Following an inspection conducted at a facility from 06/03/2016 to 12/02/2016, the Occupational Safety and Health Administration (OSHA) issued citations for ergonomic hazards. During the inspection OSHA’s Office of Occupational Medicine and Nursing identified characteristics of the facility’s medical management program that pose several problems that contribute to injured workers receiving treatments that do not meet accepted standards of care which may contribute to workers developing serious musculoskeletal disorders (MSDs). OSHA’s concerns are described below.
1. [company] does not ensure appropriate clinical oversight
For over four years, from February 2012 until September 2016, [company] has_not provided appropriate clinical supervision for its Licensed Practical Nurse (LPN) and Emergency Medical Technicians (EMTs) at the facility. During this time, two physicians periodically reviewed and signed [company] “Medical Directives and Nursing Procedures” document.
[company] LPN and EMTs are under the impression they have been working under the medical licenses of these physicians. However, OSHA spoke with both physicians, who said their involvement with [company] was limited to an occasional review of the medical directives. Both physicians unequivocally stated that they have never been [company] medical director, have never supervised [company] clinical providers, and have not allowed [company] LPN and EMTs to work under their medical licenses. No contract or other agreement was provided indicating any other physicians agreed to be medical director at the facility. LPNs and EMTs possess neither the training nor the legal authority to practice medicine independently. The state of Delaware requires LPNs to work “at the direction and under the supervision of a recognized licensed authority” Typically, LPNs are directly supervised by a Registered Nurse within a system of care in which ultimate oversight is provided by a physician or advanced practice nurse. Similarly, EMTs “function as part of a comprehensive EMS response system, under medical oversight” We consider the lack of clinical oversight to be a very important problem. Most of the other issues identified below could have been avoided if a licensed physician or advanced practice nurse had properly supervised [company] LPN and EMTs.
2. [company] Providers are Asked to Work Outside
Their Scope of Practice In Delaware, LPN “standards of practice” are defined by the Board of Nursing. LPN scope of practice does not include supervision of other clinicians. Therefore, clinical supervision of EMTs is outside the scope of practice of the [company] LPN. In Delaware, the LPN scope of practice does not include medical diagnoses. The North American Nursing Diagnosis Association defines a nursing diagnosis as a description of “human response to actual or potential health problems and life processes,” while a medical diagnosis is a “concept that defines a disease process or injury”.
- For example, a medical diagnosis of “carpal tunnel syndrome” might result in a nursing diagnosis of”finger pain.” [company]’s medical directives instruct the LPN and EMTs to evaluate and treat medical diagnoses like “Sprains and Strains” despite the fact that making these diagnoses is outside their scope of practice. National Emergency Medical Services guidelines state that EMT scope of practice includes “basic skills focused on the acute management and transportation of critical and emergency patients’. EMTs are not trained to manage chronic medical conditions, and they must work within an EMS system overseen by a physician. Evaluating work-related injuries and making decisions about work restrictions is not within an EMT’s usual scope of practice. Further, no physician provides oversight of the [company] EMTs.
3. Medical Directives are Inappropriate
For some work-related disorders, [company]’s medical directives recommend appropriate evaluation and treatment. In other cases, the directives are incomplete or inappropriate. For example, the “Back Injuries and Back Complaints” section does not instruct the nurse to ask about “red flag” back symptoms that could signify a potentially serious injury. Red flags include fever, incontinence, major trauma, and a history of cancer. Asking about red flag symptoms is an important part of the standard of care for occupational back injuries.
For some work-related disorders, [company]’s medical directives recommend appropriate evaluation and treatment. In other cases, the directives are incomplete or inappropriate. For example, the “Back Injuries and Back Complaints” section does not instruct the nurse to ask about “red flag” back symptoms that could signify a potentially serious injury. Red flags include fever, incontinence, major trauma, and a history of cancer. Asking about red flag symptoms is an important part of the standard of care for occupational back injuries.
The [company] medical directives for “Pain in the Upper Extremity” instruct the nurse to “determine [the] probable cause of pain” and “give restrictions as needed.” These directives are inappropriate. LPNs and EMTs are not qualified to make medical diagnoses, nor does their scope of practice permit them to determine work restrictions.
