Hospitals Fail To Protect Nursing Staff From Becoming Patients | KUER 90.1

Hospitals Fail To Protect Nursing Staff From Becoming Patients

Feb 4, 2015
Originally published on February 25, 2015 3:09 pm

When Tove Schuster raced to help a fellow nurse lift a patient at Crozer-Chester Medical Center near Philadelphia in March 2010, she didn't realize she was about to become a troubling statistic.

While working the overnight shift, she heard an all-too-common cry: "Please, I need help. My patient has fallen on the floor."

The patient was a woman who weighed more than 300 pounds. So Schuster did what nursing schools and hospitals across the country teach: She gathered a few colleagues, and they lifted the patient as a team.

"I had her legs — a corner of one of the legs, anyway," says Schuster, who was 43 years old at the time. "And as we swung her up onto the bed, I felt something pop. And I went 'ooo.' "

She finished the shift in pain and drove straight home to bed.

But after Schuster woke up late that afternoon, her husband, Matt, heard her shouting. He says he ran to the bedroom and found her crawling across the floor. "I thought it was a joke at first," he says. "And she says, 'I can't walk.' "

Schuster had injured her back moving the patient, which the hospital acknowledged. And today, X-rays of her back show how a surgeon repaired a damaged disk in her spine using a metal cage and four long, sharp screws.

"I can finally walk and sit again without being in excruciating pain," Schuster says. "But the career I had as a floor nurse is over."

According to surveys by the Department of Labor's Bureau of Labor Statistics (BLS), there are more than 35,000 back and other injuries among nursing employees every year, severe enough that they have to miss work.

Nursing assistants and orderlies each suffer roughly three times the rate of back and other musculoskeletal injuries as construction laborers.

In terms of sheer number of these injuries, BLS data show that nursing assistants are injured more than any other occupation, followed by warehouse workers, truckers, stock clerks and registered nurses.

The number one reason why nursing employees get these injuries is by doing their everyday jobs of moving and lifting patients.

BLS surveys first revealed the high rate of injuries among nursing staff in 2006. But an NPR investigation reveals:

  • Studies by university and government researchers began to show decades ago that the traditional way hospitals and nursing schools teach staff to move patients — bend your knees and keep your back straight, using "proper body mechanics" — is dangerous.

    "The bottom line is, there's no safe way to lift a patient manually," says William Marras, director of The Ohio State University's Spine Research Institute, which has conducted landmark studies on the issue. "The magnitude of these forces that are on your spine are so large that the best body mechanics in the world are not going to keep you from getting a back problem."

  • Some hospitals, including the Baptist Health System in Florida and medical centers in the Department of Veterans Affairs, report that they have reduced lifting injuries among nursing staff by up to 80 percent — using an approach often called "safe patient handling." They use special machinery to lift patients, similar to motorized hoists that factory workers use to move heavy parts. The hospitals also conduct intensive training among the staff. Yet the majority of the nation's hospitals have not taken similar action.

    "There are, you know, just a minority of hospitals that are ... really moving forward with this," says Carla Luggiero, the senior associate director of federal relations and a lobbyist for the American Hospital Association. "Most of them are very slow to get on the train."

  • Many hospital administrators overlook injuries among the nursing staff partly because they're preoccupied with other priorities. Industry sources told NPR that nursing employees have traditionally ranked low in the hospital industry's hierarchy.

    "Too many hospital administrators see nursing staff as second-class citizens," says Suzanne Gordon, author of Nursing Against the Odds. "Historically, hospital administrators have viewed nurses as a disposable labor force."

David Michaels, the assistant secretary of Labor who heads the U.S. Occupational Safety and Health Administration (OSHA), says injuries among nursing staff are "a very important issue. It means that workers who are relatively young have to stop working early, in many cases."

But he says OSHA's powers have been so limited by Congress and court decisions that the agency can do little to require hospitals to protect nursing employees.

Michaels says Congress could help prevent widespread injuries by passing a new law. "There's no question: A national law requiring protection in hospitals would protect workers and would result in the reduction in musculoskeletal injuries in hospitals," he says. "A lot of hospitals still believe this old myth that hospitals are safe places to work."

