Guidelines

for Nursing

Homes

OSHA 3182-3R 2009

Ergonomics

for the Prevention of

Musculoskeletal Disorders

Guidelines for Nursing Homes

Ergonomics for the Prevention

of Musculoskeletal Disorders

U.S. Department of Labor

Elaine L. Chao, Secretary

Occupational Safety and Health Administration

John L. Henshaw, Assistant Secretary

OSHA 3182-3R 2009

Guidelines for Nursing Homes 1
2 Guidelines for Nursing Homes
Table of Contents

5 Executive Summary

7 SECTION I:

Introduction

9 SECTION II:

A Process for Protecting Workers

9 Provide Management Support

9 Involve Employees

10 Identify Problems

10 Implement Solutions

10 Address Reports of Injuries

11 Provide Training

11 Evaluate Ergonomics Efforts

12 SECTION III:

Identifying Problems and Implementing Solutions for Resident

Lifting and Repositioning

12 Identifying Problems for Resident Lifting and Repositioning

■ Figure 1. Transfer to and from: Bed to Chair, Chair to Toilet,

Chair to Chair, or Car to Chair

■ Figure 2. Lateral Transfer to and from: Bed to Stretcher, Trolley

■ Figure 3. Transfer to and from: Chair to Stretcher

■ Figure 4. Reposition in Bed: Side-to-Side, Up in Bed

■ Figure 5. Reposition in Chair: Wheelchair and Dependency Chair

■ Figure 6. Transfer a Patient Up From the Floor

17 Implementing Solutions for Resident Lifting and Repositioning

■ Transfer from Sitting to Standing Position

■ Resident Lifting

■ Repositioning in Chair

■ Ambulation

■ Lateral Transfer; Repositioning

■ Lateral Transfer in Sitting Position

■ Transfer from Sitting to Standing Position

■ Weighing

■ Transfer from Sitting to Standing Position; Ambulation

■ Repositioning

■ Bathtub, Shower, and Toileting Activities

Guidelines for Nursing Homes 3
27 SECTION IV:

Identifying Problems and Implementing Solutions for

Activities Other than Resident Lifting and Repositioning

■ Storage and Transfer of Food, Supplies, and Medications

■ Mobile Medical Equipment

■ Working with Liquids in Housekeeping

■ Working with Liquids in Kitchens

■ Hand Tools

■ Linen Carts

■ Handling Bags

■ Reaching into Sink

■ Loading or Unloading Laundry

■ Cleaning Rooms (Wet Method)

■ Cleaning Rooms (Electrical)

31 SECTION V:

Training

31 Nursing Assistants and Other Workers at Risk of Injury

31 Training for Charge Nurses and Supervisors

31 Training for Designated Program Managers

33 SECTION VI:

Additional Sources of Information

35 References

36 Appendix: A Nursing Home Case Study

Table of Contents

4 Guidelines for Nursing Homes
These guidelines provide

recommendations for nursing home

employers to help reduce the number

and severity of work-related musculoskeletal disorders (MSDs) in their

facilities. MSDs include conditions

such as low back pain, sciatica,

rotator cuff injuries, epicondylitis,

and carpal tunnel syndrome. The

recommendations in these guidelines

are based on a review of existing

practices and programs, State OSHA

programs, as well as available

scientific information, and reflect

comments received from representatives

of trade and professional associations,

labor organizations, the medical

community, individual firms,

and other interested parties. OSHA

thanks the many organizations

and individuals involved for their

thoughtful comments, suggestions,

and assistance.

More remains to be learned about

the relationship between workplace

activities and the development of

MSDs. However, OSHA believes

that the experiences of many nursing

homes provide a basis for taking

action to better protect workers.

As the understanding of these injuries

develops and information and

technology improve, the recommendations made in this document may

be modified.

Executive Summary

Although these guidelines are

designed specifically for nursing

homes, OSHA hopes that employers

with similar work environments, such

as assisted living centers, homes for

the disabled, homes for the aged,

and hospitals will also find this

information useful.

OSHA also recognizes that small

employers, in particular, may not

have the need for as comprehensive a

program as would result from

implementation of every action and

strategy described in these guidelines.

Additionally, OSHA realizes that

many small employers may need

assistance in implementing an

appropriate ergonomics program.

That is why we emphasize the

availability of the free OSHA

consultation service for smaller

employers. The consultation service is

independent of OSHA’s enforcement

activity and will be making special

efforts to provide help to the nursing

home industry.

These guidelines are advisory in

nature and informational in content.

They are not a new standard or

regulation and do not create any new

OSHA duties. Under the OSH Act,

the extent of an employer’s obligation

to address ergonomic hazards is

governed by the general duty clause,

29 U.S.C. 654(a)(1).

Guidelines for Nursing Homes 5
An employer’s failure to implement

the guidelines is not a violation, or

evidence of a violation, and may not

be used as evidence of a violation, of

the general duty clause. Furthermore,

the fact that OSHA has developed

this document is not evidence and

may not be used as evidence of an

employer’s obligations under the

general duty clause; the fact that a

measure is recommended in this

document but not adopted by an

employer is not evidence, and may

not be used as evidence, of a

violation of the general duty clause.

In addition, the recommendations

contained herein should be adapted

to the needs and resources of each

individual place of employment.

Thus, implementation of the guidelines may differ from site to site

depending on the circumstances

at each particular site.

While specific measures may

differ from site to site, OSHA

recommends that:

■ Manual lifting of residents be

minimized in all cases and

eliminated when feasible.

■ Employers implement an effective

ergonomics process that:

■ provides management support;

■ involves employees;

■ identifies problems;

■ implements solutions;

■ addresses reports of injuries;

■ provides training; and

■ evaluates ergonomics efforts.

These guidelines elaborate on

these recommendations, and include

additional information employers

can use to identify problems and

train employees. Of particular value

are examples of solutions employers

can use to help reduce MSDs in their

workplace. Recommended solutions

for resident lifting and repositioning

are found in Section III, while

recommended solutions for other

ergonomic concerns are in Section

IV. The appendix includes a case

study describing the process one

nursing home used to reduce MSDs.

Executive Summary

6 Guidelines for Nursing Homes
Nursing homes that have

implemented injury prevention efforts

focusing on resident lifting and

repositioning methods have achieved

considerable success in reducing

work-related injuries and associated

workers’ compensation costs. Providing a safer and more comfortable

work environment has also resulted in

additional benefits for some facilities,

including reduced staff turnover and

associated training and administrative

costs, reduced absenteeism, increased

productivity, improved employee

morale, and increased resident

comfort. These guidelines provide

recommendations for employers to

help them reduce the number and

severity of work-related musculoskeletal disorders in their facilities using

methods that have been found to be

successful in the nursing home

environment.

Providing care to nursing home

residents is physically demanding

work. Nursing home residents often

require assistance to walk, bathe, or

perform other normal daily activities.

In some cases residents are totally

dependent upon caregivers for

mobility. Manual lifting and other

tasks involving the repositioning of

residents are associated with an

increased risk of pain and injury to

caregivers, particularly to the back (2,

3). These tasks can entail high physical

demands due to the large amount

SECTION I

Introduction

of weight involved, awkward postures

that may result from leaning over a

bed or working in a confined area,

shifting of weight that may occur if a

resident loses balance or strength

while moving, and many other

factors. The risk factors that workers

in nursing homes face include:

■ Force - the amount of physical

effort required to perform a task

(such as heavy lifting) or to maintain control of equipment or tools;

■ Repetition - performing the same

motion or series of motions continually or frequently; and

■ Awkward postures - assuming

positions that place stress on the

body, such as reaching above

shoulder height, kneeling,

squatting, leaning over a bed, or

twisting the torso while lifting (3).

Wyandot County Nursing Home in Upper

Sandusky, Ohio, has implemented a policy

of performing all assisted resident

transfers with mechanical lifts, and has

purchased electrically adjustable beds.

According to Wyandot, no back injuries

from resident lifting have occurred in over

five years. The nursing home also reported

that workers’ compensation costs have

declined from an average of almost

$140,000 per year to less than $4,000 per

year, reduced absenteeism and overtime

have resulted in annual savings of

approximately $55,000, and a reduction in

costs associated with staff turnover has

saved an additional $125,000 (1). (see

Reference List)

Guidelines for Nursing Homes 7
Excessive exposure to these risk

factors can result in a variety of

disorders in affected workers (3, 5).

These conditions are collectively

referred to as musculoskeletal

disorders, or MSDs. MSDs include

conditions such as low back pain,

sciatica, rotator cuff injuries,

epicondylitis, and carpal tunnel

syndrome (6). Early indications of

MSDs can include persistent pain,

restriction of joint movement, or soft

tissue swelling (3, 7).

While some MSDs develop gradually over time, others may result

from instantaneous events such as a

single heavy lift (3). Activities outside

of the workplace that involve

substantial physical demands may

also cause or contribute to MSDs (6).

In addition, development of MSDs

may be related to genetic causes,

gender, age, and other factors (5, 6).

Finally, there is evidence that reports

of MSDs may be linked to certain

psychosocial factors such as job

dissatisfaction, monotonous work,

and limited job control (5, 6). These

guidelines address only physical

factors in the workplace that are

related to the development of MSDs.

