Safety is part of the Big Three

Safety is included in the Big Three because safety is a basic human need. On Maslow’s hierarchy of needs, “safety” is both a physical and a psychosocial need.

In long-term care, practicing Safety minimizes the risk of accidents and injuries without further limiting the resident’s mobility and independence.

The care team must be proactive in protecting a resident from potential accidents in their environment; for some people, an incident like a fall, burn, or scald can cause deadly complications^[1].

Slipping on some juice and breaking a hip can be the adverse event that begins a sharp decline in health and quality of life; a small scrape or scald can become a wound with an uncontrolled infection. Avoiding accidents and practicing safety is important for everybody, and it is especially important when caring for vulnerable adults.

NAs must practice safety measures to protect patients and residents. NAs must also take steps to protect any visitors, their coworkers, and themselves. Many of the risk factors for patient and residents are also risk factors for everyone else. For instance, NAs can help prevent slips and falls by reporting any spills as soon as they notice them; slipping and falling is an accident risk for everybody.

When NAs take measures to promote residents’ safety, these measures cannot infringe on residents’ rights. For example, if a resident wants to go on a walk, then their NA should not stop them from going on a walk because going on a walk can be dangerous. Instead, the NA should do everything they can to make the resident’s going a walk as safe and accident-risk free as possible.

Accident risk factors

A risk factor in general is anything in one’s environment or life that increases the likelihood of physical or psychological harm. Accident risk factors are features of a person’s way of being in the world or their environment that can make them more prone to accidents like falls, bumping into things, dropping things, taking the wrong medication, etc. Age, agitation, sensory impairments, decreased mobility, and prescribed medications are some common risk factors^[2].

Accident by Adrien Coquet from Noun Project (CCBY3.0)

Age: As a person ages, their reflexes can slow, their muscles can weaken, and their situational

awareness may decrease. When we are aware of our surroundings, it is less likely that we will slip and fall, stumble on an object, or bump into something.

The surrounding environment itself can be a risk factor to both the resident and the NA, especially when drawers are left open or clutter is allowed to accumulate on the floor.

Agitation: When somebody acts in an agitated way, they are more prone to accidents than when they are calm. This goes for both facility staff and for patients and residents.

NAs should always maintain a sense of calm; if they feel themselves getting agitated, they should turn to breathing techniques and other forms of self-regulation. If NAs are distracted by their own feelings of agitation and frustration, they will be less prepared to respond to situations that put residents at risk.

Residents being agitated or acting aggressively is an accident risk factor; overstated hand and arm movements can cause harm to the person gesticulating, and an agitated resident may be more likely to perform difficult maneuvers unassisted and may even become an elopement risk. Frustration and agitation cloud everyone’s thinking by limiting our perspective and inhibiting our capacity for careful and reasonable thought.

NAs should work with residents who experience agitation to develop self-regulation techniques so that unpleasant feelings do not become a source of physical danger or injury. Always report resident agitation to the nurse so they can develop techniques to include in the resident’s care plan.

Vision loss: A resident experiencing vision loss may not see obstructions in their path, may have a difficult time reading labels on medicine and food, and are less likely to have a keen awareness of their surroundings to help them avoid potential injuries. Residents need to know their surroundings to be safe; NAs should describe the layout of a room to residents with vision loss upon entry. NAs can assist residents around a space by offering up their arm for the resident to take, but should never take a resident’s arm.

Hearing loss: Residents may not hear a verbal warning from a NA about safety precautions or the presence of other accident risk factors.

Impaired sense of touch: Residents may not realize when something, such as bath water, coffee, or a food item is dangerously hot. If a dangerously hot liquid come into contact with human skin, it can cause a scald. A scald is a burn caused by liquids, and they can worsen, become infected, and lead to severe complications.

Impaired mobility: Residents with impaired mobility are more likely to fall, and are less likely to catch themselves or fall safely. NAs should assist residents with mobility impairments with any ADLs that can lead to accidents such as getting dressed, or moving between bed and a chair. Always lock the wheels of the bed and chair when transferring somebody between their bed and their wheelchair.

Medication: Medication poses a risk factor, particularly for residents with vision impairments or unreliable memories. In some circumstance residents will be responsible for their own medication, while in others their medication will be administered by facility staff. Residents with vision loss may not be able to administer their own medications because they run the risk of poisoning themselves.

New medication can pose a risk factor because of side effects. Some medications will have behavioral side effects, while others may induce vertigo. NAs should be aware of any medications that residents are taking and familiarize themselves with potential side-effects to be aware of, particularly those that pose additional accident risk factors.

What is a safe environment?

A safe environment is one in which a person’s risk factors have been minimized. A safe environment involves basic physical safety, in that the risk of injury from infection, falls, burns, poisoning, and other accidents is low. A resident has a right to a safe environment, which means that residents’ rights and safety are closely intertwined.

Sensory safety

A safe environment is a comfortable environment. It produces feelings of safety and security, in addition to minimizing accident risk factors.

• The temperature of the room should be comfortable for the resident and set between the required 71 - 81 degrees Fahrenheit.
• Noise should be at a reasonable level that does not impede communication, or pose an unwelcome distraction.
• Any smells in the space ought to be pleasant to the resident when possible.

The resident’s room

Safety concerns relate closely to a resident’s physical environment.