Hospitals Are Not Taking Aggressive Action

Executives who run the nation's hospitals have known for decades that there's an epidemic among their staff — or, at least, they should have known from the medical literature. "Occasionally the complaint is made," warns Nursing: Its Principles and Practice, a textbook published in 1898, "that a nurse has injured her back ... in moving a patient."

Leap ahead to the early 1990s: Federal researchers at the National Institute for Occupational Safety and Health (NIOSH) started studying why so many nursing staff were hurting their backs. They were stunned by what they learned.

James Collins, a research manager in the NIOSH Division of Safety Research, says before studying back injuries among nursing employees, he focused on auto factory workers. His subjects were "93 percent men, heavily tattooed, macho workforce, Harley-Davidson rider type guys," he says. "And they were prohibited from lifting over 35 pounds through the course of their work."

Nursing employees in a typical hospital lift far heavier patients a dozen or more times every day.

"That was my biggest shock and surprise," Collins says. "And the big deal is, the injuries are so severe that for many people, they're career-ending."

But officials and researchers throughout the health care industry say that most hospitals have not taken aggressive action to protect the nursing staff from lifting injuries.

Luggiero, the American Hospital Association lobbyist, hesitates when asked whether she views injuries among nursing staff as an important issue.

"Well, you know, I do think it's an issue we have to ... look at. Do I think it's the most important issue we have to look at? No, I don't," she says. "I mean, we are concerned. We want to make sure our employees are in the best shape possible. So you, know, to that extent... do we care about the issue? Of course we do."

A Case Study

But nursing employees who work for one of America's best-known hospital chains — Kaiser Permanente — told NPR they were getting hurt so often, and their hospitals' managers were doing so little to protect them, that they asked state officials to investigate.

Kaiser has 38 hospitals in three states, according to the company's website. They consistently win top ratings and awards for the way they take care of patients.

But members of Kaiser's nursing staff say that if you were to peek behind the employees' side of the curtain — at least at Kaiser's hospital in Walnut Creek, Calif. — you would see a troubling picture of the way hospital officials have treated them.

There's no evidence that Kaiser Permanente hospitals have higher rates of nursing injuries than any others among the nation's roughly 4,000 acute care hospitals. Actually, there's no good way at all to compare injury rates among most of the nation's hospitals, because the federal and state governments do not require companies to reveal enough details about injured employees to do an analysis.

But NPR focused this story on Kaiser for two main reasons: First, we obtained some of Kaiser's internal documents, which shed rare light on their nurses' injuries. Second, the case shows how injured nursing staff sometimes have to shout to get help.

The Kaiser hospital in Walnut Creek sits prominently on Main Street, about 45 minutes northeast of San Francisco. Ashley Moore, a registered nurse in the intensive care unit, says to understand why nursing employees get injured, it helps to know that they do more than measure patients' blood pressure, hook them up to IVs and assess how patients are faring. Their work is also physically grueling, and the surging rate of obesity is making it worse.

"A 250- to 300-pound patient can be very common in our unit. And to even be able to lift their leg is probably 60, 70 pounds maybe," Moore says. "And I can barely lift it myself."

In addition, most patients staying in hospitals today are sicker than the patients of 20 years ago. Hospitals are treating as many people as they can in outpatient clinics, saving inpatient beds for those who most need round-the-clock care. But no matter how sick or heavy they are, there's a push to get them out of bed as soon as possible and moving — even if the patients can't even swing themselves to the edge of the bed.

"So what we do is, we put our arm out, and the patient latches on to your arm and then just pulls, and then we almost do a dance," she says, imitating what it's like to hold up and drag a heavy body and then lower it gently into a chair. "And the next thing you know, their light's on 20 minutes later" because the patient wants to go back to bed — so she has to do it all in reverse.

Moore estimates that she moves patients in much the same way 15 to 20 times each shift. And that, nursing employees say, is how they get hurt.

Despite Some Help, Injuries Continue

NPR talked with 16 nurses and nursing assistants at Kaiser's Walnut Creek hospital who have been injured while lifting patients during the past several years.

