{i any,? 1i. - - Occupational Safety and Health e, i. LI. 1. one! Mum Ma Mm 701 Route 73 South. Building 2, Suite 120 Marlton, New Jersey 08053 August 19, 2019 Mr. Andrew- Ming Senior Regional EHS Manager 50 Canton Way Robbinsville, New Jersey 08691-2350 Dear Mr. Ming The Occupational Safety and Health Administration (OSHA) performed an inspection of the workplace at Amazon Ful?llment Center at 50 New Canton Way, Robbinsville, New Jersey, on or about February 15, 2019. As part of the inspection, OSHAevaluated the AMCARE medical unit. During a previous inspection conducted on July 1, 2015, OSHA found that the Robbinsville AMCARE - unit was providing medical care beyond ?rst aid. OSHA also determined that emergency medical technicians (EMTs) at AMCARE were providing medical care outside their scope of practice, without proper supervision. These issues were the subject of a letter that OSHA sent your facility on January 6, 2015. The current inspection revealed similar issues. A summary of ?ndings follows. The AMCARE protocols in effect in 2015 allowed AMCARE to provide non-emergent care for up to 14, days before referring an injured worker to a ician. An updated version of Amazon?s Conservative Care is now in ?ch a physician who is not licensed to practice medicine in New Jersey, reviewed and signed these protocols on October 3, 2018. The updated protocols allow AMCARE to provide care for up to 21 days before referring a worker to a physician. A delay in physician-supervised treatment of that duration is not consistent with the standard of medical care expected at a health care facility. OSHA has noted that there are inconsistencies between AMCARE facilities operating in different states. For example, the updated Conservative Cure Preroccis limit AMCARE ireatrnent duration to 10 days in Tennessee. Thus, workers in Tennessee obtain a referral to a physician in less than halfthe wait time compared to workers in New Jersey. A geographic variation is inappropriate and violates the principle that standards of medical care should be the same for workers everywhere. Additionally, the current OSHA inspection again revealed instances indicating that the EMTs and Athletic Trainers (AT5) at AMCARE are working outside their scope of practice, without proper supervision. New Jersey state laws do not allow EMTs and ATs to practice medicine independently; a physician must supervise their work. At AMCARE, there is no on-site physician. A physician to verify whether AMCARE sta?' follow the written protocols does not review clinic notes. The EMTs have failed to can the Health Force Physician Health Lincm (PHL), sense by physicians at(7) (C) company, even when the AMCARE protocols explicitly require that they do so. OSHA reviewed AMCARE documents and identi?ed multiple recent instances in which EMTs and ATs did not follow the Conservative Care Protocols approved by Dr. Jones. 5 On February 6, 2019, a worker su?'ered - Pain intensity was described by the patient as ?10? the maximum possible pain on a scale of 0 to 10 as per the Conservative Care Protocols page 6) and the pain did not improve after ice therapy. An EMT and AT returned the worker to work with no restrictions, despite written instructions in the Conservative Care Protocols to refer workers to an urgent care clinic immediately when pain intensity is described as On February 28, 2019, a falling object struck a worker in the head. The worker-reported headache and blurred vision. The Conservatoire Care Prerecots on page 61 states that all head injury cases should be discussed with the PHL. The protocols also instruct AMCARE to refm workers urgently for same day evaluation if there are any of concussion. Despite these instructions,.it appears that AMCARE did not call the PHL or offer outside medical evaluation. On March 12, 2019, a worker su?'ered a (6 . jury. An EMT noted swelling, rednus, and pain over the proximal interphalmgeal joint. These signs and could be due to a fracture. The Conservative Care Protocols page 52 instruct AMCARE to refer workers to an outside provider when there is signi?cant discoloration, swelling, or in?ammation around a joint. The EMT did not refer the worker to an outside physician. On March 30, 2019, a worker reported _ain due to repetitive motions. The pain increased greatly over the following days. The worker asked to see a physician several times, including on March 31 and April 13. Each time, an AMCARE EMT convinced him not to go to a physician. The EMTs disregarded the following instruction in the Conservative Care Protocols page 6: ?If Associate states directly they want to see a physician at any time during the 21 day period, the ?rst aid provider must immediately stop care and refer the Associate to an outside medical provider.? On May 4, 2.019, a work suffered era-injury. The worker asked to go to a hospital to see a physician. EMT and Safety Specialist denied the request. After lunch, the worker - reiterated his desire to see a physician. AMCARE again dissuaded him ?'om seeing a doctor. AMCARE violated the written Conservativie Care Protocols page 6, which mandate immediate referrals to a physician upon request. Furthermore, the Protocols pages 55?57, instruct AMCARE to call the PHL for guidance whenever there is an injury (even if the workerdoctor). have neither the training nor skills to evaluate injuries. On May 11, 2019, a worker suffered a (6) injury. Pain intensity was described as either or ?1 0? (there is a discrepancy between two AMCARE notes) and an EMT documented ?nger swelling. The worker then visited AMCARE three more times, once per day for the next three days, with pain intensity each time. From May 12 through May 14, AMCARE assessed the worker only once per day, in violation of the Conservative Care Protocols instruction that pain intensity of should trigger follow-up at AMCARE every two hours. In summary, Amazon has not adequately addressed the issues that OSHA identi?ed during the prior inspection. In fact, the increase in maximum treatment duration prior to physician referral from 14 days to 21 days represent a less protective policy. OSHA has decided not to issue a citation for these patient care issues at this time, which would be addressed under the General Duty Clause of the Occupational Safety and Health Act of 1970. Instead, OSHA will refer the matter to state agencies with jurisdiction over clinics, physicians, EMTs, and ATS. These referrals will allow the state agencies to conduct their own investigations regarding the scope of practice and medical treatment. In the interest of workplace safety and health, OSHA recommends that Amazon voltmtarily take following steps to address the problems that we identi?ed: - Ensure adequate physician supervision of AMCARE EMTs and ATS. Recommend that a physician review clinic notes on a regular basis to maintain an adequate standard of care. a Ensure that AMCARE BMTs and ATs follow all relevant patient care protocols. a Do not discourage Associates from seeking medical care ?our a physician when requested. Reduce the dm'ation of care by AMCARE staff prior to physician referral, and make consistent between states. To evaluate your progress in addressing these issues, please send me a letter no later than September 23, 2019 detailing the actions you have taken or plan to take. OSHA?sMarlton Area Of?ce will evaluate the response, and may follow up to evaluate any newly implemented or enhanced policies, procedures, training, or other measures taken to address the hazards identi?ed above. If you have any questions, please feel free to contact me at 856-596-5200. Respectfully -- ct?iQ Paula Dixon-Roderick, Area Director