• Spaciousness is an important dimension of safety. If a room is too cramped for someone to move around comfortably and freely, then it is not safe, especially for those with a heightened risk of falling.
• Keep the room free of clutter. A cluttered space is a fall risk.
• The room should be well-lit so it can be maneuvered easily and safely.
• A person in a long-term care facility has a right to their own possessions, and it is the responsibility of everyone involved to help keep resident possessions safe from theft, intruders, and fire. This is often accomplished by placing a small safe in resident’s room.
• NAs should always respect residents’ privacy. If someone does not have access to privacy, they will not feel safe.
• NAs should never lock a resident in their room. This is a violation of residents’ rights and poses a danger in the event of a fire.

Emotional wellbeing

A safe environment includes emotional as well as physical features.

• Residents should not feel afraid in a safe environment. If a resident is expressing ongoing fear and concern about being in a particular space, the NA should inquire further.
• Persistent feelings of fear and anxiety may be a result of disorientation. If a resident’s fear or anxiety persists beyond managing risk factors, the nurse should be notified.
• If a resident expresses fear or anxiety around particular staff members, other residents, their family, or specific spaces in the facility, the resident may be experiencing abuse. NAs should report suspected abuse to the nurse immediately.
• Residents have a right to a home-like environment. NAs should listen attentively when discussing how they can make the resident feel most comfortable and at-home in their space.

What are common accidents? How can we avoid them?^[3]

Falls

Falls are the most common form of accident in assisted living facilities. They usually occur during the hours of 6 and 9 p.m. in resident rooms and bathrooms during the staff’s shift change. The most common causes of falls are poor lighting and cluttered floors, although many things can cause someone to fall.

Accident by Adrien Coquet from Noun Project (CCBY3.0)

• Before their shift change, NAs should always assist residents with using the restroom and any other activity that requires movement.
• Help residents keep a tidy space, remove clutter and cords from all walkways, and keep frequently used objects within easy reach.
• Never move a resident alone. Attempting to move a resident by oneself can result in serious harm to the resident and the NA. When helping residents in and out of bed or in and out of a wheelchair always lock the wheels first.
• Residents must wear non-skid footwear.
• If raising a bed to provide care, make sure the bed has been returned to its lowest position after giving care. Non-skid bath mats should be used when helping residents bathe and shower.
• If the NA notices any unsteady objects like rugs, loose handrails, or damaged walkways, benches, or ramps, they should report it immediately.
• When helping a resident to stand or walk transferring from a horizontal position, NAs should give them a moment to sit upright as a transitionary posture. Sitting upright in between laying down and standing up can help prevent lightheadedness, and preventing lightheadedness can help prevent a fall.
• NAs should assist residents with bathroom needs promptly, and offer residents the bathroom often. This will prevent residents from needing to attempt to use the bathroom on their own, and can help avoid the risk of a fall on the way to or while inside the bathroom.
• NAs should never move furniture without being told to do so by a nurse, and they should always tell the resident before moving the furniture.
• Long-term care facilities should perform fall risk assessments on all of their residents. NAs should make sure they consult the care plan for any specific fall-prevention measures.

Missouri Employers Mutual. (2015, November 6). Healthcare slips, trips, and falls [Video]. Youtube. https://youtu.be/YnTIv3VZ7Aw

Responding to a fall

If a resident is falling, the proper way to minimize damage is not to try and completely stop the fall. Instead, the NA should use their body as leverage to gently lower the resident to the floor.

Bring the resident’s body close to one’s own and slowly and carefully lower the resident to the floor. The resident cannot get up until a nurse has arrived and checked them for injuries. NAs should sit with the resident until a nurse arrives.

Even if a resident has a fall and is uninjured and says that they feel fine, always report it by completing an incident report form.

Burns and scalds

Burns and scalds can be caused by hot electrical appliances or hardware, hot liquids, or dangerous chemicals. Burns can happen quickly, are extremely painful, and may require complicated interventions like surgery and long-term wound treatment. A burn can be the event that causes a downturn in a resident’s physical condition. Elderly people are at the greatest risk of injury from burns due to a less sensitive sense of touch.

Burn by Adrien Coquet from Noun Project (CCBY3.0)

• Always check bath water temperature with a thermometer; bath water should not exceed 105 degrees Fahrenheit. Always check the water temperature before a resident enters the bath.
• Make sure hot beverages have cooled before prompting a resident to drink; older adults’ skin is fragile, and spilled coffee or tea can cause a harsh scald. Always be careful when pouring hot drinks, and be conscious of where hot drinks are placed on a table.
• Be conscious of the harmful capabilities of the sun. Do not leave use-objects such as wheelchairs in the sun for long periods of time; if a use object has been left in sunlight, NAs should check the temperature of the object before allowing residents to use it. Residents should also not be left in the sun; when going outside, have residents use sunscreen and wear hats.

Poisoning and choking

Poisoning is a risk for residents because there is a high concentration of toxic materials in facilities. Glue, cleaning products, paint, soap, perfume, and medication are all things that be dangerous or deadly if consumed or consumed improperly.

• Items like plants, fragrances, soap, hair products, and nail polish and nail polish remover should all be kept away from disoriented residents. Such products should be stored in a locked place or kept outside of the resident’s room.
• Poison Control’s phone number should be posted wherever there is a telephone.
• Make sure there is proper ventilation in every space, since chemical products can release fumes that residents may find unpleasant or overwhelming.
• NAs should check resident drawers or stowing locations for rotten or spoiled food.