After implementing a program designed

to eliminate manual lifting of residents,

Schoellkopf Health Center in Niagara

Falls, New York, reported a downward

trend in the number and severity of

injuries, with lost workdays dropping

from 364 to 52, light duty days

dropping from 253 to 25, and workers’

compensation losses falling from

$84,533 to $6,983 annually (4).

At Citizens Memorial Health Care Facility

in Bolivar, Missouri, establishment of an

ergonomics component in the existing

safety and health program was reportedly

followed by a reduction in the number of

OSHA-recordable lifting-related injuries of

at least 45% during each of the next four

years, when compared to the level of

injuries prior to the ergonomics efforts.

The number of lost workdays associated

with lifting-related injuries was reported

to be at least 55% lower than levels

during each of the previous four years.

Citizens Memorial reported that these

reductions contributed to a direct savings

of approximately $150,000 in workers’

compensation costs over a five year

period (8).

Introduction

8 Guidelines for Nursing Homes
The number and severity of

injuries resulting from physical

demands in nursing homes — and

associated costs — can be substantially reduced (2, 9). Providing an

alternative to manual resident lifting

is the primary goal of the ergonomics

process in the nursing home setting

and of these guidelines. OSHA

recommends that manual lifting of

residents be minimized in all cases

and eliminated when feasible. OSHA

further recommends that employers

develop a process for systematically

addressing ergonomics issues in their

facilities, and incorporate this

process into an overall program to

recognize and prevent occupational

safety and health hazards.

An effective process should be

tailored to the characteristics of

the particular nursing home but

OSHA generally recommends the

following steps:

Provide Management Support

Strong support by management

creates the best opportunity for

success. OSHA recommends that

employers develop clear goals, assign

responsibilities to designated staff

members to achieve those goals,

provide necessary resources, and

ensure that assigned responsibilities

are fulfilled. Providing a safe and

healthful workplace requires a

SECTION II

A Process for Protecting Workers

sustained effort, allocation of

resources, and frequent follow-up

that can only be achieved through

the active support of management.

Involve Employees

Employees are a vital source of

information about hazards in their

workplace. Their involvement adds

problem-solving capabilities and

hazard identification assistance,

enhances worker motivation and job

satisfaction, and leads to greater

acceptance when changes are made

in the workplace. Employees can:

■ submit suggestions or concerns;

■ discuss the workplace and

work methods;

■ participate in the design of

work, equipment, procedures,

and training;

■ evaluate equipment;

■ respond to employee surveys;

■ participate in task groups with

responsibility for ergonomics; and

■ participate in developing the nursing home’s ergonomics process.

Guidelines for Nursing Homes 9
An Identify Problems

Nursing homes can more

successfully recognize problems by

establishing systematic methods for

identifying ergonomics concerns in

their workplace. Information about

where problems or potential

problems may occur in nursing

homes can be obtained from a

variety of sources, including OSHA

300 and 301 injury and illness

information, reports of workers’

compensation claims, accident and

near-miss investigation reports,

insurance company reports,

employee interviews, employee

surveys, and reviews and observations

of workplace conditions. Once

information is obtained, it can be

used to identify and evaluate elements

of jobs that are associated

with problems. Sections III and IV

contain further information on

methods for identifying ergonomics

concerns in the nursing home

environment.

Implement Solutions

When problems related to

ergonomics are identified, suitable

options can then be selected and

implemented to eliminate hazards.

Effective solutions usually involve

workplace modifications that

eliminate hazards and improve the

work environment. These changes

usually include the use of equipment,

work practices, or both. When

choosing methods for lifting and

repositioning residents, individual

factors should be taken into account.

Such factors include the resident’s

rehabilitation plan, the need to restore

the resident’s functional abilities,

medical contraindications, emergency

situations, and resident dignity and

rights. Examples of solutions can be

found in Sections III and IV.

Address Reports of Injuries

Even in establishments with

effective safety and health programs,

injuries and illnesses may occur.

Work-related MSDs should be

managed in the same manner and

under the same process as any other

occupational injury or illness (10).

Like many injuries and illnesses,

employers and employees can benefit

from early reporting of MSDs. Early

diagnosis and intervention, including

alternative duty programs, are

particularly important in order to

limit the severity of injury, improve

the effectiveness of treatment,

minimize the likelihood of disability

or permanent damage, and reduce

the amount of associated workers’

compensation claims and costs.

OSHA’s injury and illness recording

and reporting regulation (29 CFR

1904) requires employers to keep

records of work-related injuries and

illnesses. These reports can help the

nursing home identify problem areas

A Process for Protecting Workers

10 Guidelines for Nursing Homes
and evaluate ergonomic efforts.

Employees may not be discriminated

against for reporting a work-related

injury or illness. [29 U.S.C. 660(c)]

ProvideTraining

Training is necessary to ensure

that employees and managers can

recognize potential ergonomics issues

in the workplace, and understand

measures that are available to

minimize the risk of injury. Ergonomics training can be integrated

into general training on performance

requirements and job practices.

Effective training covers the problems

found in each employee’s job. More

information on training can be found

in Section V.

Evaluate Ergonomics Efforts

Nursing homes should evaluate

the effectiveness of their ergonomics

efforts and follow-up on unresolved

problems. Evaluation helps sustain

the effort to reduce injuries and

illnesses, track whether or not

ergonomic solutions are working,

identify new problems, and show

areas where further improvement is

needed. Evaluation and follow-up are

central to continuous improvement

and long-term success. Once solutions

are introduced, OSHA recommends

that employers ensure they are

effective. Various indicators (e.g.,

OSHA 300 and 301 information

data and workers’ compensation

reports) can provide useful empirical

data at this stage, as can other techniques such as employee interviews.

For example, after introducing a new

lift at a nursing home, the employer

should follow-up by talking with

employees to ensure that the problem

has been adequately addressed. In

addition, interviews provide a

mechanism for ensuring that the

solution is not only in place, but is

being used properly. The same methods

that are used to identify problems in

many cases can also be used for

evaluation.

A Process for Protecting Workers

Guidelines for Nursing Homes 11
Identifying Problems

for Resident Lifting

and Repositioning

Assessing the potential for work

to injure employees in nursing homes

is complex because typical nursing

home operations involve the repeated

lifting and repositioning of the

residents. Resident lifting and

repositioning tasks can be variable,

dynamic, and unpredictable in

nature. In addition, factors such as

resident dignity, safety, and medical

contraindications should be taken

into account. As a result, specific

techniques are used for assessing

resident lifting and repositioning

tasks that are not appropriate for

assessing the potential for injury

associated with other nursing

home activities.

An analysis of any resident lifting

and repositioning task involves an

assessment of the needs and abilities

of the resident involved. This

assessment allows staff members to

account for resident characteristics

while determining the safest methods

for performing the task, within the

context of a care plan that provides

for appropriate care and services for

the resident. Such assessments

typically consider the resident’s

safety, dignity and other rights, as

well as the need to maintain or

restore a resident’s functional abilities.

SECTION III

A Identifying Problems and Implementing Solutions

for Resident Lifting and Repositioning

The resident assessment should

include examination of factors

such as:

■ the level of assistance the resident

requires;

■ the size and weight of the resident;

■ the ability and willingness of

the resident to understand and

cooperate; and

■ any medical conditions that may

influence the choice of methods

for lifting or repositioning.

These factors are critically

important in determining

appropriate methods for lifting and

repositioning a resident. The size

and weight of the resident will, in

some situations, determine which

equipment is needed and how many

caregivers are required to provide

assistance. The physical and mental

abilities of the resident also play an

important role in selecting

appropriate solutions. For example,

a resident who is able and willing to

partially support their own weight

may be able to move from his or her

bed to a chair using a standing assist

device, while a mechanical sling lift

may be more appropriate for those

residents who are unable to support

their own weight. Other factors

related to a resident’s condition may

need to be taken into account as

well. For instance, a resident who

has recently undergone hip

replacement surgery may require

specialized equipment for assistance

in order to avoid placing stress on

the affected area.

A number of protocols have been

developed for systematically examining

resident needs and abilities and/or

12 Guidelines for Nursing Homes
■ For seated transfer aid, must have chair with arms that

recess or are removable.

■ For full body sling lift, select a lift that was specifically

designed to access a patient from the car (if the car is

the starting or ending destination).

■ If partial weight bearing, transfer toward stronger side.

■ Toileting slings are available for toileting.

■ Bathing mesh slings are available for bathing.

Seated transfer aid; may use gait/transfer belt until the

patient is proficient in completing transfer independently.

Yes

Yes

No

Is the patient

cooperative?

Can patient

bear weight? Fully

Partially

Stand and pivot technique using a gait/transfer belt

(1 caregiver) -or- powered standing assist lift

(1 caregiver)

Use full body sling lift and

2 caregivers.

Caregiver assistance not needed;

stand by for safety as needed.

Is the patient

cooperative?

No

Yes

No

No

Does the

patient have

upper extremity

strength?

Caregiver assistance not needed;

stand by for safety as needed.