In several places, the medical directives state that injured workers should be referred to a physician “if necessary” or “if indicated.” The directives do not explain how to make these determinations. Delegating these decisions to an LPN or EMT is inappropriate, as these decisions fall outside the LPN and EMT scope of practice. Typically, EMTs work under Emergency Medical Services (EMS) protocols that require them to transport all patients to a healthcare facility for evaluation by a physician. Additionally, the medical department frequently distributes NSAIDs. Use of these medications can cause serious health effects including gastrointestinal irritation and increased risk of heart attack. The medical directives do not mention that healthcare providers should warn patients about these side effects. 4. Harm to Workers Review of [company]’s medical records revealed several instances in which workers were harmed, or likely to be harmed, by medical management practices at the company. These practices include accepting inappropriate inter-facility transfers, misdiagnosing injuries and illnesses, not assessing tetanus vaccine status for workers who suffer lacerations, accusing injured workers of dishonesty and threatening adverse HR actions, actively discouraging injured workers from seeking treatment at a hospital emergency department, and inappropriately returning injured employees to work with no restrictions.
4. Harm to Workers Review of [company]’s medical records revealed several instances in which workers were harmed, or likely to be harmed, by medical management practices at the company. These practices include accepting inappropriate inter-facility transfers, misdiagnosing injuries and illnesses, not assessing tetanus vaccine status for workers who suffer lacerations, accusing injured workers of dishonesty and threatening adverse HR actions, actively discouraging injured workers from seeking treatment at a hospital emergency department, and inappropriately returning injured employees to work with no restrictions.
Review of [company]’s medical records revealed several instances in which workers were harmed, or likely to be harmed, by medical management practices at the company. These practices include accepting inappropriate inter-facility transfers, misdiagnosing injuries and illnesses, not assessing tetanus vaccine status for workers who suffer lacerations, accusing injured workers of dishonesty and threatening adverse HR actions, actively discouraging injured workers from seeking treatment at a hospital emergency department, and inappropriately returning injured employees to work with no restrictions.
5. Excessive Delays in Physician Referrals Some workers visit the [company] medical department daily, for up to several months, due to upper extremity pain. One of these workers has signs and symptoms of undiagnosed carpal tunnel syndrome and has not been referred to a physician. Another worker was delayed physician referral for two months and required surgical intervention for carpal tunnel syndrome (CTS). The LPN and EMTs at [company] do not always follow the company’s written medical directives, which explicitly state that workers must be referred to a physician if their upper extremity pain does not resolve within two weeks.
Some workers visit the [company] medical department daily, for up to several months, due to upper extremity pain. One of these workers has signs and symptoms of undiagnosed carpal tunnel syndrome and has not been referred to a physician. Another worker was delayed physician referral for two months and required surgical intervention for carpal tunnel syndrome (CTS). The LPN and EMTs at [company] do not always follow the company’s written medical directives, which explicitly state that workers must be referred to a physician if their upper extremity pain does not resolve within two weeks. Early physician referral is especially important in the case of suspected CTS because the [company] medical directives are completely inappropriate for CTS management. The “Pain in the Upper Extremity” directives instruct [company] providers to use ibuprofen, which is not recommended for subacute or chronic CTS pain. The directives do not mention important interventions such as CTS education, nocturnal wrist splinting, and carpal tunnel injections 6. [company] Misrepresents the Credentials of Medical Department Staff [company] has given an EMT the job title “daytime nurse.” EMTs are not nurses. They do not possess the same training, qualifications, and credentialing as nurses. Under Delaware law, only registered nurses and LPNs may use the title “nurse”.
6. [company] Misrepresents the Credentials of Medical Department Staff [company] has given an EMT the job title “daytime nurse.” EMTs are not nurses. They do not possess the same training, qualifications, and credentialing as nurses. Under Delaware law, only registered nurses and LPNs may use the title “nurse”.
[company] has given an EMT the job title “daytime nurse.” EMTs are not nurses. They do not possess the same training, qualifications, and credentialing as nurses. Under Delaware law, only registered nurses and LPNs may use the title “nurse”.
[company] workers should be informed of the true qualifications of company medical department providers. Unfortunately, based on multiple interviews in which they used the term “nurse” (or “enfermera” in Spanish), [company] workers may be under the impression that the company’s medical department is staffed by nurses. 7. Lack of Appropriate Medical Recordkeeping All three medical department healthcare providers stated that they do not document every patient visit. This lack of documentation was confirmed by worker interviews in which injured workers stated that the “nurses” often did not keep notes. As such, there is evidence of missing documentation of many of the in-house treatments provided by the [company] medical department.
7. Lack of Appropriate Medical Recordkeeping
All three medical department healthcare providers stated that they do not document every patient visit. This lack of documentation was confirmed by worker interviews in which injured workers stated that the “nurses” often did not keep notes. As such, there is evidence of missing documentation of many of the in-house treatments provided by the [company] medical department.