• NAs should closely observe residents when they eat and drink; some residents may be at high risk for choking due to weakness or dysphagia.
• Dysphagia can lead to choking on food, drink, or another foreign substance. The inhalation of matter into the lungs is called aspiration, and can lead to severe medical complications. Dysphagic residents may require prescription diets of naturally viscous or thickened liquids.
• Residents should have their bed in an upright position when consuming food or drink. When assisting a resident with consumption, NAs should proceed slowly and switch between solids and liquids. All food should be cut into small, bite-sized pieces that will not be laborious to chew.
• Dentures must fit properly and securely.
• Know residents’ specific swallowing needs and precautions. If a resident would have an easier time eating with a different diet, NAs should report this insight to the nurse.

The Safety Data Sheet (SDS)

The Safety Data Sheet (SDS), formerly referred to as the Material Safety Data Sheet, is a resource that provides information on specific chemicals and chemical products, why and how each is dangerous, how to properly handle and dispose of them, how to use them, and which emergency actions are necessary once in direct contact or ingested.

OSHA, the Occupational Safety and Health Administration, requires that facilities keep a copy of the SDS on hand and readily available at all times.

Facilities must have SDSs for every dangerous chemical used.

NAs must be able to read and understand the information represented on an SDS, and apply it to their circumstances. Always ask for help. if unsure about something on the SDS.

“physical hazard label” by The EnergySmart Academy is licensed under CC BY-NC-SA 2.0.

Check the SDS before cleaning chemical leaks or spills. Any hazardous substance must have a warning label on its container; if an NA notices that a container for a hazardous substance looks damaged, they should immediately alert the nurse.

 Ally Safety. (2021, September 29). Safety data sheets training video by Ally Safety [Video]. Youtube. https://www.youtube.com/watch?v=_yWF-w3CwmU

General guidelines

• The danger of skin tears

  Older adults are at a high risk for accidents like cuts, scrapes, and tears because human skin weakens and thins as a person ages. Preventing skin tears is an element of Safety; it is also an element of Infection Control.

  Avoid leaving any sharp items out, like razors, after they are used. Sharps must be disposed of in a specific “sharps” container labeled with a biohazard symbol.

Biohazard by Dmitry Vasiliev from Noun Project (CCBY3.0)

• Prevent skin tears by interacting with residents in a careful and thoughtful way; dress residents slowly and smoothly, and always be conscious of their limbs and hard or rough surfaces. It won’t take much more than a brush against a rough surface for a resident’s skin to break; NAs should proceed with a heightened degree of caution whenever there is a risk of a resident’s skin tearing.
• Don’t run.
• Pay attention to the environment. Keep an eye out for spills or wet surfaces, and address spills and clutter.
• Don’t overburden extension cords, as this can lead to fires.
• Don’t overuse plugged-in items; electrical devices should be unplugged when not in use. Unplug something if it becomes overheated, stops working properly, or causes a spark. Alert management immediately about frayed cords or wires, and stop using them.
• Always ask for help when moving a resident, in addition to utilizing proper lifting techniques and equipment.

  Always report and fill out an incident report form for any injuries or workplace violence.

• Get to know each resident, and learn which residents are more likely to become combative or aggressive. Know what triggers this kind of behavior, and be prepared to respond calmly. Notify the nurse of aggressive or combative residents so you can develop a response plan together.
• If exposed to a dangerous chemical, rinse skin with water immediately and follow facility procedures for chemical exposure. The same applies when anything splashes in one’s eyes; thoroughly rinse, and report the incident to the nurse. An emergency eye flush may be necessary, as will a visit to a doctor.

Residents rely on the nursing team to meet their basic needs, and a person must be safe to have their basic needs met. The needs and rights of facility staff members must also be taken into consideration. The whole team has to exercise care, caution, and proactive thinking about risk factors to protect the safety of everyone at the facility.

Disaster Preparedness

Fire safety

Fire is a constant danger in assisted living facilities. All a fire needs to occur is heat to produce the flame, fuel for the fire to burn, and oxygen to maintain the fire.

What is a fire hazard? A “fire hazard” is something in an environment that has a higher likelihood of causing a fire.

Smoking is a major fire hazard. If a facility allows any smoking indoors, smokers should never be left unattended.

• Always check ashtrays and put out anything that is still smoldering. Check the surrounding area to make sure no smoking materials have become lost.
• Always double check an ashtray before emptying it to avoid the risk of starting a trash fire.
• If residents use vaporizers or e-cigarettes, make sure the battery does not overcharge or become overheated. Remove the battery at night.

Frayed or overused electrical infrastructure, such as outlets and cords, are fire hazards.

• Don’t use cords that have been wrapped in electrical tape.
• NAs should report any damaged electronics as soon as they see them.
• Don’t overburden power strips.

If you smell gas, report it immediately.

Oxygen tanks are fire hazards because they contain large of amounts of compressed fire-fuel. Since fires burn on oxygen, compressed oxygen tanks are notable fire hazards. Oxygen tanks must always be stored properly when not in use. Never smoke, or allow anyone else to smoke, near an oxygen tank.

Responding to a fire

Fires do occur in medical facilities. It is extremely important for NAs to prepare, and keep their wits about them when they do occur^[4].

• Everyone should know where a facility’s fire evacuation plans are kept. If a fire occurs, stay calm – calmness allows for clear and critical thinking.
• Rescue residents in immediate danger while following the evacuation plan.
• If a building is on fire, check doorknobs and under doors before opening them, and remain low to the ground to minimize smoke inhalation. Make sure exits are clear and free of debris.
• Do not use an elevator during a fire.
• Close all doors and windows to keep the fire contained.
• Turn off any oxygen or electrical equipment in the fire’s area.

It is important to know the location of all of the facility’s fire alarms. If the NA wonders what to do in case of a fire, they can remember the acronym “RACE.”

              Remove anyone in danger, unless you are actively in or escaping danger.