If patient is <100 pounds:

Use a lateral sliding aid and 2 caregivers.

If patient is 100-200 pounds:

Use a lateral sliding aid -or- a friction reducing

device and 2 caregivers.

If patient is >200 pounds: Use a lateral sliding aid

and 3 caregivers -or- a friction-reducing device or

lateral transfer device and 2 caregivers -ora mechanical lateral transfer device.

Can patient assist?

Partially Able

Not At All Able

Source: The Patient Safety Center of Inquiry (Tampa, FL).

Veterans Health Administration & Department of Defense.

October 2001.

Source: The Patient Safety Center of Inquiry (Tampa, FL). Veterans

Health Administration & Department of Defense. October 2001.

Yes

■ Surfaces should be even for lateral patient moves.

■ For patients with Stage III or IV pressure ulcers, care

must be taken to avoid shearing force.

FIGURE 1 Transfer to and from: Bed to Chair, Chair to Toilet, Chair to Chair, or Car to Chair

FIGURE 2 Lateral Transfer to and from: Bed to Stretcher, Trolley

Guidelines for Nursing Homes 13

Identifying Problems and Implementing Solutions

for Resident Lifting and Repositioning
for recommending procedures and

equipment to be used for performing

lifting and repositioning tasks. The

following are some examples:

■ The Resident Assessment Instrument,

published by the Centers for

Medicare and Medicaid Services

(CMS), provides a structured,

standardized approach for assessing

resident capabilities and needs

that results in a care plan for each

resident. Caregivers can use this

information to help them determine

the appropriate method for lifting

or repositioning residents. Many

nursing homes use this system to

comply with CMS requirements

for nursing homes. Employers

can access this information from

www.cms.hhs.gov/medicaid/

mds20/.

■ Patient Care Ergonomics Resource

Guide: Safe Patient Handling and

Movement is published by the

Patient Safety Center of Inquiry,

Veterans Health Administration and

the Department of Defense. This

document provides flow charts

(shown here in Figures 1-6) that

address relevant resident assessment

factors and recommends solutions

for resident lifting and repositioning

problems. This material is one

example of an assessment tool that

has been used successfully. Employers

can access this information from

www.patientsafetycenter.com.

Nursing home operators may

find another tool or develop an

assessment tool that works better in

their facilities.

■ Appendix A of the Settlement

Agreement between OSHA and

Beverly Enterprises, entitled Lift

Program Policy and Guide,

recommends solutions for resident

lifting and repositioning problems,

based on the CMS classification

system. (A rating of “4” indicates

a totally dependent resident; a “3”

rating indicates residents that need

extensive assistance; a “2/1”

rating indicates residents that need

only limited assistance/general

supervision. Residents rated “0”

are independent.) Employers can

access this information from

www.osha.gov.

The nursing home operator should

use an assessment tool which is

appropriate for the conditions in an

individual nursing home. The special

needs of bariatric (excessively heavy)

residents may require additional

focus. Assistive devices must be

capable of handling the heavier

weight involved, and modification of

work practices may be necessary.

A number of individuals in nursing

homes can contribute to resident

assessment and the determination of

appropriate methods for assisting in

transfer or repositioning. Interdisciplinary

teams such as staff nurses,

certified nursing assistants, nursing

supervisors, physical therapists,

physicians, and the resident or his/her

representative may all be involved. Of

critical importance is the involvement

of employees directly responsible for

resident care and assistance, as the

needs and abilities of residents may

vary considerably over a short period

of time, and the employees responsible

for providing assistance are in the

best position to be aware of and

accommodate such changes.

Identifying Problems and Implementing Solutions

for Resident Lifting and Repositioning

14 Guidelines for Nursing Homes
Use full-body sling lift and

2 or more caregivers.

Caregiver assistance not needed;

stand by for safety as needed.

If exam table/stretcher can be positioned

to a low level, use a non-powered

stand-assist aid. If not, use a full-body sling lift.

Use full-body sling lift and

2 or more caregivers.

Is the patient

cooperative?

Can the patient

bear weight?

Yes

No

Fully

No

Comments:

High/low exam tables and stretchers would be ideal.

■ This is not a one person task - DO NOT PULL FROM HEAD OF BED.

■ When pulling a patient up in bed, the bed should be flat or Trendelenburg

position to aid in gravity, with the side rail down.

■ For patient with Stage III or IV pressure ulcers, care should be taken to

avoid shearing force.

■ The height of the bed should be appropriate for staff safety (at the elbows).

■ If the patient can assist when repositioning “up in bed”, ask the patient to

flex the knees and push on the count of three.

If patient is <200 pounds:

Use a friction-reducing device

and 2-3 caregivers.

If patient is >200 pounds:

Use a friction-reducing device

and at least 3 caregivers.

Caregiver assistance not

needed; patient may/may

not use positioning aid.

Encourage patient

to assist using a

positioning aid or cues.

Partially

Able

Fully

No

Use full-body sling lift -orfriction-reducing device and 2 or

more caregivers.

Can Patient

assist?

Source: The Patient Safety Center of Inquiry (Tampa, FL).

Veterans Health Administration & Department of Defense.

October 2001.

Source: The Patient Safety Center of Inquiry (Tampa, FL). Veterans

Health Administration & Department of Defense. October 2001.

FIGURE 4 Reposition in Bed: Side-to-Side, Up in Bed

FIGURE 3 Transfer to and from: Chair to Stretcher

Identifying Problems and Implementing Solutions

for Resident Lifting and Repositioning

Guidelines for Nursing Homes 15
Comments:

■ This is not a one person task: DO NOT PULL FROM BEHIND CHAIR.

■ Take full advantage of chair functions, e.g., chair that reclines, or use of

arm rest of chair to facilitate repositioning.

■ Make sure the chair wheels are locked.

No

No

Does chair

recline?

Fully

Partially

Yes

No

If patient has upper extremity strength in

both arms, have patient lift up while

caregiver pushes knees to reposition.

If patient lacks sensation, cues may

be needed to remind Patient to reposition.

Recline chair and use a friction-reducing

device and 2 caregivers.

Use full-body sling lift -or- non-powered

stand-assist aid and 1 to 2 caregivers.

Use full-body sling lift and

2 or more caregivers.

Caregiver assistance not needed;

stand by for safety as needed.

Is patient

cooperative?

Can patient

assist?

Yes

Comments:

Use full-body sling that goes all the way down to the

floor (most of the newer models are capable of this).

1

Modifications made with concurrence of Dr. Audrey

Nelson at Veterans Administration Hospital, Tampa,

Florida.

Caregiver assistance not

needed; stand by for

safety as needed.

Is patient

independent?

Depends on type and severity of injury

(follow Standard Operating Procedures).

Was patient

injured?

Was the

injury minor?

Full-body sling lift needed with

2 or more caregivers.

Yes No

No

Yes

No Yes 1

Source: The Patient Safety Center of Inquiry (Tampa, FL). Veterans Health Administration & Department of Defense. October 2001.

Source: The Patient Safety Center of Inquiry (Tampa, FL).

Veterans Health Administration & Department of Defense. October 2001.

FIGURE 6 Transfer a Patient Up From the Floor

FIGURE 5 Repostition in Chair: Wheelchair and Dependency Chair

Identifying Problems and Implementing Solutions

for Resident Lifting and Repositioning

16 Guidelines for Nursing Homes
Implementing Solutions

for Resident Lifting

and Repositioning

The recommended solutions

presented in the following pages are

not intended to be an exhaustive list,

nor does OSHA expect that all of

them will be used in any given

facility. The information represents a

range of available options that a

facility can consider using. Many of

the solutions are simple, common

sense modifications to equipment or

procedures that do not require

substantial time or resources to

implement. Others may require more

significant efforts. The integration of

various solutions into the nursing

home is a strategic decision that, if

carefully planned and executed, will

lead to long-term benefits. Equipment must meet applicable regulations regarding equipment design and

use, such as the restraint regulations

from the Centers for Medicare and

Medicaid. In addition, administrators

should follow any manufacturers’

recommendations and review guidelines, such as the FDA Hospital Bed

Safety Workgroup Guidelines, to

help ensure patient safety. Management should also be cognizant of

several factors that might restrict the

application of certain measures, such

as residents’ rehabilitation plans, the

need for restoration of functional

abilities, other medical contraindications, emergency conditions,

and residents’ dignity and rights.

The procurement of equipment

and the selection of an equipment

supplier are important considerations

when implementing solutions.

Employers should establish close

working relationships with equipment

suppliers. Such working relationships

help with obtaining training for

employees, modifying the equipment

for special circumstances, and

procuring parts and service when

needed. Employers will want to pay

particular attention to the effectiveness

of the equipment, especially the

injury and illness experience of other

nursing homes that have used the

equipment. The following questions

are designed to aid in the selection of

the equipment and supplier that best

meets the needs of an individual

nursing home.

■ Availability of technical service - Is

over-the-phone assistance, as well

as onsite assistance, for repairs

and service of the lift available?

■ Availability of parts - Which parts

will be in stock and available in a

short time frame and how soon can

they be shipped to your location?

■ Storage requirements - Is the equipment too big for your facility? Can

it be stored in close proximity to the

area(s) where it is used?