One of them is Abigail Velez, who tells the same basic story as many employees. In one incident, she and a colleague were moving a patient, "and when I pulled her up in bed, I felt this searing, burning pain in my shoulder," Velez says.

That was just the beginning of her painful medical saga. Velez has so many medical records from Kaiser about her shoulder and elbow injuries that the documents practically cover her dining room table. They show that she went over and over again to Kaiser's staff health unit. Doctors kept giving her pain pills and steroid injections, but little seemed to help.

She says the pain got so intense and her motion was so restricted that she couldn't pick up a glass of water.

"I could not lift my arm. I couldn't even raise it up to brush my hair," she says with exasperation.

Velez eventually had two operations and went on disability leave for eight months.

Velez and other nursing staff told NPR that Kaiser's management did take a few steps toward promoting "safe patient handling." For instance, Kaiser bought some of the same kinds of lifting machines that Baptist Health and VA hospitals use. And Kaiser trained teams of "patient care technicians" to help.

But staff like Moore, the ICU nurse, say they kept warning Kaiser's managers that while the steps seemed good on paper, they often did not work. When the nurses would need a lifting machine to move a patient, they would discover that some other unit had borrowed it, or it was stuck behind cleaning equipment in a distant closet. Or the machine's battery was dead. And when they would urgently request a lift team, they would learn that none was available because the team members had been reassigned to other duties.

"Every day you call and say, 'We don't have anybody to help us,' " Moore says. "And again it would be the same thing every single day, being jerked around. And by the end of the day, nobody ever came to help us."

NPR obtained documents that corroborate that. For example, five nursing employees signed a memo to management on Nov. 13, 2011: "No lift team... Unable to turn patients due to no available workers." Another memo a few days later: "No lift team." And another memo: "ICU patients are in excess of 3 to 400 pounds... No lift team."

Meanwhile, Kaiser managers were keeping their own records that showed employees kept getting hurt. Federal law requires businesses to keep records via Form 300 — the "Log of Work-Related Injuries and Illness." The law does not require companies to make those logs public, but NPR obtained some of the logs that Kaiser kept on Walnut Creek. For example, an entry dated Jan. 21, 2012, lists an incident affecting a nurse's aide: "back injury while performing daily job duties of lifting." Another entry the same day records an incident involving a registered nurse: "low back injury while assisting with a patient in the ICU."

Leesa Evans was another employee listed on that injury log. Evans, a registered nurse, remembers the exact moment that lifting a patient changed her life. It was midday on Oct. 3, 2010, and the patient was dying from congestive heart failure.

"He felt he was going to have an episode of diarrhea," Evans says. "This is a big man, and he could not move. And getting diarrhea out of [his bed] was not going to be an easy project. And he knew it."

Evans says she called for a lift team — they needed four members to maneuver the 300-pound patient. She was told that the team would show up within 10 minutes. But Evans says only one person came to help, a woman.

Evans says she worried that they couldn't safely handle the patient. But they also knew if they didn't act quickly the patient would soil himself, "which would humiliate him," she says.

So, as the helper pulled the patient's shoulder and hip, "I'm pushing on the other side, one hand on his back and one hand to slide a bedpan underneath him," Evans says. "And it's really hard. He's having pain from his chest tubes, he's short of breath, he's panicking, he's saying, 'Hurry, hurry.' "The helper was almost as frenetic, "saying, 'Are you ready yet? Have you got the pan in place?' Because we're both straining trying to hold him in place and do the maneuvering that's necessary for this procedure."

The two were able to get the bedpan under the patient in time. But a couple of days later, Evans could hardly walk. Kaiser sent her a letter acknowledging that she had suffered an "occupational injury." She had to take months off work.

As the injuries at Walnut Creek mounted, nursing employees started debating where they could turn for help. Then, something happened in the state capital that pointed them in a new direction: On Jan. 1, 2012, the state of California put into effect the Hospital Patient and Health Care Worker Injury Protection Act.

The law, which had been pushed for years by the California Nurses Association union and public health groups, specifically requires hospitals to protect nursing staff from getting hurt lifting patients. Nine other states have passed similar measures.

