Fire, Safety and OSHA Training for the CNA and HHA

Occupational Safety and Health Administration (OSHA) is part of the United States Department of Labor. OSHA covers most private-sector employers and their workers, in addition to some public-sector employers and workers.¹

Employers must comply with the General Duty Clause of the OSHA Act of 1970. This clause requires employers to keep their workplaces free of serious recognized hazards. OSHA covers most private-sector employers and workers. Federal OSHA does not cover state and local government workers. Still, they do have protections in states that operate their programs.¹

Employers are required to meet OSHA standards. These standards include ¹:

• Follow all relevant OSHA safety and health standards
• Find and correct safety and health hazards
• Inform employees about chemical hazards through training, labels, alarms, color-coded systems, chemical information sheets, and other methods
• Notify OSHA within 8 hours of a workplace fatality or within 24 hours of any work-related inpatient hospitalization, amputation, or loss of an eye
• Provide required PPE (PPE) at no cost to workers
• Keep accurate records of work-related injuries and illnesses
• Post-OSHA citations, injury and illness summary data, and the OSHA Job Safety and Health "It's the Law" poster where they are visible to all employees
• Not retaliate against any worker for using their rights under the law

Every time an individual decides to leave the comfort and control of their home environment and enter the workplace, there are risks. Every American needs to know their rights under American law. Employees have the right to¹:

• Working conditions that do not pose a risk of serious harm
• Receive information and training (in a language that the workers can understand) about chemical and other hazards, methods to prevent harm, and OSHA standards that apply to their workplace
• Review records of work-related injuries and illnesses
• Obtain copies of test results performed to find and measure hazards in the workplace
• File a complaint asking OSHA to inspect their workplace if they believe there is a serious hazard or that their employer is not following OSHA rules
• Request that identity remains confidential
• Use their rights under the law without retaliation. If an employee is fired, demoted, transferred, or retaliated against in any way for using their rights under the law, they can file a complaint with OSHA. This complaint must be filed within 30 days of the alleged retaliation
• Report any incident or hazard to your immediate supervisor

While OSHA may not be able to protect every worker from every possible accident or scenario, OSHA standards are created to establish a system from which risk, hazard, and responsibility may or may not be applicable. Specifically, OSHA standards are rules that describe how employers are legally required to follow to protect their workers from hazards.¹

Standards protect workers from a wide range of serious hazards. These standards limit the amount of hazardous chemicals workers can be exposed to, require the use of certain safe practices and equipment, and require employers to monitor certain workplace hazards.¹

Examples of OSHA worker safety standards include¹:

• Requirements to provide fall protection
• Prevent trenching cave-ins
• Prevent exposure to some infectious diseases
• Ensure the safety of workers who enter confined spaces
• Prevent exposure to such harmful substances as asbestos and lead
• Put guards on machines
• Provide respirators or other safety equipment
• Provide training for certain dangerous jobs

Few workplaces are as complex as a healthcare facility. Such complex situations provide a lot of potential health and safety hazards.¹ When compared with the total civilian workforce, healthcare workers have a greater percentage of workers' compensation claims for sprains and strains, infectious and parasitic diseases, dermatitis, hepatitis, mental disorders, eye diseases, influenza, and toxic hepatitis.¹

The list of potential hazards includes radiation, toxic chemicals, biological hazards, heat, noise, dust, and stress.¹ The risks and exposures for blood and body fluids are important but not included in this course. Information about the risks and exposures to blood and body fluids is available in a separate course entitled OSHA: Occupational Exposure to Blood and Body Fluids at www.CEUFast.com.

All healthcare and home care facilities are required to have detailed information about the chemicals that are at the worksite. This information is in a standard format called a Material Safety Data Sheet (MSDS).³

Nursing aides, orderlies, and attendants have the highest rates of musculoskeletal disorders (MSDs). The rate is more than seven times the average for all industries. The average incidence rate for MSD cases with days away from work increased by four percent, while the MSD incidence rate for nursing aides, orderlies, and attendants increased by ten percent.^3,5,6

These injuries are largely due to overexertion related to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring and repositioning patients and working in extremely awkward postures.^3,5,6

The most common causes of all work-related back pain are^3,5,6:

• Job performance by a worker who is unfit or unaccustomed to the task
• Postural stress
• Work that approaches the limit of a worker's strength

Factors that contribute to these causes of back pain are:

• Understaffing
• The lack of regular training programs in proper procedures for lifting and other work motions
• Inadequate general safety precautions