■ If needed, is a charging unit and

back up battery included? What is

the simplicity of the charging unit

and space required for a battery

charger if one is needed?

Identifying Problems and Implementing Solutions

for Resident Lifting and Repositioning

Guidelines for Nursing Homes 17
■ If the lift has a self-contained

charging unit, what is the amount

of space necessary for charging

and what electrical receptacles are

required? What is the minimum

charging time of a battery?

■ How high is the base of the lift

and will it fit under the bed and

various other pieces of furniture?

How wide is the base of the lift or

is it adjustable to a wider and

lockable position?

■ How many people are required to

operate the lift for lifting of a

typical 200-pound person?

■ Does the lift activation device

(pendant) have remote capabilities?

■ How many sizes and types of

slings are available? What type of

sling is available for optimum

infection control?

■ Is the device versatile? Can it be a

sit-to-stand lift, as well as a lift

device? Can it be a sit-to-stand lift

and an ambulation-assist device?

■ What is the speed and noise level

of the device? Will the lift go to

floor level? How high will it go?

Based on many factors, including

the characteristics of the resident

population and the layout of the

facility, employers should determine

the number and types of devices

needed. Devices should be located so

that they are easily accessible to

workers. If resident lifting equipment

is not accessible when it is needed, it

is likely that other aspects of the

ergonomics process will be ineffective.

If the facility can initially purchase

only a portion of the equipment

needed, it should be located in the

areas where the needs are greatest.

Employers should also establish

routine maintenance schedules to

ensure that the equipment is in good

working order.

The following are examples of

solutions for resident lifting and

repositioning tasks.

Identifying Problems and Implementing Solutions

for Resident Lifting and Repositioning

18 Guidelines for Nursing Homes
Resident Lifting

Description:

Portable lift device (sling

type); can be a universal/

hammock sling or a band/

leg sling.

When to Use:

Lifting residents who are

totally dependent, are

partial- or non-weight

bearing, are very heavy,

or have other physical

limitations. Transfers

from bed to chair (wheel

chair, Geri or cardiac

chair), chair or floor to

bed, for bathing and toileting, or after a resident fall.

Points to Remember:

More than one caregiver may be needed. Look for a

device with a variety of slings, lift-height range,

battery portability, hand-held control, emergency

shut-off, manual override, boom pressure sensitive

switch, that can easily move around equipment, and

has a support base that goes under beds. Having

multiple slings allows one of them to remain in place

while resident is in bed or chair for only a short

period, reducing the number of times the caregiver

lifts and positions resident. Portable compact lifts may

be useful where space or storage is limited. Ensure

device is rated for the resident weight. Electric/battery

powered lifts are preferred to crank or pump type

devices to allow a smoother movement for the resident, and less physical exertion by the caregiver.

Enhances resident safety and comfort.

Transfer from Sitting to

Standing Position

Description:

Powered sit-to-stand

or standing assist

devices.

When to Use:

Transferring

residents who are

partially dependent, have some

weight-bearing

capacity, are

cooperative, can sit

up on the edge of

the bed with or

without assistance, and are able to bend hips, knees,

and ankles. Transfers from bed to chair (wheel chair,

Geri or cardiac chair), or chair to bed, or for bathing

and toileting. Can be used for repositioning where

space or storage is limited.

Points to Remember:

Look for a device that has a variety of sling sizes, liftheight range, battery portability, hand-held control,

emergency shut-off, and manual override. Ensure

device is rated for the resident weight. Electric/battery

powered lifts are preferred to crank or pump type

devices to allow smoother movement for the resident,

and less physical exertion by the caregiver.

Guidelines for Nursing Homes 19

Identifying Problems and Implementing Solutions

for Resident Lifting and Repositioning
Ambulation

Description:

Ambulation assist device.

When to Use:

For residents who are weight

bearing and cooperative and

who need extra security and

assistance when ambulating.

Points to Remember:

Increases resident safety

during ambulation and

reduces risk of falls. The

device supports residents as

they walk and push it along

during ambulation. Ensure height

adjustment is correct for resident before ambulation.

Ensure device is in good working order before use

and rated for the resident weight to be lifted. Apply

brakes before positioning resident in or releasing resident from device.

Repositioning in Chair

Description:

Variable position

Geri and Cardiac

chairs.

When to Use:

Repositioning

partial- or nonweight-bearing

residents who are

cooperative.

Points to

Remember:

More than one caregiver is needed and use of a frictionreducing device is needed if resident cannot assist to

reposition self in chair. Ensure use of good body

mechanics by caregivers. Wheels on chair add versatility.

Ensure that chair is easy to adjust, move, and steer.

Lock wheels on chair before repositioning. Remove

trays, footrests, and seat belts where appropriate.

Ensure device is rated for the resident weight.

20 Guidelines for Nursing Homes

Resident Lifting

Description:

Ceiling mounted lift device.

When to Use:

Lifting residents who are totally dependent, are partial- or non-weight bearing, very

heavy, or have other physical limitations. Transfers from bed to chair (wheel chair,

Geri or cardiac chair), chair or floor to bed, for bathing and toileting, or after a

resident falls. A horizontal frame system or litter attached to the ceiling-mounted

device can be used when transferring residents who cannot be transferred safely

between 2 horizontal surfaces, such as a bed to a stretcher or gurney while lying on

their back, using other devices.

Points to Remember:

More than one caregiver may be needed. Some residents can use the device without

assistance. May be quicker to use than portable device. Motors can be fixed or portable

(lightweight). Device can be operated by hand-held control attached to unit or by

infrared remote control. Ensure device is rated for the resident weight. Increases residents’

safety and comfort during transfer.
Guidelines for Nursing Homes 21

Lateral Transfer; Repositioning

Description:

Devices to reduce friction force when transferring a resident such as a draw

sheet or transfer cot with handles to be used in combination slippery sheets,

low friction mattress covers, or slide boards; boards or mats with vinyl

coverings and rollers; gurneys with transfer devices; and air-assist lateral

sliding aid or flexible mattress inflated by portable air supply.

When to Use:

Transferring a partial- or non-weight bearing resident between 2

horizontal surfaces such as a bed to a stretcher or gurney while lying on

their back or when repositioning resident in bed.

Points to Remember:

• More than one caregiver is needed to perform this type of transfer or repositioning.

Additional assistance may be needed depending upon resident status, e.g., for heavier or

non-cooperative residents. Some devices may not be suitable for bariatric residents.

When using a draw sheet combination use a good hand-hold by rolling up draw sheets or use other

friction-reducing devices with handles such as slippery sheets. Narrower slippery sheets with webbing handles

positioned on the long edge of the sheet may be easier to use than wider sheets. When using boards or mats

with vinyl coverings and rollers use a gentle push and pull motion to move resident to new surface.

• Look for a combination of devices that will increase resident’s comfort and minimize risk of skin trauma. Ensure

transfer surfaces are at same level and at a height that allows caregivers to work at waist level to avoid extended

reaches and bending of the back. Count down and synchronize the transfer motion between caregivers.

Lateral Transfer; Repositioning

Description:

Convertible wheelchair, Geri or cardiac chair to bed; beds that

convert to chairs.

When to Use:

For lateral transfer of residents who are partial- or non-weight

bearing. Eliminates the need to perform lift transfer in and out of

wheelchairs. Can also be used to assist residents who are partially

weight bearing from a sit-to-stand position. Beds that convert to

chairs can aid repositioning residents who are totally dependent, nonweight bearing, very heavy, or have other physical limitations.

Points to Remember:

More than one caregiver is needed to perform lateral transfer. Additional assistance

for lateral transfer may be needed depending on residents status, e.g., for heavier or non-cooperative residents.

Additional friction-reducing devices may be required to reposition resident. Heavy duty beds are available for

bariatric residents. Device should have easy-to-use controls located within easy reach of the caregiver, sufficient

foot clearance, and wide range of adjustment. Motorized height adjustable devices are preferred to those

adjusted by crank mechanism to minimize physical exertion. Always ensure device is in good working order

before use. Ensure wheels on equipment are locked. Ensure transfer surfaces are at same level and at a height

that allows caregivers to work at waist level to avoid extended reaches and bending of the back.
22 Guidelines for Nursing Homes

Lateral Transfer in

Sitting Position

Description:

Transfer boards – wood or plastic

(some with movable seat).

When to Use:

Transferring (sliding)

residents who have good

sitting balance and are

cooperative from one

level surface to another,

e.g., bed to wheelchair,

wheelchair to car seat or toilet. Can also be used by

residents who require limited assistance but need additional safety and support.

Points to Remember:

Movable seats increase resident comfort and reduce

incidence of tissue damage during transfer. More than one

caregiver is needed to perform lateral transfer. Ensure

clothing is present between the resident’s skin and the

transfer device. The seat may be cushioned with a small

towel for comfort. May be uncomfortable for larger

residents. Usually used in conjunction with gait belts for

safety depending on resident status. Ensure boards have

tapered ends, rounded edges, and appropriate weight

capacity. Ensure wheels on bed or chair are locked and

transfer surfaces are at same level. Remove lower bedrails

from bed and remove arms and footrests from chairs as

appropriate.