              Activate the alarm and call 911

              Contain the fire; close all doors and windows.

              Extinguish the fire if you can do so safely. If not, evacuate and the fire department                                will extinguish the fire.

Using a fire extinguisher can be nerve-wracking, especially in a stressful situation like a fire. Remember the acronym “PASS” to know the steps for successfully using a fire extinguisher.

              Pull the pin

              Aim at the base of the fire (not the middle or top of the flames)

              Squeeze the handle

              Sweep back and forth at the base of the fire.

Disaster response

A disaster is a sudden catastrophic event. Nobody likes to think about the possibility of disasters, whether natural or man-made, but they do occur, and it is important to be prepared for them. Natural disasters include floods, earthquakes, tornadoes, and some fires, while man-made disasters include events like things like shootings and acts of terrorism.

When disasters occur, NAs must respond calmly and intentionally. Facilities will have plans in place for disasters; NAs must closely follow facility protocol in the event of a disaster.

Planning for disaster

Facilities will have plans and drills in place for specific kinds of disasters.

A facility’s disaster plan necessarily involves steps to protect the safety of both staff and residents.

A facility’s plan will outline the process for discharging those who are able to go home, and using the facility’s designated emergency areas. Off-duty staff may be called in for extra assistance if  possible.

All evacuation procedures should be followed when initiated.

Always remain calm – calmness  allows for clear and critical thinking.

Understand how to keep yourself safe by identifying situations that put NAs at risk

Workplace Violence Prevention

Workplace violence refers to any situation in which an employee has attempted harm enacted upon them. This harm could either be physical or psychological. Threats and bullying are forms of workplace violence, in addition to physical violence.

Someone does not have to successfully harm an employee for it to be an instance of workplace violence. Actual physical violence and verbal threats to violence are both instances of violence, as is harassment and other forms of violent behavior that do not always involve physical contact.

Workplace violence occurs more frequently in healthcare careers than in any other industry. The vast majority of healthcare workplace violence comes from patients or residents who act aggressively towards staff members. NAs are at particular risk of experiencing workplace violence because they have the most direct contact with patients and residents^[5].

Workplace violence can also come from co-workers. Such workplace violence is referred to as “lateral violence.”

American Nurses Association. (2023, March 24). ANA workplace violence defining scope of violence [Video]. Youtube. https://www.youtube.com/watch?v=8tvMtB91ghE&list=PLf2d17tjKiop_fIRXbI5Jz9WC44Xz0Qei&index=3

According to Schub and Karakashian, the majority of incidents of workplace violence in hospitals were against staff by patients or visitors. Relatedly, NAs’ rates of workplace violence were 2.8 times higher than the national average^[6]. NAs should recognize that their safety is at stake in conversations about workplace violence.

OSHA publishes guidelines for workplaces to follow that can help to decrease the risk of workplace violence. OSHA recommends that workplaces maintain a written program for workplace violence prevention. Make sure that you know what your facility’s workplace violence prevention plan involves.

It is essential that all NAs understand and follow their workplace’s violence prevention program. These plans are in place as a result of careful analysis of threats and the best responses to them^[7].

• Always voice concerns. If you are concerned about a potential risk, whether regarding an aggressive resident, a suspicious and unknown person in the facility, bullying, or something else, speaking up could make the difference between resolving the risk and a workplace violence incident. Early awareness of a potential threat can provide an opportunity to intervene, and helps staff be prepared in the occurrence of violence.
• Always report incidents of violence promptly and accurately. Violent incidents require an incident report form.
• NAs can take extra steps to help ensure their safety and the safety of those around them by signing up for any extra safety trainings offered. Special trainings on workplace violence can help employees recognize and manage aggression, agitation, assaultive behavior, and intent to commit violence.
• Consider joining the health and safety committee that reviews information on workplace violence and implements procedures to minimize it.

Risk management

Almost everything discussed thus far, from proactively preventing common accidents to navigating the possibility of workplace violence, falls under the idea of risk management.

Risk management refers to identifying and managing the risks and safety hazards that impact a healthcare agency. Managing risks is about protecting everybody’s safety from accidents, risks of violence from patients or visitors, and risks of violence from other staff members.

Facility risk management deals with:

• Accidents and fire prevention
• Preventing negligence and malpractice by medical staff
• Preventing abuse of patients
• Preventing workplace violence
• Always meeting federal and state safety requirements and quality of care standards.

If these things are going to be done effectively, then plans and decisions must be made according to data collected from within the facility. Incident report forms are vital to a facility’s ability to manage risks.

Incident Reports

An incident is an event that has harmed or may have harmed a patient, resident, visitor, or staff member. When an incident occurs, an incident report will need to be filled out^[8].

Incident reports are compiled and reviewed as data by facility risk management personnel and committees. The risk management team analyzes the incident data to look for trends and patterns in the reported accidents, errors, or violent incidences.

Fill out incident reports as soon as possible. It is important to remember details accurately and completely, so filling out the incident report form quickly will allow for a clear and detailed memory .

What kinds of incidents require and incident report form?

• Any and all accidents involving patients, residents, visitors, or staff. Anything from a resident falling and breaking a hip to the scheduler getting a papercut warrants an incident report.
• Incidents of workplace violence.
• Errors in care require incident report forms.

  For example, if Mr. Jones was supposed to get a bath, but Ms. Smith is bathed instead by mistake, report the incident.

  Errors in care include giving the wrong care to someone, giving care to the wrong person, and not giving care to someone who was supposed to receive it. Tell the nurse if an error in care occurs so everyone who needs care still receives it properly.