Within days, nursing employees at Walnut Creek had filed a complaint with the state, alleging that Kaiser was violating the law. That brought a state investigator from California's Division of Occupational Safety and Health, Cal/OSHA, to meet with key managers and representatives from the nurses union.

The investigator's files, which NPR obtained under California's open records law, show that the investigator came two more times to the Kaiser hospital in Walnut Creek, setting up shop in the cafeteria, then in the courtyard.

Nursing staff and others lined up to tell him their own stories about how they had been injured. And on Jan. 31, 2014, state Administrative Law Judge Mary Dryovage issued an order that declared that Kaiser had failed to have "specific procedures in place to ensure that sufficient staff was available to perform patient handling tasks safely."

The order also said Kaiser had "failed to ensure" that patient lifting equipment "was accessible to employees to perform patient lifts"; instead, equipment "was sometimes blocked or access to equipment was obstructed." The judge declared that Kaiser had not trained employees effectively to know how to use the equipment. And she gave Kaiser 90 days to fix the problems.

The way Kaiser officials portrayed the administrative law judge's findings to NPR, they were technicalities that had little impact on the way Kaiser operates the hospital in Walnut Creek.

"Kaiser Permanente as an employer is deeply committed to the safety of our employees, including our registered nurses," Helen Archer-Duste, executive director for Northern California Regional Kaiser Permanente Workplace Safety, told NPR.

"We care about our registered nurses, and we honor and appreciate everything they do, ­­day in and day out, to care for our patients. We want them and our patients to be safe," she said in a conference room off the lobby of the Walnut Creek hospital.

NPR requested a tour of the facility, but a Kaiser spokesperson declined the request.

"In that any injury is preventable we don't want our employees to be injured on the job," Archer-Duste said. "Walnut Creek did not have an injury rate that's higher than any of our other facilities. In fact, they're in the average level and we have reduced those injuries an additional 23 percent. Our goal is to have no one injured on the job, and that rate is dropping every month, every year."

Kaiser officials declined NPR's request to substantiate her claims by providing the recent OSHA Form 300 logs, in which they are required under federal law to list employee injuries.

But Archer-Duste said Kaiser is demonstrating its commitment to protecting its nursing staff with money: It decided to spend at least $40 million to install more lifting machines in its older hospitals, including Walnut Creek, she said. Plus, Kaiser recently opened three brand new hospitals, and many of their rooms were designed from the start with patient-lifting equipment hanging from the ceiling.

Archer-Duste said Kaiser was already planning these steps before its nursing staff filed the complaint with the state of California, and before the administrative law judge ordered Kaiser to make changes.

In Constant Pain

The changes are coming too late for nurses like Leesa Evans. Her husband, Steven Danziger, says she's been in pain since that day in 2010, when she lifted a patient so he could use the bedpan. "I would say it's pretty constant," Danziger says. "I would say it's rare that she has a day that she doesn't take pain medication."

Danziger says he and Evans used to love to garden, hike and ski together. But now his wife can't do much because of her back. "She has a medicine cabinet here of prescriptions," he says — including powerful painkillers that Evans says make her feel "loopy." That echoes what many injured nursing employees have told NPR: The painkillers compound their injuries.

"I do see an effect on her cognitive abilities," says Danzinger. "Sometimes forgetfulness — sometimes, places we've been many, many times together, she said, 'You know, I kind of got lost today.' "

Evans retired from nursing last year when she was 57 years old. She says she decided to quit partly because she couldn't bear working in pain.

"It's sad," she says. "It's sad to be injured and to be apart from your work. And the satisfaction that comes from patient care, that livelihood disappears. I mean, that's huge."

NPR's Robert Benincasa, Lydia Emmanouilidou, Samantha Sunne and Barbara Van Woerkom contributed reporting and research to this story.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.

Transcript

AUDIE CORNISH, HOST:

Over the next few weeks, we're taking a close look at one of the most dangerous jobs in America. Back and other injuries occur in this profession at far higher rates than even the construction industry. It also sees more of these injuries than law enforcement. And an NPR investigation finds many of the executives who run the companies where these workers are getting hurt are doing little to prevent it. NPR Danny Zwerdling shows us this troubling side of health care.