Written guides and programs for preventing back injuries are available for all workers. The primary approach to preventing back injury involves reducing manual lifting and other load-handling tasks biomechanically (body movement) stressful. The secondary approach is to train workers on how to perform stressful tasks while minimizing the biomechanical forces on their backs and how to maintain flexibility and strengthen the back and abdominal muscles.^3,5,6

To prevent back injury, workers should^3,5,6:

• Use proper lifting techniques
• Request help. When in doubt about whether a task may strain the back, a worker should request help rather than take a chance
• Use back exercises to strengthen the back muscles and help prevent back injuries. A physician or physical therapist should be consulted

Patient transfers are particularly hazardous for healthcare workers. The following fundamental points should be emphasized to prevent back injuries during transfers^3,5,6:

1. Communicate the plan of action to the patient and other workers to ensure that the transfer will be smooth and without sudden, unexpected moves
2. Position equipment and furniture effectively (for example, move a wheelchair next to the bed) and remove obstacles
3. Ensure good footing for the workers and patients (patients should wear slippers that provide good traction)
4. Maintain eye contact and communication with the patient. Be alert for trouble signs
5. If help is needed, request that a coworker stand by before attempting the transfer

Accident hazards such as wet floors, stairway obstructions, and faulty ladders should be reduced. Wet-floor hazards can be reduced by proper housekeeping procedures such as marking wet areas, cleaning up spills immediately, cleaning only one side of a passageway at a time, keeping halls and stairways clear, and providing good lighting for all halls and stairwells. Workers should be instructed to use the handrail on stairs to avoid undue speed and to maintain an unobstructed view of the stairs ahead of them. Request help to manage a bulky load.^3,5,6

The consequences of work-related musculoskeletal injuries among CNAs and HHAs are substantial. Along with higher employer costs due to medical expenses, disability compensation, and litigation, injuries are also costly regarding chronic pain and functional disability, absenteeism, and turnover. Approximately 20% of nurses who leave direct patient care positions do so because of risks associated with the work. Many healthcare workers who experience pain and fatigue can be less attentive, less productive, more susceptible to further injury, and can be more likely to affect the health and safety of others.^3,5,6

David, a float CNA, was educated on how to use the newest lift equipment and techniques to use when transferring patients from their wheelchairs to their beds and visa-versa. He constantly encouraged the staff he worked with to ask for assistance when handling residents who were unable to help themselves or required more than one person to assist them in moving. Before using any lifting equipment, he made sure all lines and hooks were secure and the equipment functioned safely and properly. Especially in the secured units where many of the patients have dementia or Alzheimer's disease, he instructed the staff to always work as a cohesive team. The individual at the head of the patient is designated to be in charge, and they would discuss the process they would use ahead of time. Patients are told what will be done and why before staff transfer them. Questions are answered at the patient's level of understanding.

This approach is time-consuming and may seem redundant. However, these steps can prevent injuries.

A major point to remember is that the better healthcare workers care for their own bodies and protect themselves from diseases and injuries, the more patients they can help daily. Taking care of yourself is just as important as caring for your patients. There are many ways to be injured in the healthcare workspace, and the savvy healthcare worker knows how to work with those risks while protecting their health & safety!

Healthcare facility fires and disasters are especially dangerous because workers must protect themselves and evacuate large numbers of patients.⁷ Almost one-third of healthcare facility fires originated within patient rooms or worker quarters. Matches and smoking is the most frequent cause.⁷ Other causes are malfunctioning or misused electrical equipment, including hot plates, coffeepots, and toaster ovens.⁷

Deaths during healthcare facility fires are overwhelmingly due to inhaling the toxic products of combustion rather than direct exposure to the fire. Another obvious fire hazard is the use of oxygen within patient areas. Oxygen increases the combustion of fire. Fires can occur in an oxygen-enriched atmosphere because of patient smoking, electrical malfunctions, and the use of flammable liquids. Procedures should be developed and strictly enforced to prevent fire hazards within patient areas where oxygen is used. When entering a new work area, look around and find fire alarms, fire extinguishers, exit signs, and oxygen cut-off valves.⁷

One way to remember fire safety is the acronym RACE⁷:

• R: rescue
• A: alarm
• C: contain the fire (if possible)
• E: extinguish or evacuate

When rescuing anyone in immediate danger, remember to stay low. Smoke rises to the ceiling, forming a heavy, dense cloud that slowly descends. This cloud is deadly because it contains toxic gases. Never hesitate to sound the alarm with any suspicion of fire, but never yell fire. That will only create panic. Call out the facility's code for fire. Call the switchboard to report the fire and pull the fire alarm. When calling the switchboard, be sure to stay on the phone long enough to ensure they have the correct information.⁷