Transfer from Sitting to

Standing Position

Description:

Lift cushions and lift chairs.

When to Use:

Transferring residents who are

weight-bearing and cooperative

but need assistance when standing

and ambulating. Can be used for

independent residents who need

an extra boost to stand.

Points to Remember:

Lift cushions use a lever that

activates a spring action to

assist residents to rise up. Lift

cushions may not be appropriate for heavier residents.

Lift chairs are operated via a hand-held control that

tilts forward slowly, raising the resident. Residents

need to have physical and cognitive capacity to be

able to operate lever or controls. Always ensure device

is in good working order before use and is rated for

the resident weight to be lifted. Can aid resident independence.

Transfer from Sitting to

Standing Position

Description:

Stand-assist devices can be fixed to bed or chair or be

free-standing. There is a variety of such devices on

the market.

When to Use:

Transferring residents who are weight-bearing and

cooperative and can pull themselves up from sitting to

standing position. Can be used for independent residents

who need extra support to stand.

Points to Remember:

Check that device is stable before use and is rated for

resident weight to be supported. Ensure frame is firmly

attached to bed, or if it relies on mattress support that

mattress is heavy enough to hold the frame. Can aid

resident independence.

Weighing

Description:

Scales with ramp to accommodate

wheelchairs; portable-powered lift

devices with built-in scales; beds

with built-in scales.

When to Use:

To reduce the need for additional

transfer of partialor non-weightbearing or totally dependent

residents to weighing device.

Points to Remember:

Some wheelchair scales can accommodate larger wheelchairs. Built-in bed scales

may increase weight of the bed and prevent it from

lowering to appropriate work heights.
Guidelines for Nursing Homes 23

Transfer from Sitting to Standing Position;

Ambulation

Description:

Gait belts/transfer belts with handles.

When to Use:

Transferring residents who are partially dependent, have some weight-bearing

capacity, and are cooperative. Transfers such as bed to chair, chair to chair, or

chair to car; when repositioning residents in chairs; supporting residents during

ambulation; and in some cases when guiding and controlling falls or assisting a

resident after a fall.

Points to Remember:

• More than one caregiver may be needed. Belts with padded handles are easier

to grip and increase security and control. Always transfer to resident’s strongest

side. Use good body mechanics and a rocking and pulling motion rather than lifting

when using a belt. Belts may not be suitable for ambulation of heavy residents or residents

with recent abdominal or back surgery, abdominal aneurysm, etc. Should not be used for

lifting residents. Ensure belt is securely fastened and cannot be easily undone by the resident during

transfer. Ensure a layer of clothing is between residents’ skin and the belt to avoid abrasion. Keep

resident as close as possible to caregiver during transfer. Lower bedrails, remove arms and foot rests

from chairs, and other items that may obstruct the transfer.

• For use after a fall, always assess the resident for injury prior to movement. If resident can regain standing

position with minimal assistance, use gait or transfer belts with handles to aid resident. Keep back straight,

bend legs, and stay as close to resident as possible.

If resident cannot stand with minimal assistance, use a powered portable or ceiling-mounted lift device to

move resident.

Repositioning

Description:

Electric powered

height adjustable bed.

When to Use:

For all activities

involving resident

care, transfer, repositioning in bed, etc., to

reduce caregiver bending

when interacting with resident.

Points to Remember:

Device should have easy-to-use controls located within

easy reach of the caregiver to promote use of the electric

adjustment, sufficient foot clearance, and wide range of

adjustment. Adjustments must be completed in 20

seconds or less to ensure staff use. For residents that may

be at risk of falling from bed some beds that lower closer

to the floor may be needed. Heavy duty beds are available

for bariatric residents. Beds raised and lowered with an

electric motor are preferred over crank-adjust beds to

allow a smoother movement for the resident and less

physical exertion to the caregiver.

Repositioning

Description:

Trapeze bar; hand blocks and

push up bars attached to the

bed frame.

When to Use:

Reposition residents that have

the ability to assist the caregiver

during the activity, i.e., residents

with upper body strength and

use of extremities, who are

cooperative and can follow

instructions.

Points to Remember:

Residents use trapeze bar by grasping bar suspended from

an overhead frame to raise themselves up and reposition

themselves in a bed. Heavy duty trapeze frames are

available for bariatric residents. If a caregiver is assisting,

ensure that bed wheels are locked, bedrails are lowered,

and bed is adjusted to caregiver’s waist height. Blocks also

enable residents to raise themselves up and reposition

themselves in bed. Bars attached to the bed frame serve

the same purpose. May not be suitable for heavier

residents. Can aid resident independence.
24 Guidelines for Nursing Homes

Repositioning

Description:

Pelvic lift devices (hip lifters).

When to Use:

To assist residents who

are cooperative and can

sit up to a position on a

special bed pan.

Points to Remember:

Convenience of device

may reduce need for resident

lifting during toileting. Device is positioned

under the pelvis. The part of the device located under

the pelvis gets inflated so the pelvis is raised and a

special bedpan put underneath. The head of the bed is

raised slightly during this procedure. Use correct body

mechanics, lower bedrails, and adjust bed to caregivers

waist height to reduce bending.

Bathtub, Shower,

andToileting Activities

Description:

Height adjustable

bathtub and easyentry bathtubs.

When to Use:

Bathing residents

who sit directly in

the bathtub, or to

assist ambulatory

residents climb

more easily into a

low tub, or easyaccess tub. Bathing residents in portable-powered or ceiling

mounted lift device using appropriate bathing sling.

Points to Remember:

Reduces awkward postures for caregivers and those

who clean the tub after use. The tub can be raised to

eliminate bending and reaching for the caregiver. Use

correct body mechanics, and adjust the tub to the

caregiver’s waist height when performing hygiene

activities. Increases resident safety and comfort.

Bathtub, Shower,

andToileting Activities

Description:

Shower and toileting chairs.

When to Use:

Showering and toileting

residents who are partially

dependent, have some

weight bearing capacity,

can sit up unaided, and are

able to bend hips, knees,

and ankles.

Points to Remember:

Ensure that wheels move easily and

smoothly; chair is high enough to fit over toilet; chair

has removable arms, adjustable footrests, safety belts,

and is heavy enough to be stable; and that the seat is

comfortable, accommodates larger residents, and has a

removable commode bucket for toileting. Ensure that

brakes lock and hold effectively and that weight

capacity is sufficient.

Bathtub, Shower,

andToileting Activities

Description:

Toilet seat risers.

When to Use:

For toileting partially

weight-bearing residents

who can sit up unaided,

use upper extremities

(have upper body

strength), are able to

bend hips, knees, and

ankles, and are cooperative. Independent

residents can also use these devices.

Points to Remember:

Risers decrease the distance and amount of effort

required to lower and raise residents. Grab bars and

height-adjustable legs add safety and versatility to the

device. Ensure device is stable and can accommodate

resident’s weight and size.
Guidelines for Nursing Homes 25

Bathtub, Shower,

andToileting Activities

Description:

Bath boards and transfer benches.

When to Use:

Bathing residents who are partially weight bearing, have good sitting balance, can use

upper extremities (have upper body strength), are cooperative, and can follow instructions. Independent residents can also use these devices.

Points to Remember:

To reduce friction and possible skin tears, use clothing or material between the

resident’s skin and the board. Can be used with a gait or transfer belt and/or

grab bars to aid transfer. Back support and vinyl padded seats add to bathing

comfort. Look for devices that allow for water drainage and have heightadjustable legs. May not be suitable for heavy residents. If wheelchair is used,

ensure wheels are locked, the transfer surfaces are at the same level, and device

is securely in place and rated for weight to be transferred. Remove arms and

foot rests from chairs as appropriate and ensure that floor is dry.

Bathtub, Shower,

andToileting Activities

Description:

Grab bars and stand assists; can be fixed or mobile.

Long-handled or extended shower heads, or brushes can be used for

personal hygiene.

When to Use:

Bars and assists help when toileting, bathing, and/ or showering residents

who need extra support and security. Residents must be partially weight

bearing, able to use upper extremities (have upper body strength), and be

cooperative.

Long-handled devices reduce the amount of bending, reaching, and

twisting required by the caregiver when washing feet, legs, and trunk of

residents. Independent residents who have difficulty reaching lower

extremities can also use these devices.

Points to Remember:

Movable grab bars on toilets minimize workplace congestion.

Ensure bars are securely fastened to wall before use.
26 Guidelines for Nursing Homes

Bathtub, Shower,

andToileting Activities

Description:

Height adjustable

shower gurney or lift

bath cart with

waterproof top.

When to Use:

For bathing nonweight bearing

residents who are

unable to sit up.

Transfer resident to

cart with lift or lateral

transfer boards or other

friction-reducing devices.

Points to Remember:

The cart can be raised to eliminate bending and

reaching to the caregiver. Foot and head supports

are available for resident comfort. May not be

suitable for bariatric residents. Look for carts that

are power-driven to reduce force required to move

and position device.

Bathtub, Shower,

andToileting Activities

Description:

Built-in or fixed

bath lifts.

