ*,CA*,Guam,HI*,NV*,Trust Territories of the Pacific)
71 Stevenson Street
Room 420
San Francisco, CA 94105
Telephone: (415) 975-4310
Region X
(AK*,ID,OR*,WA*)
1111 Third Avenue
Suite 715
Seattle, WA 98101-3212
Telephone: (206) 553-5930
*These states and territories operate their own OSHA-approved job safety and health
programs (Connecticut and New York plans cover public employees only.) States with
approved programs must have a standard that is identical to, or at least as effective as,
the federal standard.
Electronic Revision Date: 4 April 2000
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