Earlier this year, a falling object struck a worker’s head at an Amazon fulfillment center in Robbinsville, New Jersey. The worker visited Amcare, the company’s on-site medical unit, and told the emergency medical technicians on staff there that they had a headache and blurred vision — classic symptoms of a concussion. According to company protocol, Amazon’s medical staff should have sent the worker to a hospital or doctor’s office for further evaluation, or at least called a physician for advice. They did neither. This was one of six instances at the Robbinsville fulfillment center between February and May in which staff at the Amcare clinic failed to provide adequate medical care to injured employees, according to a warning letter issued in August by the Department of Labor’s Occupational Safety and Health Administration, the federal agency responsible for workplace safety. In another incident, a worker came to the clinic with a possibly fractured finger, but Amcare medical staff failed to send them to an outside clinic for a professional opinion. A worker with an eye injury repeatedly asked to be sent to the hospital, but Amcare staff denied the requests. The next week, another worker came to the clinic four days in a row complaining of intense finger pain. According to company protocol, the clinic should have been checking on the employee every two hours. Instead, Amcare evaluated them once per day for three days without recommending outside care. In various instances, OSHA investigators found that Amcare medical staff decided to treat the employees in-house, rather than referring them to doctors or hospitals — decisions that potentially violated New Jersey state law and federal regulations, such as OSHA’s “general duty” clause requiring employers to maintain workplaces free of hazards that put workers in danger. This wasn’t the first time OSHA had investigated Amcare, nor was it the first time the agency alerted Amazon to problems at the clinics. “The current OSHA inspection again revealed instances indicating that the EMTs and Athletic Trainers (ATs) at AMCARE are working outside their scope of practice, without proper supervision,” regulators wrote in a warning letter to Amazon, reported here for the first time. “New Jersey state laws do not allow EMTs and ATs to practice medicine independently; a physician must supervise their work.”

An investigation by The Intercept and Type Investigations — drawing on previously unreported documents, an interview with a former OSHA medical expert, and interviews with 15 current and former Amcare employees — found multiple instances in which clinic staffers violated Amazon’s own rules as well as government regulations. The investigation found that Amcare employees nationwide were pressured to sweep injuries and medical issues under the rug at the expense of employee health. Amazon, a company that is now worth $800 billion and has reshaped the global retail landscape, will handle nearly 40 percent of all online shopping in the U.S. this year. The company’s warehouses are especially busy around Black Friday and Cyber Monday; last year, Amazon received orders for 180 million items during the holiday weekend — a company record. To handle the rising demand, Amazon has added fulfillment centers around the country and hired an army of workers to pick items off warehouse shelves and prepare packages for delivery. Since 2014, the company’s workforce has increased nearly fivefold, from 154,000 to around 750,000 — a figure that includes Amazon-owned Whole Foods, but does not take into account the thousands of additional contractors and temporary workers who are brought in to help fulfill orders in Amazon’s warehouses during the busy holiday shopping season. The strenuous nature of the work at Amazon’s warehouses can take its toll on the human body: As Reveal and The Atlantic reported last week, the rates of serious injury at 23 fulfillment centers from which data could be obtained were more than double the industry average in 2018. The company’s Amcare clinics are intended to address the many minor aches and pains workers experience on the job. The company claims that this care falls under the category of “first aid,” which, according to an OSHA letter to Amazon, is defined as “emergency care provided for injury or sudden illness before emergency medical treatment is available.” These clinics operate in most, if not all, of the company’s warehouses, and they are staffed by EMTs and supervised by safety managers. According to a former OSHA medical officer and multiple former Amazon employees interviewed for this story, safety managers are not required to have extensive medical training. (Amazon declined to answer specific questions about its safety managers’ training as well as other details reported in this story.)