Healthcare units are separated by heavy fire doors that close automatically when the alarm is sounded to keep the fire from spreading. Additional measures to take to confine a fire include:

• Closing doors, windows, and all vertical openings like the laundry chute
• Stuffing wet towels under doors to keep smoke out
• Shutting off oxygen supplies if directed to do so

Usually, someone in charge is designated to decide when to turn off oxygen supplies.⁷

If a fire is small and confined, you may be able to extinguish it. If a patient's clothes are on fire, wrap the patient tightly in a large blanket to extinguish the flames. If a piece of equipment catches fire, pull the plug or cut the electricity as soon as possible.⁷

If a fire cannot be extinguished and smoke, fumes, or flames threaten patient safety, you may have to evacuate (move patients out of danger). Evacuate ambulatory patients first. Stay calm and give clear directions. Evacuate horizontally (sideways) as long as you can. Then, evaluate vertically (up and down) to a lower level. Never use an elevator to escape during a fire. A sudden loss of power could leave you trapped inside the elevator.⁷

Fire extinguishers come in different classes for use on fires of different sources. The extinguisher has small pictures on the label that help you identify the type of fire source material the canister will extinguish. Class A puts out fires involving ordinary combustibles (cloth, wood). Class B extinguishers smother fires involving flammable liquids or gases. Class C extinguishers put out fires in or near electrical equipment. Type ABC extinguishers can be used to fight all three types of fires. To use an extinguisher, pull the pin, aim the nozzle at the base of the fire, and squeeze the trigger while you make sweeping strokes.⁷

For anyone at a healthcare site, having clear and explicit directions for fire safety, as well as disseminating that knowledge to other colleagues at that site, is critical to everyone's safety. Fires can get out of control very quickly. The more informed the staff is, and the more frequently the staff practices important fire safety protocols, the more lives will be saved should a terrible situation occur!

Disaster plans should be prepared for natural events (e.g., tornadoes, earthquakes, and hurricanes), gas leaks, and bomb threats. The plans should be written and readily available. Supervisory workers will initiate the disaster plan and designate tasks to workers. Workers are responsible for knowing the alarm code for a disaster and the exit routes.

Workplace violence is a serious concern for the approximately 15 million healthcare workers in the United States.¹⁴ OSHA does not require employers to implement workplace violence prevention programs. Still, it provides voluntary guidelines and may cite employers for failing to provide a workplace free from recognized serious hazards.¹⁴

The circumstances of healthcare and home care facility violence differ from the circumstances of workplace violence in general. Violence most often relates to robbery in other workplaces, such as convenience stores and taxicabs. Violence in healthcare and home care facilities usually results from patients and occasionally from their family members who feel frustrated, vulnerable, and out of control.¹⁴

Common risk factors for healthcare and home care facilities violence include the following¹⁴:

• Working directly with volatile people, especially if they are under the influence of drugs or alcohol or have a history of violence or certain psychotic diagnoses
• Working when understaffed-especially during mealtimes and visiting hours
• Transporting patients
• Long waits for service
• Overcrowded, uncomfortable waiting rooms
• Working alone
• Poor environmental design
• Inadequate security
• Lack of staff training and policies for preventing and managing crises with potentially volatile patients
• Drug and alcohol abuse
• Access to firearms
• Unrestricted movement of the public
• Poorly lit corridors, rooms, parking lots, and other areas

Violence may occur anywhere in healthcare or home care facilities, but it is most frequent in psychiatric wards, emergency rooms, waiting rooms, and geriatric units. Studies indicate that violence often takes place during times of high activity and interaction with patients. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, or tobacco or alcohol use.¹⁴

Patients with a condition that causes confusion and impaired judgment are more likely to become violent than a patient with normal mentation.¹⁴ Confusion and impaired judgment may be caused by neurologic conditions, seizures, hypoglycemia, or dementia. Watch for signals that may be associated with impending violence¹⁴:

• Verbally expressed anger and frustration
• Body language, such as threatening gestures
• Signs of drug or alcohol use

Note how your coworkers behave. If a colleague's demeanor or behavior has changed for the worse, notify the person in charge.¹⁴ For example, slamming equipment around is red-flag behavior. Learn from their history. If a patient has a history of violent behavior (such as acting combative in the ambulance or waiting room), prepare yourself for potentially violent behavior and warn others who are caring for this patient. Let security know if you feel threatened or if you find or suspect that the patient is carrying a weapon. Notify your nursing supervisor, manager, and healthcare facility security if you suspect a patient will be violent. In a home care situation, leave and call the police if needed.  Keep your patient informed. Help relieve patient tension and anxiety by informing them about when examinations/treatments will be performed and what is happening.¹⁴

