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February 2012

Printable Version

Most healthcare providers are aware of common slip-and-trip hazards. However, familiarity with your environment may have allowed you to adjust, making it easy to overlook, or even not notice, situations that can cause injury to others less familiar with the surroundings.  In this article we will examine the mechanics, environment and client profile that lead to injuries, and we will provide strategies to improve the safety of your office setting. 

 

Falls

By understanding the mechanics of how humans walk we can better appreciate what conditions lead to falls. A person’s gait cycle consists of four basic phases: toe off, foot swing, heel strike and weight bearing.  Each of these fits into one of two fall categories – slips or trips.

 

Trips typically happen during the “toe off” and “foot swing” phases.  During these phases, weight is being transferred forward in our stride. Those with a normal gait will swing their foot only one half inch above the walking surface.  If an outside force interrupts either of these phases, a person will typically fall forward. Individuals that fall forward or trip may incur injury to their knees, wrists, shoulders, face and head. Elderly people are more susceptible to hip injuries due to compromised bone density. Most trips occur when walking on irregular level surfaces or traversing steps (either up or down).

 

Slips tend to happen during the heel strike and weight bearing phases. During these phases our weight is landing and being stabilized so the next step can occur. The energy produced by the locomotion of our body is being absorbed by the heel strike; therefore it is critical that the walking surface have enough friction to provide and maintain a steady landing. When moving forward we bear weight onto our entire foot and balance our body mass so the next foot swing can take place. Once again it is critical that the walking surface be flat and that it provide sufficient friction to maintain a secure foot plant. Slips tend to cause backward falls. Individuals that fall backward or slip often incur back, elbow, neck, shoulder, head and hip injuries. 

 

Common Hazards

Most common slip-and-trip hazards are fairly obvious: lose or wrinkled carpet, uneven wooden decking, broken or irregular sidewalk slabs, wet or icy surfaces and loose steps. Other hazards can be much tougher to recognize. Consider the following: 

 

·      Inconsistent Steps (i.e. the rise or tread dimensions vary from step to step)    
All steps should have uniform riser heights and tread widths to prevent trip up or heel slip situations. This is not an easy condition to fix. If the steps cannot be replaced or corrected, clear signage warning others of the hazard should be present along with a sturdy hand rail with a good grip rating.

 

·      Single Monochromatic Steps (where the floor covering and/or the walls are of the same color or pattern)
When we walk, we typically look forward, not down. A single step may not provide enough depth perception to be seen, especially if the décor acts to camouflage the step.  Poor lighting magnifies this problem. Several precautions can improve this situation:

 

o    Mount a hand rail along the step for assistance while also giving a visual cue to the presence of the step.

o    Install warning signs, brightly colored anti-slip toe covering and adequate lighting to improve the person’s ability to recognize the hazard.

 

·      Ramps   
Ramps are a practical solution for accommodating walker and wheelchair traffic; however, danger exists on either side of the ramp. Typically the transition from the side of the ramp to the lower level is abrupt and may be the same color as the ramp. This has led to litigation resulting from ankle injuries sustained when patrons step too close to the edge of the ramp and roll their ankles on the curb. The ramp curb should be painted in a highly contrasting color to make it more obvious. In addition, the installation of handrails on both sides of the ramp is imperative.

 

·      Mats and Area Rugs   
Individuals with walking impairments often experience difficulties when encountering mats and area rugs. Rug edges are a particular hazard for those with a walker, suffering from toe drop, or otherwise shuffle when they walk. It might be a good idea to consider removing decorative area rugs all together. Although, mats used to contain wet conditions at exterior doorways may be a necessity. In this application, be sure the rugs have tapered edges and anti-slip backings. In cases of extreme weather, the rugs may need to be cleaned or replaced more often than usual.