The clinics’ care protocols were approved by a contracted physician in Seattle, but this doctor does not appear to supervise their day-to-day operations. EMTs are available to administer very basic care, like providing ice packs and Advil, and refer workers with more serious injuries to doctors or hospitals. Given this limited scope of care, the clinics are not required by some states’ laws to register with health care authorities, nor are they required to employ doctors and nurses on site to supervise the EMTs. At Amcare clinics across the country, however, staff members have made medical decisions that go beyond basic first aid, the investigation by The Intercept and Type Investigations uncovered. Since 2015, Amazon workers have filed at least 10 complaints about problems at Amcare — all of which OSHA deemed “valid” — according to previously unreported documents obtained through a Freedom of Information Act request. These 10 complaints represent a small fraction of the hundreds of general health and safety complaints filed by Amazon workers in the last seven years. The complaints alleged that employees were being sent back to work with no medical care after requesting treatment, that injured employees were being told they must wait two weeks to see if their conditions worsened before being seen by doctors, and that Amcare staffers were not adequately trained. One complaint, made by phone in December 2017 from Tracy, California, alleged that Amcare simply refused to treat an injury. Though the complaints were determined to be valid, the agency did not follow up with an inspection in every case; OSHA is a small agency that employs about one inspector for every 59,000 U.S. workers. Still, in response to these complaints and others, OSHA has investigated Amcare clinics at least three times: beginning from summer 2015 at an Amazon fulfillment center in Robbinsville, New Jersey; from fall 2017 to spring 2018 at a fulfillment center in Florence, New Jersey; and again at the Robbinsville warehouse in an investigation that concluded in September 2019. Each time, the federal agency found that EMTs were providing care beyond first aid. Twice, OSHA recommended that they be supervised by on-site physicians. Twice, in Florence and during the first Robbinsville investigation, the agency also found evidence that Amazon was underreporting injuries on federally mandated logs. The results of the Florence investigation and the 2019 Robbinsville investigation are being reported here for the first time.

Ten EMTs said their bosses pressured them to send injured employees back to the warehouse floor.

Accounts from Amcare employees across the country reveal that problems identified by OSHA are likely not confined to the warehouses it inspected. In interviews with The Intercept and Type Investigations, 15 current and former on-site medical representatives — Amazon’s term for the EMTs who staff Amcare — from fulfillment centers in 11 states bolster OSHA’s findings. Ten of the medical technicians said their bosses pressured them to send injured employees back to the warehouse floor when they likely needed additional medical attention. Eight felt like there was a conflict of interest between their manager’s priorities and their duties as medical professionals. Four said they were pressured to underreport or misclassify injuries. Some Amcare staff members described a positive experience with Amazon; even so, they expressed concerns about tensions between the company’s bottom line and injured employees’ best interests. “As a person who prides himself on being a medical professional, and caring about people who I’m expected to evaluate,” said David Troutman, an EMT who formerly worked at Amazon, “I felt like I was given the wrong deal.” Troutman believes he was fired from Amcare for sending an injured employee to the hospital. (Amazon declined to comment on the circumstances of Troutman’s dismissal.) He takes a dour view of Amazon’s medical practices: “There are probably several other people who would say the exact same thing, that Amazon cares more about numbers than they do about their employees.” In response to a detailed inquiry, an Amazon spokesperson said, “Safety is our top priority. Amcare, amongst a variety of other programs, ensures that employees are taken care of while in our building by offering first aid to injured or ill associates. Our Onsite Medical Representatives follow clear, established company guidelines for first aid treatment in accordance with local, state, and federal regulations. At any point associates can choose to visit a doctor, no associate should ever be discouraged from seeking care, and all full-time employees receive comprehensive health benefits starting on day one of employment.”

Employees organize bins for orders at the Amazon fulfillment center in Robbinsville, N.J., on Nov. 27, 2017. Photo: Victor J. Blue/Bloomberg/Getty Images