• Broken or lost items, money, or clothing
• Incidents involving hazardous substances such as chemicals or cleaning solutions
• Sentinel events are unexpected events that result in a person’s severe injury or death, and require immediate investigation.

When reporting an incident, stick to facts. Include exactly what happened and peoples’ responses to it, the time, and date.

Incident report forms are confidential and intended for internal use only. NAs should never make a photocopy of an incident report form, and should not include statements like “incident report filed” in a patient’s medical chart since this might lead to a breach in confidentiality.

Movement and body mechanics

Body mechanics refers to the way that the different parts of our body work together; good body mechanics refer to ways of performing motions like lifting, bending, and running that maintain the physical health of the body. For example, sitting up straight and tall is an example of good body mechanics because it helps maintain spinal health over time.

Good body mechanics are necessary for the long-term health and functioning of all human bodies; NAs really have to consider body mechanics to protect themselves from injury, and to protect the people they care for from injury as well. Musculoskeletal injuries are a common issue in healthcare, and can be debilitating.

Alignment

A person’s body is in alignment when a vertical line can be drawn from the tip of their head to their tailbone. Humans should try to maintain alignment whenever possible, whether they are laying down, sitting, or standing.

The left and right sides of one’s body should be mirror images of one another, particularly when carrying something heavy, large, or awkward.

When carrying a heavy object, maintain bodily alignment by keeping the object close to one’s body and avoiding twisting or hinging one’s body at the waist. If lifting a heavy object, a person should keep the back straight and lift with their legs. Use the thighs, upper arms, and should to lift, as these are some of a person’s strongest muscles. Never lift with your back.

Video by Allie Tiller is licensed under CC BY-NC 4.0

Base of support & center of gravity

The base of support for any object refers to an object’s foundation^[9]. For most humans, one’s feet will be their base of support. Widening the base of support by spreading one’s legs further apart and bending one’s knees can help to maximize stability. Standing with feet at shoulder-width will allow stability and balance; keeping one’s feet together narrows the base of support and leaves you prone to imbalance.

A person’s center of gravity is the point in their body where the most weight is concentrated;

the placement of a person’s center of gravity depends on how their body is positioned. Standing normally, the center of gravity is around the pelvis.

Hold the objects or people you lift close to your body. Holding objects or people away from one’s own body can cause a person to strain and injure their muscles, especially their back.

Good body mechanics are Safety

Assisting with ADLs and nursing tasks involves a lot of moving and lifting, as well as other care activities that, if done without good body mechanics, could cause a musculoskeletal injury. Such activities include lifting and moving residents, tidying a bedroom and doing laundry, helping a resident move in or out of a facility, taking out the trash, moving equipment such as a bed, and even simply cleaning the floor. Try to make good body mechanics a habit.

Any activity that involves lifting and bending carries a risk of injury if the person does not consciously practice good body mechanics.

Keep these tips in mind:

• Raise the bed before making it or replacing the linens, and lower it again afterwards.
• Always keep the lifted object close to oneself and stand with a wide base of support. Lift with the legs. If possible and safe, slide heavy objects across the floor rather than lifting them. When lifting, always bend at the knees and not at the waist.
• Maintain alignment by facing the object or person being lifted.
• Pivot, don’t twist.
• Always use both arms and hands when moving objects.
• Get help from coworkers when moving a heavy object or a resident.
• Always talk to residents before attempting to move them. Explain what is going to happen, discuss any ways that the resident can help or make the movement more easy and comfortable, and coordinate your movements by counting to three so that everybody moves synchronously.
• Always bend a resident’s knees before moving them in bed; if their knees are not bent, then residents are more likely to sustain a back injury

Ergonomics

Maintaining good posture in the residents one cares for is an important aspect of a NA’s job. Ergonomics refers to the practice of creating equipment that suits the needs of human bodies, or modifying work procedures and motions to promote the health of the body. Examples include devices like ergonomic chairs and eating utensils, or practices like adjusting beds to a good working height instead of bending down.

Medical equipment to be ergonomically sound. Beds and chairs need to be supportive, and mobility devices need to keep a person’s body safe and secure. Canes and walkers need to be designed with aging human hands in mind. Medical equipment needs to have high ergonomic standards because the likelihood and consequences of injury are raised in healthcare contexts, especially when caring for elderly people.

Ergonomic equipment, particularly assistive devices that are used to safely transfer and move residents, is necessary to protect both caregivers and the recipients of care.

Healthcare workers also need to have good ergonomic work practices. Ergonomically sound body movements help protect staff members from back injuries.

The Right to Safety

OSHA mandates a safe work setting. Part of maintaining a safe work setting is minimizing activities that put staff members at risk. Musculoskeletal injuries are a high risk for direct care staff because of the frequent lifting, moving, and range of motion the job requires; musculoskeletal problems account for over half of NA’s days away from work^[10]. OSHA guidelines require that employers take measures to avoid or minimize the conditions that result in back and muscle injuries.

Back injuries can occur from a motion repeated over time, or from one adverse event. Even though a single movement, such as twisting while carrying an object instead of pivoting, may not feel like a strain when done once, it may cause a back injury when done repeatedly.

Symptoms of back injuries include:

• pain when sitting or standing
• decreased mobility and range of motion
• pain when rising from a seated position

Report the symptoms of a back injury right away. Assistive technology such as over-the-counter back braces can help staff members practice good body mechanics on the job.

Lifting an uncooperative or unsuspecting resident poses a risk factor. It is pertinent to both Safety and Resident Rights to communicate effectively with the resident before lifting them and while lifting them.