 

·      Downspouts   
Downspouts draining across walkways can lead to a severe hazard. Ice and snow on a roof will often thaw and run off during a sunny day, only to refreeze when temperatures drop later in the evening or when the weather takes a turn for the worse. This very thin coating of ice (“black ice”) is practically invisible to pedestrians and can lead to falls. To prevent this possibility, all downspouts should be directed towards a non-walking area and all walkways should be properly maintained during winter months. This includes keeping them clear of snow and ice and applying preventive measures such as salting and sanding. It is also recommended that you assess your walkways throughout the day as weather conditions can change rapidly.

o    Handy Tip: If possible, try keeping a small salt container in your vehicle so you can treat the walkway as you approach your building first thing in the morning.

 

·      Parking Curbs   
Movable parking curbs are used to designate parking spots and prevent vehicles from hitting a structure. At times these can be at the end of a ramp or walkway presenting a trip hazard. Care should be taken to prevent these movable curbs from becoming a trip hazard.

o    Parking curbs should never be located near the end of a ramp or walkway.

o    Curbs should be painted a bright color.

o    Consider attaching a vertical cue such as a bright colored flexible marker stick like you would see in downhill skiing.  

o    Take care not to strike or move curbs during snow removal. Return any disrupted parking curbs back to their intended position immediately and replace any that have been damaged by snow plows.

 

·      Wet Leaves   
Wet leaves can pose a very slippery condition for clients and staff. They are a pesky condition since leaves can fall off trees for several weeks. Leaves can gather at the step-off point from a walkway to the parking surface. This may seem innocent enough, however once they have become wet due to rain or snow they can and do hold moisture, creating a very slippery condition. It is essential that you maintain your walkway free of any gathering leaves as frequently as possible.

 

·      Lawns   
Although pathways from the parking lot to the building are provided, many people often cut across lawn areas to enter a building. These areas pose multiple hazards including uneven turf and slip hazards from mud or moss. Consider placing an obstacle such as decorative fencing around it or a sculpture in this area to discourage people from cutting through.

 

Finally, you should consider the population that you will be serving. Are they predominately younger or older individuals?  Become familiar with any physical limitations that your patients may have and make every effort to provide the safest environment for them. Be prepared to upgrade your practice over time.  

 

Resources

Slips, Trips and Falls in the Workplace, ISSA: http://www.issa.com/?id=shp_slips_trips_falls_in_the_workplace

 

Slip, Trip and Fall Prevention for Healthcare Workers, Department of Health and Human Services: http://www.cdc.gov/niosh/docs/2011-123/pdfs/2011-123.pdf  

September 2011

Printable Version

Accidents or unexpected disasters can result in extensive water damage to important documents such as medical records and X-ray films. In recent years, New Jersey has seen its share of flooding, including the most recent damage from Hurricane Irene and subsequent heavy rain.  Broken water pipes or an overflowing floor drain can cause unexpected damage to stored medical records in a basement or storage room. Water damage can also be the often-unanticipated side effect of fire fighting efforts.

When a practice faces a loss such as water damaged records and X-ray films, there are steps that should be taken:

  • Report the loss to your insurance carriers (general liability and property)
  • Check the records themselves
    • Are there some which are only partially destroyed and may be restored?
    • Are there records which are totally destroyed?

 

Reporting to your carrier

To facilitate any claim you make, you may wish to take pictures of the damage. A series of pictures over the period of clean-up may also be beneficial, especially when dealing with a loss suffered due to fire-related water damage.

 

Keep a copy of the letter you send to your property carrier, and copies of the pictures, too. If you are named in a malpractice suit and asked to produce the records, this evidence will help respond to any allegations that records were negligently or willfully destroyed (spoliation).

 

Partially destroyed records

Moisture in any form and paper don’t mix; paper when exposed to water begins to deteriorate.  The same process occurs with an X-ray film jacket but in a slower process. Moisture infiltrates the paper’s cell structure, followed by swelling and discoloration. An environment is then created that will permit the growth of mold and bacteria on the surface of the paper or X-ray film jacket. This can occur in a domino-like effect, spreading from folder to folder. 