DANIEL ZWERDLING, BYLINE: OK, try to guess - who are these workers who get disabled so often by back injuries? I'll give you a moment to think about it. Time's up. We're talking about nursing employees who take care of you in the hospital and other settings. We're talking about nursing assistants and orderlies and registered nurses. Government surveys estimate there are more than 35,000 back and other injuries among nursing staff every year that are so bad the employees have to miss work. And they get those injuries mainly by moving and lifting patients.

SUNNY VESPICO: My name is Sunny Vespico. I'm a registered nurse. I herniated a disc in my back at Temple University Hospital in Philadelphia, Pa.

ZWERDLING: NPR posted the note on Facebook, along with a couple other sites. We said if you're a nurse or a nursing assistant and you've suffered a back or other injury that's affected your life, will you please contact us?

UNIDENTIFIED WOMAN #1: Hi, Daniel.

UNIDENTIFIED MAN: Hi, Daniel.

UNIDENTIFIED WOMAN #2: Hi, Daniel.

UNIDENTIFIED WOMAN #3: Good morning, Daniel.

ZWERDLING: We heard from more than 800 people the first day, both women and men, although 90 percent of nursing staff are women.

KATIE HEINEMAN: My name is Katie Heineman. I am a certified nurse's assistant. I got hurt on the job at Providence Portland Medical Center.

ROBIN COHEN: My name is Robin Cohen. I'm from Rochester, N.Y., and I was working at Highland Hospital.

ZWERDLING: The three women you're going to hear now all sent us medical reports that document their injuries. And their injuries affect you, too, or anybody else who's been treated at a hospital. The insurance industry says that hospitals pay more workers' compensation to nursing staff who get hurt lifting patients than for any other kind of injury. And those costs get rolled into your hospital bill.

UNIDENTIFIED WOMAN #4: I was moving a patient...

UNIDENTIFIED WOMAN #5: And I was pulling the patient back onto the stretcher.

UNIDENTIFIED WOMAN #4: ...And immediately I felt a pop in my back and a pain down my leg.

UNIDENTIFIED WOMAN #5: I felt an instant pain in my lower back...

UNIDENTIFIED WOMAN #6: And I had a hold of the sheet under the patient. I heard something loud pop in my right shoulder.

UNIDENTIFIED WOMAN #5: ...Then was sent to a back surgeon.

UNIDENTIFIED WOMAN #6: My case was transferred to an orthopedic surgeon.

UNIDENTIFIED WOMAN #5: Currently have 60 percent disability.

UNIDENTIFIED WOMAN #4: I am 36 years old. I've had three surgeries over the last two years. And only now after this third surgery, I might have a chance of being able to return to being a bedside nurse.

ZWERDLING: Executives who run the nation's hospitals have known for decades that there's an epidemic among their staff - or at least they should have known from medical books.

JAMES COLLINS: 1898 was the earliest published work that I was able to put my hands on. It was a nursing textbook.

ZWERDLING: 1898?

COLLINS: 1898.

ZWERDLING: James Collins runs a research program in the federal government. He's with the National Institute for Occupational Safety and Health. Before he began studying nursing staff, he was studying auto workers at a Chrysler factory.

COLLINS: Ninety-three percent men, heavily tattooed, macho workforce, Harley-Davidson-rider-type guys, and they were prohibited from lifting over 35 pounds through the course of their work.

ZWERDLING: Did you catch that? Auto workers were forbidden to lift more than 35 pounds to protect their backs. Then Collins started studying nursing staff in the early 1990s, and he discovered that they routinely lift way more. They have to lift patients.

COLLINS: That was my biggest shock and surprise. I mean, the big deal is the injuries are so severe that many people - they're career-ending.

ZWERDLING: So you might think if anybody's concerned about nurses getting hurt, it'd be the hospital industry.

CARLA LUGGIERO: Well, you know, I do think it's an issue we have to look at.

ZWERDLING: That's the chief lobbyist for the American Hospital Association, Carla Luggiero. They represent most of the hospitals across the country.

LUGGIERO: Do I think it's the most important issue we have to look at? No, I don't.

ZWERDLING: Do you think that - do you think that public health groups who've been saying, you know, that injuries to nursing staff are important problem in hospitals - do you think they're exaggerating?