When to Use:

Bathing residents

who are partially

weight bearing,

have good sitting

balance, can use

upper extremities

(have upper body

strength), are cooperative, and can

follow instructions. Useful in small bathrooms where

space is limited.

Points to Remember:

Ensure that seat raises so resident’s feet clear tub, easily

rotates, and lowers resident into water. May not be

suitable for heavy residents. Always ensure lifting device is in good working order before use and rated for

the resident weight. Choose device with lift mechanism

that does not require excessive effort by caregiver

when raising and lowering device.
Guidelines for Nursing Homes 27

Some reports indicate a significant

number of work-related MSDs in

nursing homes occur in activities

other than resident lifting. (2, 3)

Examples of some of the activities

that the nursing home operator may

want to review are:

■ bending to make a bed or feed a

resident;

■ lifting food trays above shoulder

level or below knee level;

■ collecting waste;

■ pushing heavy carts;

■ bending to remove items from a

deep cart;

■ lifting and carrying when receiving

and stocking supplies;

■ bending and manually cranking

an adjustable bed; and

■ removing laundry from washing

machines and dryers.

These tasks may not present

problems in all circumstances.

Employers should consider the

duration, frequency, and magnitude

of employee exposure to forceful

exertions, repetitive activities, and

awkward postures when determining

if problems exist in these and other

areas. In the vast majority of cases,

job assessments can be accomplished

by observing employees performing

SECTION IV

A Identifying Problems and Implementing Solutions for

Activities Other than Resident Lifting and Repositioning

the task, by discussing with employees

the activities and conditions that

they associate with difficulties, and

checking injury records. Observation

provides general information about

the workstation layout, tools,

equipment, and general environmental

conditions in the workplace.

Discussing tasks with employees

helps to ensure that a complete

picture of the process is obtained.

Employees who perform a given task

are also often the best sources for

identifying the cause of a problem,

and developing the most practical

and effective solutions. Once

information is obtained and problems

identified, suitable improvements can

be implemented. Finally, there are a

number of resources available to help

determine if specific activities have

the potential for causing injuries. For

example, support is available from

OSHA’s consultation program,

insurance companies, and state

workers’ compensation programs.

The following are examples of

possible solutions for activities other

than resident lifting and repositioning.
28 Guidelines for Nursing Homes

Storage and Transfer of Food,

Supplies, and Medications

Description:

Use of carts.

When to Use:

When moving food trays,

cleaning supplies,

equipment, maintenance

tools, and dispensing

medications.

Points to Remember:

Speeds process for accessing and storing

items. Placement of items on the cart should keep the

most frequently used and heavy items within easy

reach between hip and shoulder height. Carts should

have full-bearing wheels of a material designed for the

floor surface in your facility. Cart handles that are

vertical, with some horizontal adjustability, will allow

all employees to push at elbow height and shoulder

width. Carts should have wheel locks. Handles that

can swing out of the way may be useful for saving

space or reducing reach. Heavy carts should have

brakes. Balance loads and keep loads under cart

weight restrictions. Ensure stack height does not

block vision. Low profile medication carts with easyopen side drawers are recommended to accommodate

hand height of shorter nurses.

Mobile Medical

Equipment

Description:

Work methods and tools to

transport equipment.

When to Use:

When transporting assistive

devices and other equipment.

Points to Remember:

• Oxygen tanks: Use small

cylinders with handles to

reduce weight and allow for easier gripping. Secure

oxygen tanks to transport device.

• Medication pumps: Use stands on wheels.

• Transporting equipment: Push equipment, rather than

pull, when possible. Keep arms close to the body and

push with whole body and not just arms. Remove

unnecessary objects to minimize weight. Avoid obstacles

that could cause abrupt stops. Place equipment on a

rolling device if possible. Take defective equipment out of

service. Perform routine maintenance on all equipment.

• Ensure that when moving and transporting residents,

additional equipment such as oxygen tanks and IV/

medication poles are attached to wheelchairs or gurneys

or moved by another caregiver to avoid awkwardly

pushing with one hand and holding freestanding

equipment with the other hand.

Working with Liquids in

Housekeeping

Description:

Filling and

emptying liquids

from containers.

When to Use:

In housekeeping

areas when filling

and emptying

buckets with

floor drain

arrangements.

Points to Remember:

Reduces risk of spills, slips, speeds process, and

reduces waste. The faucet and floor drain is used in

housekeeping. Ensure that casters don’t get stuck in

floor grate. Use hose to fill bucket. Use buckets with

casters to move mop bucket around. Ensure casters

are maintained and roll easily.

Working with Liquids in

Housekeeping

Description:

Filling and emptying liquids

from containers.

When to Use:

In dietary when pouring

soups or other liquid foods

that are heavy.

Points to Remember:

Reduces risk of spills and

burns, speeds process, and

reduces waste.

Use an elevated faucet or hose to fill large pots. Avoid

lifting heavy pots filled with liquids. Use ladle to empty

liquids, soups, etc., from pots. Small sauce pans can also

be used to dip liquids from pots. If the worker stands

for more than 2 hours per day, shock-absorbing floors

or insoles will minimize back and leg strain. With hot

liquids, ensure a splash guard is included.
Guidelines for Nursing Homes 29

HandTools

Description:

Select and use properly

designed tools.

When to Use:

When selecting frequently

used tools for the kitchen,

housekeeping, laundry and

maintenance areas.

Points to Remember:

Enhances tool safety,

speeds process, and reduces

waste. Handles

should fit the grip size of the user. Use bent-handled

tools to avoid bending wrists. Use appropriate tool

weight. Select tools that have minimal vibration or

vibration damping devices. Implement a regular

maintenance program for tools to keep blades sharp

and edges and handles intact. Always wear the

appropriate personal protective equipment.

Linen Carts

Description:

Spring loaded carts that automatically

bring linen within easy reach.

When to Use:

Moving or storing linen.

Points to Remember:

Speeds process for

handling linen, and

reduces wear on linen

due to excessive pulling.

Select a spring tension that

is appropriate for the

weight of the load. Carts

should have wheel locks and height-appropriate

handles that can swing out of the way.

Heavy carts should have brakes.

Handling Bags

Description:

Equipment and practices for

handling bags.

When to Use:

When handling laundry, trash,

and other bags.

Points to Remember:

Reduces risk of items being

dropped, and speeds process for

removing and disposing of items.

Receptacles that hold bags of

laundry or trash should have side openings

that keep the bags within easy reach and allow employees to slide the bag off the cart without lifting. Provide

handles to decrease the strain of handling. Chutes and

dumpsters should be positioned to minimize lifting. It

is best to lower the dumpster or chute rather than lift

materials to higher levels. Provide automatic opening

or hardware to keep doors open to minimize twisting

and awkward handling.

Reaching into Sink

Description:

Tools used to

modify a deep sink

for cleaning small

objects.

When to Use:

Cleaning small

objects in a deep

sink.

Points to Remember:

Place an object such as a plastic

basin in the bottom of the sink to raise the work

surface. An alternative is to use a smaller porous

container to hold small objects for soaking, transfer to

an adjacent countertop for aggressive cleaning, and

then transfer back to the sink for final rinsing.

Store inserts and containers in a convenient location to

encourage consistent use. This technique is not suitable

in kitchens/food preparation.
30 Guidelines for Nursing Homes

Loading or Unloading

Laundry

Description:

Front-loading washers

and dryers.

When to Use:

When loading or unloading

laundry from washers,

dryers and other laundry

equipment.

Points to Remember:

Speeds process for retrieving

and placing items, and minimizes

wear-and-tear on linen. Washers

with tumbling cycles separate clothes, making removal

easier. For deep tubs, a rake with long or extendable

handle can be used to pull linen closer to the door

opening. Raise machines so that opening is between hip

and elbow height of employees. If using top loading

washers, work practices that reduce risk include

handling small loads of laundry, handling only a few

items at a time, and bracing your body against the

front of the machine when lifting. If items are knotted

in the machine, brace with one hand while using the

other to gently pull the items free. Ensure that items go

into a cart rather than picking up baskets of soiled

linen or wet laundry.

Cleaning Rooms

(Wet Method)

Description:

Work methods and tools to

clean resident rooms with

water and chemical products.

When to Use:

When cleaning with water

and chemical products and

using spray bottles.

Points to Remember:

• Cleaning implement: use

alternate leading hand, avoid tight static grip

and use padded non-slip handles.

• Spray bottles: Use trigger handles long enough for the

index and middle fingers. Avoid using the ring and

little fingers.

• For all cleaning: Use chemical cleaners and abrasive

sponges to minimize scrubbing force. Use kneepads

when kneeling. Avoid bending and twisting. Use

extension handles, step stools, or ladders for overhead

needs. Use carts to transport supplies or carry only

small quantities and weights of supplies. Ventilation of

rooms may be necessary when chemicals are used.

• Avoid lifting heavy buckets, e.g., lifting a large, full

bucket from a sink. Use a hose or similar device to fill

buckets with water. Use wheels on buckets that roll

easily and have functional brakes. Ensure that casters

are maintained. Use rubber-soled shoes in wet areas to

prevent slipping.

• Cleaning wheelchairs: Cleaning workstation should

be at appropriate height.