 

Water-damaged medical records, film, and file jackets can be restored. The complete restoration of water-soaked documents can be an expensive process, yet it may be wise to attempt to salvage them. This process has to begin as quickly as possible, and a restoration company needs to be contacted. Since this company will be working with your patients’ records, you will need to have a HIPAA Business Associate agreement with them.

 

The restoration company will place the materials into commercial freezers. Freezing, followed by vacuum freeze drying, has been shown to be one of the most effective methods of removing water from paper records and films. This is done to stop the process of deterioration or destruction.  Once frozen, the materials are moved to a freeze-drying chamber. Air within the freeze drying chamber is removed through a vacuum process and the temperature lowered. The moisture within the materials is converted to a vapor state and then taken out of the chamber. The temperature within the freeze drying chamber is gradually increased over time, and any residue moisture is removed. Freeze-drying methods have been used in the recovery of books, manuscripts, leather, maps, historical and collectible items and textiles in the form of flags, needlework, silks and tapestries.

 

If water damage has resulted from fire-fighting measures, cooperation with the fire marshal and health and safety officials is vital for a realistic appraisal of the feasibility of a safe salvage effort. Fire officers will decide when a building is safe to enter. In these instances, salvage operations are planned so that the environment of water-damaged areas can be stabilized and controlled both before and during the removal of the medical records and films. In warm weather, mold growth may be expected to appear within 48 hours. Mold can also be expected to appear in poorly ventilated areas within the same time frame. It is therefore imperative to reduce high humidity and temperature and vent the areas as soon as feasible. Water-soaked material must be kept as cool as possible with good air circulation. To leave such materials more than 48 hours in temperatures 70 degrees Fahrenheit or higher and a relative humidity above 60% without good circulation will certainly result in heavy mold growth and lead to a higher recovery/restoration cost.

 

Completely destroyed records

When records are completely destroyed, the challenge to the practice will be twofold. The destroyed records will need appropriate disposal, and new records will have to be constructed from information the practice can assemble.

 

Destroying damaged records completely must be done to protect patient confidentiality and comply with HIPAA regulations. Dry the records and then shred them if possible. No intact record or X-ray may be discarded. As noted above, be aware of the likelihood that mold will develop. Lower humidity and ventilate the area where records are stored. When ready to destroy the records, the practice should keep a log of all records that are destroyed, as is done with planned record destruction. This log should include the following information:

  • name
  • date of birth
  • social security number
  • dates of first and last visit
  • general problems and procedures performed in the office
  • documentation of what was destroyed, how it was destroyed, and the date of destruction

 

Reconstructing records can be done by pulling together information from other systems and files available to the practice. Patients should be notified of the flood event and the damage done to records. A history form can be sent to each patient along with this notification letter with a request that the patient complete this form to the best of their ability. A copy of this letter should be filed in the patient’s reconstructed medical record.

 

Once each chart is rebuilt, there should be clear documentation explaining that it was reconstructed. This documentation should include at least the following:

  • date chart was reconstructed
  • reason for reconstruction
  • sources of information for reconstruction
  • efforts made to obtain other information (if applicable)
  • a statement that, due to reconstruction, the information contained in the chart as of the reconstruction date is considered inexact

Medicare and the patients’ other insurance carriers may also expect to be notified that patient records have been lost. These organizations expect the practice to provide medical record documentation to support patient claims. When the medical record is destroyed they may want the practice to sign a form which attests to the unexpected loss of the record.

 

Prevention

It may feel like it’s too late to talk about preventing this sort of damage, but each hurricane or nor’easter produces calls from practices that had never flooded before and thought they were safe. Some had taken what they thought were appropriate precautions, only to find later they were not enough.

 

It is appropriate to evaluate your storage space at least twice a year, though a quarterly examination would be even better. More frequent inspections are appropriate when weather is unusually harsh, no matter the season. Weather extremes expose the vulnerabilities of buildings much more quickly.