LUGGIERO: You know, I don't know. I mean, we're concerned. We want to make sure our employees are in the best shape possible. So, you know, to that extent, you know, do we care about the issue? Of course we do.

ZWERDLING: The nurses at one hospital in California say they were getting hurt so often and their company was doing so little to prevent it that they asked the government to investigate. You've probably heard of this hospital.

(SOUNDBITE OF AD)

UNIDENTIFIED WOMAN #7: At Kaiser Permanente, we want you...

ZWERDLING: Kaiser Permanente has almost 40 hospitals in three states. As their ads tell you, they win top ratings for the way they take care of patients.

(SOUNDBITE OF AD)

UNIDENTIFIED WOMAN #8: These are the hands of a surgeon, a pediatrician. These are pioneering advances in heart surgery.

ZWERDLING: We could take you in the story to any one of thousands of hospitals across the country to see how nursing employees are getting injured, because there's no evidence that Kaiser Permanente has more injuries than any other. Actually, the government does not require hospitals to reveal details about employees who get hurt, so it's hard to make comparisons at all. But we're going to focus now on Kaiser's hospital in Walnut Creek, Ca., and we're doing it for a couple of reasons. First, NPR obtained internal documents from that hospital and they shed a rare light on nurses' injuries. Second, the case shows how injured nurses sometimes have to shout to get help.

ASHLEY MOORE: OK, ready?

UNIDENTIFIED GIRL: Yeah.

MOORE: How does it start?

UNIDENTIFIED GIRL: (Singing) I love you, you love me.

ZWERDLING: We're starting at the home of one of Kaiser's nurses who got the government to pay attention. Ashley Moore is 33. She works in the intensive care unit. But she's off on this day, and she's juggling the interview and her daughter.

UNIDENTIFIED GIRL: (Singing) Won't you say you love me, too?

MOORE: Yes, I love you very much. I love you so much.

ZWERDLING: The Kaiser hospital where Moore works is right on Main Street in Walnut Creek. It's about 45 minutes northeast of San Francisco. Moore says before you hear why she and her colleagues asked the government to investigate, it helps to understand what nurses and nursing assistants do. They measure your blood pressure, yes. They hook you up to IVs. But, as Moore says, a lot of their work is physically grueling. And it's getting worse. Federal surveys show that roughly 70 percent of adults are overweight or obese.

MOORE: So a 250- to 300-pound patient is - can be very common in our unit. And to even be able to lift their leg is 60, 70 pounds maybe. And I can barely lift it myself.

ZWERDLING: On top of that, most patients who stay in hospitals are sicker than they were 20 years ago. That's because hospitals are treating as many people as they can in outpatient clinics. And they're saving inpatient beds for more serious cases. Still, there's a push to get those patients out of bed and get them moving.

MOORE: But they can't quite get themselves swung over to the edge of the bed. So what we do is we put our arm out and the patient latches onto your arm and then just pulls. And then we almost do a dance, you know, walking over to the chair. And the next thing you know, their light's on. Twenty minutes later, I want to get up. I want to go back to bed.

ZWERDLING: How many times by the end of the day have you handles a person who can't move very well on their own?

MOORE: Fifteen to 20 times - with your own body move them.

ZWERDLING: And that's how nursing employees get hurt. Do you mind showing me your scars?

ABIGAIL VELEZ: Well, there's one. That's the elbow - so about three or four inches. And then the shoulder one...

ZWERDLING: I talked with 16 nurses and nursing assistants who've been injured at Walnut Creek just over the past few years. Abigail Velez is one of them. We're sitting at her dining room table. It's buried under medical files.

VELEZ: It's just kind of spread out. I mean, this is like almost two-and-a-half years dealing with this.

ZWERDLING: Velez had to have two operations after she got hurt moving patients- one on her shoulder, one on her elbow. She was off work on disability for eight months.

VELEZ: The worst it was was when I tried to pick up a glass of water and I couldn't.

ZWERDLING: You literally could not lift a glass of water?

VELEZ: I could not lift my arm. I couldn't even raise it up - couldn't brush my hair.