• Whenever lifting or moving a person, or when helping a person move, always remember to be gentle and respectful of the person’s body.
• Tell them exactly what is going to happen before performing the task; if it would be helpful, involve them in the task by coordinating so they help execute the maneuver; for instance, by saying “push up with your legs on three.”
• The important part is to keep communicating through the whole process, from entering the person’s room until the move has been completed.
• Always check in with the person afterwards to make sure they are stable and comfortable.

Equipment and techniques for promoting safety

Various pieces of equipment, like transfer belts and wheelchairs, can help keep both staff and residents safe. However, if safety and assistive equipment is going to keep people safe, it needs to be used properly. Improperly used safety equipment quickly becomes a risk factor.

Transfer/gait belt

Transfer belts are thick belts made of strong material that facility staff can use to help residents get from their bed and into a chair or wheelchair. Transfer belts are also used to assist a resident with ambulation, and in such cases may be called a gait belt. NAs can grasp the belt firmly and use it to help move the resident.

• Transfer belts are used to help people who are unsteady or disabled.
  • Tighten the belt around the resident’s waist until it is snug but not tight – the NA should still be able to fit all four of their fingers under it.
  • Grasp the belt on either side with fingertips upwards and spread out. Never place the transfer belt over a resident’s bare skin.
  • The resident should not hold onto the NA for extra support, since doing so could take both the NA and the resident off-balance.
  • If a resident is wearing a transfer belt, they should not stand without assistance. Do not take your hands off of the transfer belt when the resident is standing.
  • Always raise the resident’s bed to help them into a seated position to assist them out of the bed. NAs should raise the resident’s bed whenever providing care to maintain good posture.

Video by Allie Tiller is licensed under CC BY-NC 4.0

• If a person is falling while being assisted, the NA should not attempt to catch the resident. Instead, the NA should use the gait belt (another word for transfer belt) to ease the resident slowly to the floor.
  • The NA can brace the resident against their body; as they lower the resident to the floor, they should remember to maintain good alignment, keep their center of gravity low, and bend and lower from the knees rather than the back.
  • A resident that has fallen should not be allowed to get back up until a nurse checks them for injuries. Always complete an incident report right after a resident falls, even if they appear to be uninjured.

Video by Allie Tiller is licensed under CC BY-NC 4.0

Wheelchairs

Practicing thoughtful wheelchair safety is important to keeping residents and oneself uninjured. Some wheelchairs are motorized, while others are propelled by the person using the wheelchair or by another person using the chair’s push handles.

(ICC video how to transfer someone into a wheelchair)

• Before transferring a person into a wheelchair, make sure that the wheelchair’s brakes are activated. The wheelchair needs to remain stationary while the transfer is performed.
• Make sure that the tires are sufficiently inflated and properly secured to the wheels. Check the wheels for any damage.
• When positioning a resident in the wheelchair, it will be helpful to situate their hips in the back of the chair by having the resident move themselves backward into the wheel-locked chair while bracing themselves on the chair’s arm rests. After the resident is situated, help them get comfortable.
• Once the resident is in position, make sure that all four wheels are pointed forward. Next, position the person’s feet squarely on the footplates, and double check that they are in place before unlocking the wheels and pushing the chair forward.
  • Always push a wheelchair forward, unless going through a doorway or entering an elevator. When going through a doorway or entering an elevator, it is appropriate to pull the person in the wheelchair in reverse.
  • Never let the person stand on the footplates.
• Some people may need accessories added to their wheelchairs. For instance, somebody who needs to be kept on oxygen will have a specific accessory that affixes the oxygen equipment to the chair. A person who uses a catheter bag will also have a specific wheelchair accessory that allows them to easily and discretely travel with it. Always make sure that a person’s necessary wheelchair accessories are in place.

Video by Allie Tiller is licensed under CC BY-NC 4.0

Stretchers

If a resident cannot sit up or must remain laying down as part of their care, then they will not be able to use a wheelchair. In such cases, NAs will likely need to use a stretcher. A stretcher is a small platform, like a very narrow bed, with four wheels.

Image by Dan Zen is licensed under CC BY 2.0.

• Stretchers come with safety belts to make sure that the person does not fall out of the stretcher. Make sure that the stretcher’s safety belt and straps secure the patient.
• Always ask at least 2 or more colleagues for help when moving someone from their bed to a stretcher.
• Make sure that the stretcher’s wheels are locked before and after the transfer occurs.
• Before unlocking the stretcher’s wheels, raise the side rails and keep them raised for the duration of the transport.
• Keep talking with someone who is being moved, first by narrating what is going on, and then by continuing the conversation if the person seems open to it. Transportation via stretcher can be uncomfortable and vulnerable, and people may appreciate an attempt at casual human connection through pleasant conversation.
• Always keep a person on a stretcher covered so they remain warm, and to minimize unpleasant feelings of exposure. Blankets and coverings can help someone feel more secure.

Bariatric equipment

Bariatric equipment is any medical equipment that is designed to have a higher weight capacity than standard versions. Beds, wheelchairs and chairs, stretchers, toilets, commodes, and other equipment usually have a weight capacity of 250 to 350 pounds. However, some people who need care will exceed the standard weight capacities of most equipment.

Never exceed the listed weight capacities on equipment; the equipment used must be able to safely support the full weight of a person. Bariatric equipment is built with weight capacities between 250 and over 1,000 pounds. This equipment is labeled with “expanded capacity,” and will be labeled with the suggested weight limits.