Be Alert¹⁴:

• Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor
• Be vigilant throughout the encounter
• Do not isolate yourself with a potentially violent person
• Plan your exit
• Watch your surroundings

Always keep an open path for exiting. Do not let the potentially violent person stand between you and the door. When you are with an upset patient or coworker, avoid areas of the room that do not have an accessible exit. If you go to an isolated part of your facility, let others know where you are going and when you expect to return. Consider asking for an escort.

Observe your surroundings and note anyone who is not wearing a staff ID and is lingering where they should not be. Ask politely if you can help and notify security if you are unsatisfied with the answer. Call security and provide a full description if you would rather not approach someone.

Evaluate the way you wear equipment to be sure it cannot be used as a weapon against you. For example, consider that a stethoscope or ID badge without a breakaway necklace can be used to choke you. Carry your stethoscope in a pocket and use an ID badge necklace that has a breakaway feature. If you wear a necktie, opt for a clip-on style. If your hair is long, wear it in a way that is not easy to pull, and do not wear dangling jewelry.¹⁴

The demand for home care services is escalating in step with the aging population, resulting in an ever-growing number of paid caregivers providing in-home services for individuals with illnesses and disabilities.

CNAs and HHAs have identified multiple types of home hazards.¹⁵ Homes can harbor a variety of hazards, including throw rugs, pests, tobacco smoke, mold, sharps, inadequate lighting, cluttered hallways and rooms, and inaccessible bathrooms.¹⁵

Despite high rates of work-related injuries and the identification of a variety of hazards, scant research describes hazards by specific locations in the home. Hazards also negatively affect job performance, job satisfaction, and health.¹⁵ In the only published study describing particular locations in the home of injuries incurred by HHC providers, researchers found that 60% of HHAs injuries occurred inside patient homes, with the most common locations being the bedroom (24%), bathroom (18%), and kitchen (9%).¹⁵

Half of the injuries were associated with patient handling, 8% with specific objects (e.g., needles, pets), 8% with cleaning, 4% with lifting objects, 2% with trash disposal, and 28% were not specified. Patient handling tasks that resulted in injury included moving patients in bedding, bathing, and transferring patients.¹⁵

Recommendations to reduce exposure to trip/slip/lift hazards include making changes in the work environment (e.g., removing throw rugs, securing cords, providing adequate lighting), using assistive devices such as transfer or gait belts, participating in ergonomics training, and wearing sturdy shoes with slip-resistant soles.¹⁵

Water and grease spills were described frequently on kitchen floors; tight spaces and missing equipment in bathrooms; clutter, tight spaces, and lifting hazards in the bedroom; electrical cords and oxygen tubing in the living room; and clutter in the hallway.¹⁵

Pet droppings were key biohazards in the kitchen and living room; human waste was commonly noted as bathroom and bedroom hazards.¹⁵ The rooms in patients' homes where HHAs work varied by type of healthcare worker and patient needs. For example, nurses may not go into a patient's bedroom or kitchen if patient care is provided in the living room.¹⁵

By contrast, home health aides are often in all rooms if they provide cleaning, meal preparation, and personal care services. A key implication of these findings is that healthcare agencies should provide tailored training addressing the hazards HHC providers will likely encounter by room.¹⁵

Many healthcare workers must constantly deal with exposure to neoplastic and hazardous drugs. New drugs are developed every year, and each has specific side effects. Fortunately, organizations such as NIOSH, CDC, and DHHS are constantly updating important information, telling us how to be safe, along with the side effects of new chemical agents. Healthcare workers in all departments need to know where their MSDS book is located and have easy access to it. Educators must constantly update their safety manuals and educate workers on all shifts and in all departments. In today's volatile world, healthcare workers and others need to stay informed on how to handle fires and be prepared for disasters, both man-made and natural.

Knowing how to use equipment that can prevent injuries, along with practicing utilizing this equipment, is necessary. Workplace violence is everybody's concern. The key to success is to learn to listen effectively, know when to speak and what to say, respect everybody's personal distance, and show genuine concern for all those you are in contact with. People need to feel valued and appreciated and know the consequences of their actions. Administrators are responsible for ensuring healthcare workers are protected from injuries while at work and enforcing the consequences when a patient, relative, or coworker physically or mentally abuses a worker.

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