Cleaning Rooms

(Electrical)

Description:

Work methods and tools to vacuum and

buff floors.

When to Use:

Vacuuming and buffing floors.

Points to Remember:

• Both vacuum cleaners and buffers

should have lightweight construction,

adjustable handles, triggers (buffer)

long enough to accommodate at least

the index and middle fingers, and easy to reach controls.

Technique is important for both devices, including use of

appropriate grips, avoiding tight grips, and for vacuuming,

by alternating grip. The use of telescoping and extension

handles, hoses, and tools can reduce reaching for low areas,

high areas, and far away areas. Maintain and service the

equipment and change vacuum bags when 1/2 to 3/4 full.

• Vacuums and other powered devices are preferred over

manual equipment for moderate-to-long duration use.

Heavy canisters or other large, heavy equipment should

have brakes.
Guidelines for Nursing Homes 31

Training is critical for employers

and employees to safely use the

suggestions identified in these guidelines. Of course, training should be

provided in a manner and language

that all employees can understand.

The following describes areas of

training for nursing home employees,

their supervisors, and program

managers who are responsible for

planning and managing the nursing

home’s ergonomics efforts. OSHA

recommends refresher training be

provided as needed to reinforce

initial training and to address new

developments in the workplace.

Nursing Assistants and Other

Workers at Risk of Injury

Employees should be trained

before they lift or reposition residents,

or perform other work that may

involve risk of injury. Ergonomics

training can be included with other

safety and health training, or

incorporated into general instructions

provided to employees. Training is

usually most effective when it

includes case studies or demonstrations

based on the nursing home’s polices,

and allows enough time to answer

any questions that may arise.

Training should ensure that these

workers understand:

SECTION V

Training

■ policies and procedures that

should be followed to avoid

injury, including proper work

practices and use of equipment;

■ how to recognize MSDs and their

early indications;

■ the advantages of addressing early

indications of MSDs before

serious injury has developed; and

■ the nursing home’s procedures for

reporting work-related injuries

and illnesses as required by

OSHA’s injury and illness

recording and reporting regulation

(29 CFR 1904).

Training for Charge Nurses

and Supervisors

Charge nurses and supervisors

should reinforce the safety program

of the facility, oversee reporting

guidelines, and help ensure the

implementation of resident and task

specific ergonomics recommendations,

e.g., using a mechanical lift. Because

charge nurses and supervisors are

likely to receive reports of injuries,
32 Guidelines for Nursing Homes

and are usually responsible for

implementing the nursing home’s

work practices, they may need more

detailed training than nursing

assistants on:

■ methods for ensuring use of

proper work practices;

■ how to respond to injury reports;

and

■ how to help other workers implement

solutions.

Training for Designated

Program Managers

Staff members who are responsible

for planning and managing ergonomics

efforts need training so they can

identify ergonomics concerns and

select appropriate solutions. These

staff members should receive

information and training that will

allow them to:

■ identify potential problems related

to physical activities in the workplace

through observation, use of

checklists, injury data analysis,

or other analytical tools;

■ address problems by selecting

proper equipment and work

practices;

■ help other workers implement

solutions; and

■ evaluate the effectiveness of

ergonomics efforts.

Training
Guidelines for Nursing Homes 33

The following sources may be

useful to those seeking further

information about ergonomics and

the prevention of work-related MSDs

in nursing homes.

A Back Injury Prevention

Guide for Health Care Providers,

Cal/OSHA Consultation Programs,

(800) 963-9424, www.dir.ca.gov/

dosh/dosh_publications/backinj.pdf

This guide discusses the scope of the

back injury problem in health care,

how to analyze the workplace, how

to identify and implement improvements, and how to evaluate results.

It includes checklists that can assist

in analyzing the work environment.

Patient Care Ergonomics

Resource Guide: Safe Patient

Handling and Movement, Patient

Safety Center of Inquiry, Veterans

Health Administration and

Department of Defense, (813) 558-

3902, www.patientsafetycenter.com

This document describes a comprehensive program developed to prevent

MSDs related to resident lifting

and repositioning. It includes

assessment criteria and flowcharts

for selecting equipment and techniques

for safe lifting and repositioning

based on resident characteristics.

Resident Assessment Instrument,

U.S. Department of Health and

Human Services - Centers for Medicareand Medicaid Services (CMS),

www.cms.hhs.gov/medicaid/mds20/

SECTION VI

Additional Sources of Information

This document is used by many

nursing homes to evaluate resident

needs and capabilities.

Elements of Ergonomics Programs,

U.S. Department of Health and

Human Services - National

Institute for Occupational Safety

and Health, (800) 356-4674,

www.cdc.gov/niosh/ephome2.html

The basic elements of a workplace

program aimed at preventing workrelated musculoskeletal disorders are

described in this document. It

includes a “toolbox,” which is a

collection of techniques, methods,

reference materials, and sources for

other information that can help in

program development.

In addition, OSHAC’s Training

Institute in Arlington Heights,

Illinois, offers courses on various

safety and health topics, including

ergonomics. Courses are also offered

through Training Institute Education

Centers located throughout the

country. For a schedule of courses,

contact the OSHA Training Institute,

2020 South Arlington Heights Road,

Arlington Heights, Illinois, 60005,

(847) 297-4810, or visit OSHA’s

training resources webpage at

www.osha.gov. Choose “Training”

from the blue column on the right,

under Compliance Assistance.
There are many states and

territories that operate their own

occupational safety and health

programs under a plan approved by

OSHA (23 cover both private sector,

state and local government employees,

and three only cover public employees).

See the map on www.osha.gov

for information on how to contact a

state plan directly for information

about specific state nursing home

initiatives and compliance assistance,

or state standards that may apply to

nursing homes.

A free consultation service is

available to provide occupational

safety and health assistance to

businesses. OSHA Consultation is

funded primarily by federal OSHA

but delivered by the 50 state

governments, the District of Columbia,

Guam, Puerto Rico, and the Virgin

Islands. The states offer the expertise

of highly qualified occupational

safety and health professionals to

employers who request help to

establish and maintain a safe and

healthful workplace. Developed for

small and medium-sized employers in

hazardous industries or with

hazardous operations, the service is

provided at no cost to the employer

and is confidential. Information on

OSHA consultation can be found at

www.osha.gov. Choose “Consultation”

from the blue column at the right

under Compliance Assistance, or

request the booklet Consultation

Services for the Employer (OSHA

3047) from OSHA’s Publications

Office at (202) 693-1888.

More information on ergonomics

and other safety and health issues is

available on OSHA’s website at

www.osha.gov. See the index at the

top of the home page. For any

additional information regarding

Guidelines for Nursing Homes,

please contact the OSHA’s

Directorate of Standards and

Guidance at 202-693-1950.

Additional Sources of Information

34 Guidelines for Nursing Homes
(1) Documents submitted to OSHA by Wyandot County Nursing Home. (Ex. 3-12)

(2) Garg, A. 1999. Long-Term Effectiveness of “Zero-Lift Program” in Seven Nursing

Homes and One Hospital. U.S. Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for Occupational Safety and Health

(NIOSH), Cincinnati, OH. August. Contract No. U60/CCU512089-02. (Ex. 3-3)

(3) Fragala, G., PhD, PE, CSP. 1996. Ergonomics: How to Contain On-the-Job Injuries in

Health Care. Joint Commission on Accreditation of Healthcare Organizations.

(4) Occupational Safety and Health Administration, Region II. Summer, 2002. New York

OSHA E-Newsletter, Vol. 1, Issue 2.

(5) National Institute for Occupational Safety and Health (NIOSH). 1997. Musculoskeletal Disorders and Workplace Factors - A Critical Review of Epidemiologic Evidence for

Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back.

(Ex. 3-4)

(6) National Research Council and Institute of Medicine. 2001. Musculoskeletal Disorders and the Workplace - Low Back and Upper Extremities. National Academy of

Sciences. Washington, DC: National Academy Press. (Ex. 3-6)

(7) Taylor and Francis. 1988. Cumulative Trauma Disorders: A Manual for MSDs of the

Upper Limb. Putz-Anderson, V., ed.

(8) Documents submitted to OSHA by Citizens Memorial. (Ex. 3-25)

(9) U.S. General Accounting Office. 1997. Worker Protection - Private Sector Ergonomics Programs Yield Positive Results. August. GAO/HEHS-97-163. (Ex. 3-92)

(10) American Health Care Association, American Association of Homes and Services

for the Aging, National Center for Assisted Living. 2002. Comments submitted to

OSHA. (Ex. 4-15)

References

Guidelines for Nursing Homes 35
36 Guidelines for Nursing Homes

Introduction

Wyandot County Nursing Home

used a process that reflects many of

the recommendations in these

guidelines to address safety and

health concerns and phase-in its

current program that entails no

manual lifting of residents. First and

foremost, Wyandot’s administrator

provided strong commitment and

support in addressing the home’s

problems. He also involved

Wyandot’s workers in every phase

of the effort. He talked to his

employees, learned about stressful

parts of their jobs, and then found

solutions. He and his employees

identified existing and potential

sources of injury at the home and

worked to implement solutions.