NAs should always ask themselves whether they are doing something in the safest way, or whether there are any safety concerns that are being overlooked. The safety of everyone, residents, patients, staff, and visitors, is the utmost priority. NAs should always ask for help if they need it or if they are unsure of correctly and safely performing a task.

Restraints and restraint-free care

Restraints are either physical or chemical; a physical restraint is any method or equipment that restricts or limits a person’s capacity for movement, such as special straps, belts, and mittens. A chemical restraint is a medication used to manipulate mood and behavior^[11].

Restraints can only be used when they are determined to be medically necessary, usually by a doctor’s order, and/or by consent of the person. A person can consent to restraint in advance – in these cases, such information will be included in the person’s care plan.

If a resident cannot remove equipment designed to enable them, then the enabler may become a restraint; an example would be a laptop tray on a wheelchair that, if it cannot be removed without assistance, traps the resident in their seat and restricts the movements they can perform from that position.

Make sure that residents can easily remove enablers; if they cannot, the NA should remain with the resident to provide assistance for the duration of the enabler’s use^[12].

Bed rails

Patients’ raised bed rails may be either an enabler or a restraint depending on their use. The NA should always lower the bed rails after completing care tasks. Leaving the bed rail raised increases the risk of entrapment.

Entrapment occurs when a person becomes physically trapped in a physical structure, such as their bed’s headboard or bedframe. A resident can easily trap their arms, legs, or head in the spaces provided by a fully raised bed frame.

Avoid leaving patients or residents in situations that could result in their entrapment. Bedrails can only be used when they are necessary for care. Raised bed rails are sometimes needed by unconscious, sedated, or disoriented people.

Resident Rights

Before the passage of OBRA, restraint use was common for everything from fall prevention to keeping confused residents in place, or to prevent people from removing their own tubing and IV lines. This environment created conditions where the irresponsible use of restraints was normalized for caregiver convenience, rather than the wellbeing of the resident.

Restraining people for convenience leads to injuries and abuse, so the federal government determined that restraints need to be limited to specific, proper uses. Now, restraints can only be used when they are medically necessary, and the least restrictive effective restraint must be used. Restraint application as discipline, punishment, or convenience is illegal and abusive.

Whenever a restraint is being used to care for a resident, strict guidelines must be followed involving close monitoring of vital signs, mental condition, and skin health. Close monitoring is required because residents can suffer complications from restraint use that can result in injury and death.

Complications

Complications from restraint use can be extensive and varied^[13].

Restraints, when used improperly or for too long, can cause:

• bruising and other skin contusions and damage
• suffocation
• negative impacts on the circulatory system and heart health
• decreased mobility from muscle atrophy
• musculoskeletal complications and nerve injuries.
• falling
• entrapment
• strangulation
• poor nutrient consumption
• urinary tract infections
• incontinence
• constipation

Restraints can also have negative effects on a person’s mental wellbeing, including:

• depression
• poor sleep
• loss of independence and dignity
• increased anxiety and agitation
• social isolation
• confusion

In severe cases, restraint use can result in death.

Using restraints carries high-stakes risks, so many workplaces aim toward restraint-free care, or at least emphasize finding alternatives to restraint before deploying it as a last resort.

Facilities are legally required to take restraint use seriously, and can only use one “if it is the least restrictive means necessary to attain and maintain the resident’s highest practicable physical, mental, or psychosocial wellbeing,” as found in the Illinois Nursing Home Care Act^[14].

Restraints can only be ordered by specific personnel such as medical doctors, medical social workers, nurse practitioners, and in some cases RNs. If a person poses an immanent physical threat to themself or others a restraint may be ordered immediately.

A resident must be monitored regularly while restrained, and must be able to access their call light. Persons being restrained must have their call lights answered immediately.

NAs must let a person out of their restraint every two hours (at least) to receive care and perform basic ADLs, and to check in on their physical and psychological comfort. NAs should make sure to check for discoloration or swelling of the skin and notify the nurse of any abnormalities, especially in the areas making contact with the restraint.

Adverse side effects like sedation, confusion, and disorientation often accompany chemical restraints. Such side effects may cause or constitute harm, and should be avoided when possible.

Documentation

Documentation is an important dimension of using restraints, and is required by federal and state law. Once someone makes the decision to use a restraint, multiple parties must be notified, including members of hospital administration and any individuals or organizations the person being restrained had officially indicated.

NAs must document certain things in a person’s chart while caring for them during restraint use. Always document:

• what type of restraint was used
• how it was used
• the time it was applied
• each subsequent removal
• Document any care given in between or after restraint use, including a person’s vital signs. Make sure to take note of any circulation, skin, or behavioral abnormalities.

Restraint alternatives

All patients and residents have a right to be free from restraint. This right can only ever be infringed upon when it is in conflict with their right to safety. The right to be free from restraint has led many facilities to adopt a restraint-free care policy.

A facility uses restraint-free care when they never use restraints for any reason. Not all facilities have restraint-free policies, but those that do set the standard and help to advance the use of restraint alternatives. A restraint alternative is a measure or adaptation a facility makes to minimize or eliminate the need for restraints.

Understanding the underlying reasons for a dangerous behavior or condition allows for the possibility of addressing them in a way that avoids the need for restraints.

If a resident is agitated, NAs can try and redirect their attention and energy towards engaging activities, or calming them with breath work. It is also a good idea to make sure residents are physically comfortable by offering a snack, inquiring about pain levels, or offering assistance with the rest room.

Agitated people often experience irritation as a result of understimulation. Providing interesting things to do, opportunities for physical exertion, and people to talk to can help. Sometimes people experience irritation instead as a result of overstimulation and tension; NAs can prompt the resident to engage in relaxing activities, or use their knowledge of what relaxes the resident to create a soothing environment.