ZWERDLING: But federal studies suggest that nurses like Velez don't have to get hurt. The study showed that some hospitals have reduced the rate of injuries up to 80 percent. Now, to do it, they had to buy special machines to move patients.

So if you were a patient, they'd use a hoist to move you kind of like factory workers move heavy parts. Now, Kaiser's management did buy some of those machines and they trained special teams of lifters to help. But nurses like Ashley Moore say they kept warning Kaiser's managers we can't find the machines or the lift teams when we need them.

MOORE: Every day you call and say we don't have anybody to help us. And again it would be the same thing every single day, being jerked around. And by the end of the day, nobody ever came to help us.

ZWERDLING: NPR got documents that corroborate that. For instance, five nursing staff signed a memo to management on Nov. 13, 2011. No lift team - unable to turn patients due to no available workers. Another memo a few days later - no lift team. And another memo - ICU patients are in excess of 300 to 400 pounds - no lift team.

Meanwhile, Kaiser managers were keeping their own records that showed employees kept getting hurt. Federal law requires businesses to keep something called the Form 300 Log of Work-Related Injuries and Illnesses. The law does not require companies to make those logs public, but NPR obtained some of the logs that Kaiser kept on Walnut Creek. For instance, Jan. 21, 2012 - nurse's aide, back injury while lifting. The same day - nurse, low back injury while assisting with a patient in the ICU.

LEESA EVANS: This particular patient had been here for many weeks, and he was deteriorating.

ZWERDLING: Leesa Evans was one of the nurses listed on Kaiser's injury logs. She remembers the moment that a back injury changed her life. It was midday back on Oct. 3, 2010. Her patient had congestive heart failure. He weighed around 300 pounds, and he called out.

EVANS: At that point, he felt he was going to have an episode of diarrhea. This was a big man, and he could not move. And getting diarrhea out of there was not going to be an easy project. And he knew it. Well, I called the lift team. And they said OK, I'll be there in 10 minutes. And so great, I go into the isolation room. I have all my isolation gear on. And one person shows up - just one.

ZWERDLING: How many were supposed to show up?

EVANS: Four. With this patient you needed four.

ZWERDLING: When the man came on the lift team, I'm assuming...

EVANS: (Laughter) It was a woman on the lift team, and there was just the two of us. And nurses were all busy. There isn't anybody else who can help, and she kept saying we can do this. And I kept thinking I don't know. But then, you know, between her confidence and the urgency of the patient we tried it.

So she stands and she holds his shoulder and his hip and pulls. And I'm pushing on the other side, one hand on his back and one hand to slide a bedpan underneath him. And it's really hard. He's having pain from his chest tubes. He's short of breath. He's panicking. He saying hurry, hurry. She's saying are you ready yet? Have you got the pan in place? Because we're both straining, trying to hold him in place and do the maneuvering that's necessary for this procedure. And that's - that's what happened.

ZWERDLING: They did get the bedpan under him in time. But a couple of days later, Evans could hardly walk. Kaiser sent her a letter acknowledging she was hurt on the job. Evans had to take months off work.

So the nursing staff at Walnut Creek knew they had problems. But since management wasn't doing much about it, they couldn't figure out where to get help. Then, finally, something happened that helped show them the way. The state of California put a new law into effect in early 2012 - only nine other states have done this. The law specifically requires hospitals to protect nursing staff from getting hurt lifting patients.

So the staff at Walnut Creek called the state. They said we need help. Next thing they know, a state investigator shows up at Kaiser. He meets with managers and the nurses union in the conference room. Ashley Moore joins them. She's the nurse with the young daughter. And she hears Kaiser's managers tell the investigator we don't have many problems with injuries here.

MOORE: And then he would turn to me and say is that true? And in front of, you know, all these higher-ups that I don't even know, I would say no, that is not what happened.

ZWERDLING: And how did the managers react when you said that?

MOORE: They were just - kind of just jaws dropped.

ZWERDLING: The state investigator came two more times to Kaiser in Walnut Creek. Once, he set up shop in the cafeteria. Next time, he sat in the courtyard. Nursing staff and others lined up to tell him how they got hurt. And Jan. 31 last year, a state administrative law judge issued an order that essentially confirmed what the nurses said. She declared that Kaiser had failed to have sufficient staff trained to handle patients safely. Kaiser had failed to have equipment to move patients which the staff could easily use. And the judge ordered Kaiser to fix those problems.

