OSHA requirements are set by statute, standards and regulations. Our interpretation letters explain these requirements and how they apply to particular circumstances, but they cannot create additional employer obligations. This letter constitutes OSHA's interpretation of the requirements discussed. Note that our enforcement guidance may be affected by changes to OSHA rules. Also, from time to time we update our guidance in response to new information. To keep apprised of such developments, you can consult OSHA's website at https://www.osha.gov.

June 15, 2000

Ms. Alice Freund
Health and Safety Advisor
Service Employees International Union
50 Charles Lindbergh Boulevard, Suite 602
Uniondale, New York 11553-3650

Dear Ms. Freund:

Thank you for your December 3, 1999 letter to the Occupational Safety and Health Administration (OSHA) requesting a "written opinion from OSHA on whether ... working on your knees in a nursing home is unsafe."

You are specifically concerned with the use of mattresses placed on the floor or very low beds that are not height adjustable. This is done to reduce residents' risk for falling out of bed. Employees who care for residents placed close to the floor perform a number of work tasks. These tasks include, but are not limited to:

  • administering medications,
  • turning and lifting residents,
  • changing linens and clothing, and
  • transferring residents to chairs and other devices.

Biomechanically, these tasks require the employee to kneel, bend over the resident and use primarily the upper body for reaching/moving/lifting a resident located on a mattress which is near to or directly on the floor. Awkward trunk postures while lifting have been associated with an increased risk for the development of back injuries.

There are a number of controls that have been successfully implemented to reduce injuries and illnesses in nursing homes. A lifting device is one method of reducing employee exposure. The type and number of lift devices would depend upon the needs of the facility. In fact, some nursing homes have experienced significant declines in injury and illness rates as a result of moving towards "zero-lift" work environments.

However, tasks such as administering medication, securing "slips" or "gait belts," and placing pads under a resident located near to the floor would still require the employee to kneel on the mattress while reaching around to the resident. A more effective method of preventing the need for the employee to work in a kneeling position would be to use height adjustable electric beds that can be raised from the floor level to approximately the waist height of the employees. This type of bed allows the worker to lift and transfer residents with less forward flexion of the torso.

The recommendations provided in this letter are advisory in nature and informational in content. It is intended as a response to your specific questions and not appropriate for every workplace.

Failure to implement the specific recommendations in this letter does not, in itself constitute a violation of Section 5(a)(1) (the General Duty Clause) of the OSH Act of 1970. The General Duty Clause requires each employer to furnish to each employee employment and a place of employment free from recognized hazards which are causing or likely to cause death or serious physical harm to his employees. Employers can be cited for violation of the General Duty Clause if a recognized serious hazard exists in their workplace and the employer does not take reasonable steps to prevent or abate the hazard. The information contained in this letter is not considered a substitute for any provision of the OSH Act or any standard issued by OSHA.

Thank you for your interest in occupational safety and health.


Charles N. Jeffress
Assistant Secretary

[Corrected 10/22/2004]