Always follow facility guidelines, training, and protocol on best practices to use regarding restraint and restrain-free care.

Hartford Institute for Geriatric Nursing. (2013, September 20). Avoiding restraints for elderly dementia patients [Video]. Youtube. https://youtu.be/wiJUkLflSQU

Comprehension Questions

1) Respond to the following sentences with T (true) or F (false).

____ Safety, Resident Rights, and Infection Control are all closely connected.

____ The best way to avoid accidents is to proactively remove them from a person’s environment. If they can’t be removed, the nursing team should have a plan in place to manage accident risks.

____ Age is not an accident risk factor.

____ Diminished awareness is an accident risk factor. Nursing assistants must remain observant and vigilant to protect residents from risks, especially if the resident tends to lack situational awareness.

____ Psychological and emotional factors, such as orientation and emotional regulation, are not considerations in risk management.

____ Falls are rare in healthcare settings.

2) What are some things NAs can do to help create a safe environment? Select all that apply.

a. Make sure the temperature is between 71 and 81 degrees; if the Resident is still cold, use blankets and dress them in warm, soft clothing.

b. Regularly have loud background noise on to drown out the other sounds in the facility.

c. Keep the room free of clutter and make sure the resident has adequate space to maneuver.

d. Keep lights dim and low to create a calm and comfortable ambience.

e. Observe residents closely for indications of discomfort or anxiety. Talk with residents to see what makes them feel comfortable and at-home.

3) Which of the following actions can NAs take to help prevent falls? Select all that apply.

a. If there is loose, unsteady, or broken equipment, say nothing and let someone else take care of it.

b. Make sure the resident wears non-skid footwear.

c. Answer call lights immediately for residents who are at high risk of falling.

d. Rearrange the resident’s room often to keep things fresh.

4) What is the Safety Data Sheet? Select the most correct answer.

a. Information on protecting patient’s electronic health information.

b. Facilities are required to have a Safety Data Sheet for every chemical they use.

d. A color-coded sheet with lots of symbols on it.

e. A resource that all facilities must keep on hand that provides information on specific chemicals, how each is dangerous, how to properly handle and dispose of them, how to use them, and which emergency actions are necessary once coming into direct contact or ingested.

5) Respond to the following sentences with T (true) or F (false).

____ The presence of oxygen does not require heightened awareness of fire safety.

____ Staying calm is an essential part of good disaster response.

____ Facilities mostly rely on good improvisational thinking during disaster response.

____ NAs must make sure they know all facility disaster response plans, including evacuation, lockdown, and shelter procedures.

____ If a power strip sparks when you plug something into it, that just means it’s working.

6) What qualifies as workplace violence? Select all that apply.

a. You are filing paperwork and get a papercut.

b. A coworker calls you an offensive name because of the way that your lunch smells. Even though you know it was immature, your feelings are hurt. When you talk to her about it after your shift, she tells you she isn’t joking and that you’d better bring something else for lunch tomorrow.

c. You are helping a confused resident eat his lunch. He forgets where he is and, due to poor vision, thinks that someone is trying to hurt him. He knocks the spoon out of your hand and pushes you away.

d. Your supervisor critiques your job performance without offering any constructive feedback.

7) Please list at least 5 situations that would require an incident report form.

8) Respond to the following sentences with T (true) or F (false).

____ Keeping your back straight when you lift heavy objects is an important part of good body mechanics.

____ Someone’s center of gravity is always in the same place.

____ NAs should raise the bed to a safe working height when changing linens or providing care, and return the bed to its lowest setting when complete.

____ Communicating with residents before, during, and after transferring them is an important part of practicing Safety and protecting Resident Rights.

____ Nursing assistants, like everyone, have a right to a safe working environment.

9) When is it acceptable to use restraints in a resident’s care?

a. When it will be most convenient for the nursing team.

b. When the facility does not have a restraint-free care policy.

c. Only when they are ordered by qualified personnel, are necessary for the person’s care, are used as a last resort, and are removed as soon as they responsibly can be.

d. If the resident becomes combative and issues threats to the care team.

10) Why is it so important that a resident have easy access to their call light while under restraint? What does this have to do with the Big Three?

11) You show up to work in your favorite new pair of scrubs. However, the scrubs are just an inch too long; but they fit great otherwise, and you don’t have any other clean uniform clothes to wear. Your day is going well, and you are assigned to give a resident a sponge-bath in bed. You heat the water and pour it into the basin without checking the temperature. On your way over to the resident your pant leg snags on a zipper from the resident’s handbag that is laying on the floor; you stumble, and spill water on the resident. The water was 130 degrees Fahrenheit, and causes a scald that requires treatment and infection control measure. The resident’s condition worsens and their quality of life goes down. How could this situation have been prevented?

12) You regularly care for a resident with dementia who often becomes absorbed in puzzles and word games. You notice that he has been becoming increasingly frustrated over small things, and has been quicker to anger. Recently, while confused, he tried to hit after you startled him by interrupting his activity to suggest he use the bathroom before a meal. He profusely apologized, and you were taken aback because this resident normally is kind and gentle with you, so you forget to tell the nurse about the incident at the end of your shift. The next day, he successfully hit a different nursing assistant. What is one thing you could have done to prevent this from occurring? Why is the prevention of workplace violence important for both staff members and residents?

13) Why should restraint free care always be a goal, even if the facility does not have a formal restraint-free policy? What are two restraint-alternative strategies the nursing team can use when a resident acts agitatedly or aggressively?