Inspection Detail

Inspection: 312692023 - Laguna Honda Hospital

Inspection Information - Office: San Francisco District Office

Investigation Summary

On August 15, 2011, Employee #1 was working as a food services worker at a hospital and rehabilitation center. She was working at the end of the sanitation/scrape line, a mechanized, slatted conveyor belt (Caddy Corporation, Soiled Tray Conveyor-Slatted Belt). Her task was to pick up trays from the end of the scraping line and place them into the washer/sanitizer machine, because the system was not equipped with a direct feeder. Workers on the scrape line used to wear regular washing gloves to protect their hands from direct contact with food residues and possible nonfood materials found on the soiled trays, because some of the patients/residents had mental disabilities. The trays were often stacked and had difficulty moving over a bend a few feet away from the end of the line. At approximately 9:30 a.m., Employee #1 was trying to facilitate movement of trays near the bend. A stack of trays hit her left elbow and pushed her hand into the space between the slats, where the tip of her left middle finger was crushed. Employee #1 received first aid from her employer, and she then drove herself to CPMC - Davies Campus, which was staffed with hand surgeons. The injury was diagnosed as a distal phalangeal fracture, and surgery was performed to place pins to hold the fractured bone. However, the crushed portion of the finger did not heal. It became completely necrotic and was subsequently amputated on September 21, 2011. The accident was reported to the District Office on August 31, 2011. The primary cause of the accident was failure to guard the powered slatted conveyor belt, which exposed employees to pinch point hazards. Other factors such as stacking the trays, lack of training on proper use of the conveyor belt, and wearing oversized gloves also contributed to the accident. The Employer was cited with one serious, accident-related violation. A Cal/OSHA regulation required machines or components of machines, which create among other things pinch point hazard, to be guarded. Other violations were observed and the employer was cited accordingly. The event date in the report (October 31, 2011) did not match the date of the incident in the narrative (August 15, 2011).

Keywords: FRACTURE, AMPUTATED, FINGER, GLOVE, HEALTH CARE FACILITY, CAUGHT BETWEEN, CONVEYOR, NIP POINT, UNTRAINED, UNGUARDED