All three medical department healthcare providers stated that they do not document every patient visit. This lack of documentation was confirmed by worker interviews in which injured workers stated that the “nurses” often did not keep notes. As such, there is evidence of missing documentation of many of the in-house treatments provided by the [company] medical department. Apparently, there is no documentation of the number and frequency of medical department visits by individual workers. Such information is essential to track treatment effectiveness, avoid medication overuse, and comply with protocols that specify when workers must be referred to a physician. Proper documentation is also critical in order for [company]’s providers to communicate with one another. The standard of practice for all health care providers, including LPNs and EMTs, is to document every patient interaction, even if the patient received only first aid. Nursing documentation should be accurate, complete, and timely. Additionally, the medical department does not record the name or dose of medications given to workers. Notes simply state that a worker received ”meds.” Workers could be harmed by this practice. Proper documentation of all medications is necessary in order to track treatment efficacy and avoid excessive doses and side effects.
Furthermore, the [company] medical department assesses, but does not record, the vital signs of potentially seriously ill patients, such as those with altered mental status. Proper recording of vital signs is essential in order to monitor the patient’s status and communicate this information with other healthcare providers.
8. Environment of Care and Confidentiality The environment at [company] potentially discourages workers from reporting injuries to their supervisors or the medical department, according to interviews of workers. An adverse reporting environment leads to under-reporting of injuries and illnesses, which could prevent [company] from adequately assessing workplace hazards.
The environment at [company] potentially discourages workers from reporting injuries to their supervisors or the medical department, according to interviews of workers. An adverse reporting environment leads to under-reporting of injuries and illnesses, which could prevent [company] from adequately assessing workplace hazards. Nursing notes demonstrate that the medical department contributes to the workplace environment that discourages injury reporting. In one case, the medical department accused a worker of dishonesty and threatened his job after he reported an injury. The injury was later shown to be valid by an outside hospital. Healthcare providers should not accuse patients of dishonesty simply because of a perceived lack of objective findings, nor should they threaten patients.
Confidentiality is breached when the [company] medical department relies on co-workers, supervisors, and HR managers to provide interpretation services for non-English-speaking workers. Furthermore, these untrained interpreters may be unfamiliar with medical terminology. To avoid these issues, [company] should use a professional medical interpretation service.
In the interest of employee health, we recommend that you voluntarily take the necessary steps to improve medical management practices at the facility and corporate-wide as appropriate. We recommend you consider the following regarding [company]’s medical management program:
- company] should consult with a physician who is board-certified in occupational medicine. This physician should evaluate the facility’s medical management program and make recommendations concerning structure, staffing, supervision, documentation, medical directives/protocols, and evaluation/quality assurance.
- [company] should review Delaware state law regarding scopes of practice, supervision, and other requirements for nurses and EMTs. The company should modify the staffing and practices of the medical department to ensure they meet all legal requirements.
- Decisions about work restrictions should be made in consultation with a physician or other higher level provider. Injured workers’ supervisors should not be involved in these decisions.
- The [company] medical directives should be updated to meet current standards of medical care. The medical directives should be regularly reviewed, at least annually, by an occupational medicine physician. Specific issues to be addressed include:
- Early referral to a physician or other higher level provider for definitive evaluation and treatment of injuries.
- In cases where [company] medical department determines that a worker does not need immediate physician evaluation, the worker should be assessed by a physician within a few days if symptoms continue and/or positive examination findings are present.
- Decrease in the use of NSAIDs for pain treatment and consideration of other pain medications, such as acetaminophen, as medically appropriate. o Education of workers on adverse effects of NSAIDs and any other medication being provided in the medical department.
- Removal of references to any assessments, treatments, physical examination maneuvers, or other procedures that are outside the scope of practice of [company] medical department staff.
- [company]’s medical department staff should review and comply with nursing and EMS documentation standards. All assessments, treatments, and evaluations provided in the medical department should be recorded.
- Interpretation services should be provided by an outside professional medical interpretation service.
- [company] should not refer to EMTs as “nurses.” The company should ensure that medical department providers communicate their credentials accurately at all times.
- The medical department should not interact with workers in a manner that could discourage them from reporting injuries. In particular, the medical department should not accuse workers of dishonesty or threaten their job status when they report injuries.
- Training of the medical department staff, supervisors and workers should be conducted to include:
- Identification of musculoskeletal symptoms related to ergonomic hazards;
- Early reporting of musculoskeletal symptoms, injuries, and illnesses;
- Effective communication approaches to encourage early reporting.
- OSHA 300 logs, first aid logs and other medical records, such as workers compensation records, should be regularly evaluated for the purpose of identifying workplace hazards, instituting interventions to reduce hazards and evaluating the effectiveness of the interventions. The occupational medicine physician consultant should participate in this review.
These methods are not meant to be the only ones available or feasible. OSHA welcomes and requests a report of any of your efforts to reduce the above-mentioned exposures and the results of your efforts.
Sincerely,
Erin G. Patterson
Area Director
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