 

Routine prevention steps should include stacking records and X-rays off the floor. Use shelving units, if possible, and position them as high off of the floor as possible.  Keep in mind; however, that storing records too high can pose a potential injury concern for staff.  A sturdy step stool may be needed to safely access these records. And, if you know the storm of the century is coming, take time to pull those lower boxes up out of the basement.

 

Finally, develop a system of routine record destruction so that you only keep the records you are supposed to keep. This will reduce the clutter in your storage area and reduce the number of records exposed to the risk of storm damage. You will find more information on routine record retention and destruction systems in the Princeton Insurance Office Practice Toolkit.

  

In summary, each facility or physician/dental office should perform a risk and hazard vulnerability assessment and include document restoration as part of emergency preparedness and disaster planning.

 

Ask your local emergency management office if your office is located in a known floodplain. Determine the elevation of your office in relation to local rivers, creeks, bays and the ocean.  If your practice could be subject to flooding, medical records should be located at the highest level possible inside the office.  Plastic tarps can be placed in rolls over the stored records and then unrolled when a storm approaches to protect against rain and roof damage.  Take any paper out of the lower drawers of your desks and file cabinets and place them in plastic bags or plastic containers that can be placed on top of the units.

 

Physicians who maintain paper records should also consider storing copies of their administrative records (financial, insurance, patient scheduling, patient lists) off-site in a secured area outside the floodplain area.

 

For more helpful resources, visit:

http://www.archives.gov/preservation/disaster-response/salvage-procedures.html.

 

 

Copyright 2011, Princeton Insurance Company

 

June 2011

Guide to Conducting a Post-Winter Building Inspection

 

 

Printable Version
 

We all suffered through an extremely harsh winter here in New Jersey. Snow, ice, wind and rain can affect the physical condition of your office and property over time. Extreme weather conditions can lead to potential risk exposures, creating unsafe conditions for your patients and staff. Now that warmer weather has finally arrived, we recommend that you perform a survey of your office and property’s condition. Then, put a plan in place to correct any unsafe conditions that may cause property damage or personal injury.

 

Here are some tips and things to look for when conducting your own inspection.

 

  • Start at the top of your building and work your way down.
  • Check the roof for any loose or missing shingles as well as any visible openings in flat roof material.
  • Is the chimney intact; is the chimney cover in place to prevent squirrels and birds from entering?
  • Inspect all gutters for blockages and make sure they are still securely attached to your building.
  • Inspect the siding and down spouts for loose or missing pieces.
  • Are there any cracks in foundation walls? This can affect the integrity of your outside walls, allowing water to enter the building.
  • Are wires or cables attached to the building properly secured?
  • Exterior doors and door thresholds can also be damaged by the freeze/thaw cycles of winter, so be sure to inspect them as well.

Walk the outside of your office and property:

  • Start at the perimeter and move in towards your building, focusing on uneven walking surface conditions. Uneven sidewalks, potholes and eroded soil can, and do, present trip and fall hazards for people entering or exiting your office.
  • Also check for areas where a snow plow may have lifted soil, damaged exterior lights or damaged your driveway or parking surface.
  • Inspect the trees on your property, as they may have been affected by the winter weather. Look for dead/broken branches, raised roots, cracks or injuries to the tree’s bark, holes or cavities. Any of these conditions could be problematic and may warrant contacting a certified arborist for assistance.
  • If you have wooden decking and/or railings attached to your office, be sure no nails or screws protrude from the wood’s surface, which can cause serious cuts or lead to trip-and-fall hazards. Consider repair or replacement of the decking boards or railings.
  • Remember, also, to check your office at night to be sure that the exterior lights are working properly, and that timers are set to the correct time sequence. Walkways and parking lot should be properly lit.

Early intervention and prevention will keep your property safe and free of winter-related hazards. When your property is well-maintained, it presents a safe and welcoming environment for your patients.


If you have any questions, please call our Risk Resource Line at 1-866-Rx-4RISK.

 


Copyright 2011, Princeton Insurance Company

 

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