HELEN ARCHER-DUSTE: I'm Helen Archer-Duste and I'm the executive director for Northern California Kaiser Permanente Workplace Safety.

ZWERDLING: You might be wondering by now, when are we actually going to see Kaiser's hospital in Walnut Creek? The answer is you're not. I asked Kaiser executives will you take me on a tour of the hospital so I can see how the nursing staff moves patients? A Kaiser spokesman said no, you'll interview Archer-Duste in a conference room.

ARCHER-DUSTE: Kaiser Permanente as an employer is deeply committed to the safety of our employees, including our registered nurses. We care about our registered nurses, and we honor and appreciate everything they do, day in and day out, to care for our patients. We want them and our patients to be safe.

ZWERDLING: Do you feel that there were more injuries among the nursing staff here at Kaiser Walnut Creek than there should have been?

ARCHER-DUSTE: In that any injury is preventable, we don't want our employees to be injured on the job. Walnut Creek did not have an injury rate that's higher than any of our other facilities. In fact, they're in the average level, and we have reduced those injuries an additional 23 percent. Our goal is to have no one injured on the job, and that rate is dropping every month, every year.

ZWERDLING: I asked Kaiser to substantiate that claim. I asked them to show me their recent Form 300 logs where the government says they're supposed to list employee's injuries. A spokesman said we won't provide them. But Archer-Duste says Kaiser is serious about protecting its employees. She says Kaiser has decided to spend at least $40 million to install more lifting machines in its older hospitals, including Walnut Creek. Plus, Kaiser recently opened three brand-new hospitals. And many of their rooms were built with lifts. Archer-Duste says Kaiser took these steps before the nurses complained to the state and before the judge issued an order against Kaiser.

ARCHER-DUSTE: We understood and have made a commitment to safe patient handling long before the California law went into effect.

ZWERDLING: Uh-huh, so you would have done all this, you're saying, without the law?

ARCHER-DUSTE: Correct, we would have.

ZWERDLING: Whatever the reasons, the changes are coming too late for nurses like Leesa Evans. Remember her? The nurse with the heavy patient and the bedpan? Her husband can tell you she's never recovered.

So she's in a lot of pain?

STEVEN DANZIGER: Yeah, I would say it's pretty constant. I would say it's rare that she has a day that she doesn't take pain medication.

ZWERDLING: Evan's husband, Steven Danziger, knows more than most people do about injuries on the job. He used to be one of the managers of human resources for the city of Oakland. He says his wife and her nursing colleagues at Kaiser got hurt more than the city's firefighters do. He says he and Evans used to love to garden together and hike together and ski. But now she can't do much because of her back.

DANZIGER: I mean, she has - she has a medicine cabinet here of prescriptions. And Leesa was talking about how some of the medication made her feel loopy. How should I say it? I mean, she says do you think that I seem out of it today? And I, you know, good husband - I say no, you're fine. But I do see an effect on her cognitive abilities sometimes - forgetfulness. Sometimes places we've been many, many times together, Leesa'll say, you know, I kind of got lost today. I kind of got - I'll say you don't remember how to go there? OK.

ZWERDLING: Leesa Evans retired from nursing last year. She was 57 years old. And she says she decided to quit partly because she couldn't bear working in pain. She gets teary talking about it.

EVANS: It's sad. I mean, it's sad to be injured and to be apart from your work. And the satisfaction that comes from patient care, that livelihood disappears. I mean, that's huge.

ZWERDLING: We are going to continue our investigation about injured nurses next week. I'll visit the laboratory and strap on an artificial spine, and scientists will show us exactly why moving patients is so dangerous. Daniel Zwerdling, NPR News.[POST-BROADCAST CORRECTION: The audio of this story, as did a previous Web version, misstates Carla Luggiero's title. She is the senior associate director of federal relations and a lobbyist for the American Hospital Association, not the chief lobbyist.] Transcript provided by NPR, Copyright NPR.