He trained employees each time

the nursing home introduced new

equipment. He continually checked

new equipment, and he continues to

evaluate the overall effectiveness of

his safety and health efforts.

Wyandot is located in Upper

Sandusky, Ohio. It is a 100-bed,

county-run facility that has served

Wyandot County in its present

building for the past 28 years. It is

divided into two sections to serve

residents with different levels of

need. The A- wing, with 32 rooms,

serves residents who are mostly

ambulatory and require only a

minimum of help with daily living.

Appendix - A Nursing Home Case Study

In the B- and C- wings, with 32

double rooms and four private ones,

residents receive care that ranges

from extensive to total. Wyandot

has 90 employees, 45 of whom are

nursing assistants. This makes for a

nursing staff ratio of 2.4 hours for

each resident per day.

Identifying Problems

Before Wyandot implemented its

ergonomics program, the home was

experiencing problems that were a

growing concern to both the county

and Wyandot’s administrator.

According to Wyandot, workers’

compensation costs averaged almost

$140,000 per year from 1995-1997.

The turnover rate among nursing

assistants averaged over 55 percent

This case study was developed from

information provided by Wyandot

County Nursing Home. OSHA visited

the nursing home to discuss the

ergonomics program with the nursing

home administrator, observe

ergonomics corrective actions, and talk

to employees, residents, and family

members about their experiences.
Guidelines for Nursing Homes 37

during that same time period.

This meant that of the 45 nursing

assistants working at Wyandot,

on average 25 new ones had to be

hired each year.

Wyandot’s administrator began to

look for more effective ways to

address injuries among workers and

the high turnover rate. A back injury

suffered by a worker that cost

Wyandot $240,000 in workers’

compensation expenses provided

significant motivation to find a strategy

that would work. As Wyandot’s

administrator investigated that injury,

he also examined other sources of

potential injury within the home. In

doing so, he learned that resident

transfer and repositioning tasks

presented high risks for injuries.

He called on the Ohio Bureau of

Workers’ Compensation (OBWC)

for help because he thought

Wyandot was following best

practices and people were still being

injured. An OBWC ergonomist

visited the home and told him that

he had unrealistic expectations about

his nursing staff’s ability to manually

lift and reposition residents.

Involving Employees

Wyandot’s administrator thought

that he could better use his existing

staff. After hearing about a “no lift”

policy and seeing an impressive

demonstration of mechanical lifts at

an industry conference, he began to

consider setting up a program at

Wyandot. He became convinced that

such a program would keep employees

safer and help slow the turnover rate

while ensuring safety and high

quality care for residents.

He decided that the best

approach was to involve employees

at every level in reducing injuries

and slowing the turnover rate.

More than 30 workers volunteered

to examine the tasks of moving

and repositioning residents.

Wyandot employees concluded

that better body mechanics — the

traditional method of lifting and

transferring residents at most nursing

homes — was not the answer. In fact,

he and his staff determined that there

was no safe way to lift a resident

other than with mechanical lifts. To

determine what equipment would

work best, Wyandot tried out

various pieces of equipment, evaluated

each lift, and then decided what

would be most appropriate for

Wyandot’s needs.

Implementing Solutions

With recommendations from

employees, Wyandot’s administrator

bought several portable mechanical

lifts for the B- and C-wings. These

involved portable sit-to-stand lifts,

walk/ambulating lifts, and total lifts.

Nurses and assistants could move

each of these from room to room as

they worked with individual residents.

However, many of the staff remained

unconvinced of the value of using

equipment. In fact, initially only the

workers who had actually evaluated

the lifts were using them.

Appendix
38 Guidelines for Nursing Homes

According to Wyandot’s

administrator, it was very difficult

getting workers to overcome their

insistence on doing things the old

way. Because many workers said it

took too long to use the mechanical

lifts, one of the co-charge nurses

decided to do a time study. She

wanted to test how long it took to

lift a resident manually compared to

using a mechanical lift. The mechanical

lift took about 5 minutes. Meanwhile,

to perform the manual lift, a nursing

assistant first had to find someone to

help. This took 15 minutes. Thus,

the time study showed that using the

equipment actually saved time.

One worker, who admitted that

she did not initially use the sit-tostand

lift because it was a “hassle,”

reconsidered her opinion after an

outbreak of the flu reduced the

number of staff members available

for assistance. In her words, “I was

forced to use the lift. Awesome. It

was just great. I was so sorry my

fellow employees had to suffer with

the flu bug to get me to use this

contraption.”

Wyandot’s administrator also

wanted to replace the old hand-crank

beds at Wyandot with electric beds.

To do this, he also needed to find

beds that would be used in the

“low-bed” system in place for many

residents. There were not many

options available, so he took his

ideas and engineering background to

a bed company and inquired about

having beds designed to fit Wyandot’s

needs. The bed manufacturer

designed the new beds to lift from

the floor to a height of about 30

inches in 20 seconds. In addition,

these fast beds were designed so that

residents would be less likely to slide

to the foot of the bed as they were

raised to a sitting position. As a

result, residents would not need to be

repositioned. Also, the beds could be

used with a gait-belt for ambulatory

residents to assist them from a sitting

to a standing position.

About three years after Wyandot

began its ergonomics effort, the

nursing home received a grant from

the OBWC Division of Safety and

Hygiene through an ergonomic

emphasis program to deal with

cumulative trauma disorders. The

grant enabled Wyandot’s administrator

to purchase 58 fast electric beds, a

turning point for staff acceptance.

When the first ceiling lifts were

installed seven months later,

employees were ready to use them.

One nursing assistant, who has

been with Wyandot for 19 years,

explained why she liked the new

beds so much. “We can quickly bring

the bed up to our work height with a

push of a button and we can

reposition a resident . . . with ease

without stooping or struggling.”

Appendix
Guidelines for Nursing Homes 39

The final phase of Wyandot’s

program began with the introduction

of the ceiling lifts. Wyandot’s

administrator evaluated several

ceiling lift systems. Wyandot chose a

system with a motorized lift and a

ceiling mounted track. Tracks were

retrofitted into the rooms at a cost of

about $12,000 for two double rooms

and one bathroom. The first double

room had a track that extended into

the bathroom. However, newer

systems used a transfer between the

room and bathroom, which simplified

the system and reduced costs.

Providing Training

As Wyandot purchased and

installed new equipment, workers

received training on how to use it,

and guidelines for equipment

use were put into place. An LPN

in-service director did the training.

New employees learned how to use

the devices and knew where to go

for further instruction or help.

Eventually, most of the nursing

assistants adapted to the mechanical

lifts and refused to use any other

lifting techniques.

Providing Management Support

Wyandot’s administrator took a

personal interest in ergonomic issues.

To address high injury and turnover

rates at Wyandot, he remained

committed to identifying and solving

problems. For example, on one

occasion the staff said that the lifts

were not easy to roll on the floors in

the B- and C- wings. To solve the

problem, he experimented with

different wheels that would roll more

easily and turn in tight places with

less effort. Finally, he worked with a

manufacturer to find and buy better

casters to suit the home’s flooring.

Evaluating Efforts

To start with, Wyandot’s

administrator spent $150,000 to buy

equipment. He later set aside another

$130,000 to continue his efforts,

for a total of $280,000. Wyandot

has saved $55,000 annually in

payroll costs, according to

Appendix
40 Guidelines for Nursing Homes

Wyandot’s administrator, because of

reduced overtime and absenteeism.

The home estimates savings of more

than $125,000 in turnover costs.

Meanwhile, workers’ compensation

costs also have fallen drastically.

For example, Wyandot reports that,

after the program was implemented

workers’ compensation costs declined

from an average of $140,000

per year to less than $4,000 per year.

From the time workers began to

use the sit-to-stand lifts, which were

among the first to be introduced at

Wyandot, the incidence of back

injuries stopped. Once the fast beds

were introduced only six new hires

were needed in the following year.

Worker satisfaction has increased

greatly. One nursing assistant, who

has spent most of her career working

in nursing homes, confessed to

being sore and unhappy at Wyandot

before the lifts were introduced.

After the innovations at the nursing

home, she reported that she is no

longer hurting. She concluded that

“I think my career is right here in

the Wyandot County Nursing Home

till my time is due to retire comfortable.

And you know if my time

comes to be in a nursing home I do

hope I get one like ours.”

Mechanical lifts have also helped

return a sense of dignity to

Wyandot’s residents. As one nursing

assistant put it, through the use of

the mechanical lifts, the residents are

able to wear normal clothing again,

which “improves their self-esteem

and keeps them warmer.”

The wife of one totally dependent

resident who has been at Wyandot

for eight years reports that because

of her husband’s size, he cannot help

the nurses and nursing assistants in

moving him from place to place.

Before the overhead electric lifts and

electric beds were installed in his

room, it took three and sometimes

four nursing assistants to move him

from the bed to his cart or to the

toilet. He had numerous bruises from

falling and dreaded being moved.

With the lifts in place, the resident’s

wife reports that the staff “can easily

move him about to his chair and to

the toilet. He cannot sit without help

but the sling gives him comfortable

support and makes it possible to

have some dignity.”

Appendix