“Medical Mismanagement” The EMTs at Amcare clinics are supposed to operate under a strict set of protocols, according to Amazon policy. They’re supposed to send workers for outside treatment immediately if they report pain levels of 10 out of 10. They’re supposed to send anyone with a possible concussion or fracture to a hospital or doctor’s office. If an employee asks to see a doctor, the EMTs are supposed to refer them immediately. If there’s any question about whether a worker might require more than first aid, the EMTs are supposed to call a physician hotline for advice. In practice, however, the protocols were not always followed. The OSHA investigations found that Amcare staffers sometimes disregarded internal criteria when making decisions about who went to the emergency room and who was sent back to work. According to federal regulators, that meant the medical technicians crossed the line from administering basic first aid into providing more serious medical care. At Amcare, “they refuse to send injured employees immediately to dr,” one worker at the Robbinsville fulfillment center wrote in a complaint forwarded to OSHA’s area office in Marlton, New Jersey, in September 2015. The person went on to complain that managers ignored doctors’ orders that injured employees be put on light duty. “There are many more things I could report,” the complainant added. “They had the EMTs making decisions about when a worker should go see a doctor,” said Kathleen Fagan, a former medical officer with OSHA, who helped lead investigations into Amazon’s medical practices in New Jersey. “The EMTs are doing this without any medical supervision, and this is really a violation of state law. Every single state, including New Jersey, requires that EMTs practice under the supervision of a physician.” OSHA had already launched an inspection of the Robbinsville warehouse in July 2015, and it was ongoing when this complaint was received. Fagan was part of a team that was called in to provide medical expertise; she worked at OSHA for a decade prior to her retirement earlier this summer. This is her first time speaking publicly about investigating Amazon. As part of her investigations, Fagan’s team reviewed an Amcare manual that said on-site medical representatives were allowed to treat injured employees repeatedly for up to 14 days before referring them for outside treatment. As first responders, however, EMTs aren’t trained to provide ongoing medical care — and even if they were, they aren’t allowed to practice independently. According to New Jersey law, EMTs are not allowed to make important decisions like whether or not to refer patients for further treatment without supervision from physicians. Additionally, repeat visits over a long period of time can constitute medical care beyond “first aid,” according to OSHA’s 2016 hazard alert letter. That means the clinic was potentially operating outside its legal boundaries. During that first Robbinsville investigation, Fagan found that EMTs’ decisions were not being supervised by medical professionals. The medical staff was reporting directly to safety managers, who are responsible for a wide range of building operations but not required to undergo extensive medical training. Amazon has argued that since its clinics are providing only first aid, the EMTs are not practicing under their full licenses and therefore do not require direct clinical supervision. Fagan’s investigation found that clinic operations went far beyond first aid and therefore require additional supervision. “Medical (or health) care, consisting of a clinical history, physical examination, assessment and management plan, is being performed by the Onsite Medical Representatives (OMRs) in AMCARE,” OSHA wrote in a “hazard alert” letter to Amazon following the 2015 Robbinsville investigation. “Medical care must be provided or supervised by a healthcare provider licensed to practice independently, per New Jersey State law.” (The doctor who approved Amazon’s care protocols is not licensed to practice in New Jersey. The doctor did not respond to requests for comment, and Amazon declined to answer questions on the arrangement.)

“This just is, to me, an egregious lack of care for the health and safety of their workers.”

Fagan said that many large corporations employ corporate medical departments staffed with doctors and nurses who oversee internal clinics — people on hand who could intervene in incidents like the ones uncovered in Robbinsville. When Fagan conducted a similar investigation into the poultry processing industry, several slaughterhouses responded by hiring nurses to evaluate worker injuries on site. “None of this seems to be going on” at Amazon, she said, based on her investigations in New Jersey. “They have one part-time consultant, a medical director in Seattle, who does no oversight. This just is, to me, an egregious lack of care for the health and safety of their workers.” OSHA has limited regulatory authority over health care providers. That responsibility generally falls to local health care authorities. In at least some states, Amazon’s clinics fall into a regulatory gray area: The company claims they provide only first aid, so they aren’t registered with health authorities and therefore aren’t supervised by those entities. OSHA’s only option for demanding accountability for Amcare was to cite the company under its general duty clause, which says that “each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.” OSHA can also refer cases to state health care authorities for further investigation. In the case of Amcare in the Robbinsville fulfillment center, Fagan said the agency issued a hazard alert letter instead of a citation because the company was still relatively new.(Both OSHA and Amazon declined to produce copies of Amazon’s responses to the agency’s hazard alert letters.) The letter also recommended that Amazon voluntarily take certain steps to address the issues it identified, including bringing on a local doctor to oversee the clinic’s operations. Fagan said Amazon largely dismissed their concerns in its response letter. “They say they’re not actually working under that license,” Fagan said of the EMTs. “They don’t think they need any kind of medical supervision, so they blew off our suggestions.”

Commuters use a shuttle bus at the Amazon fulfillment cnter in Robbinsville, N.J., on April 12, 2017. Photo: John Taggart/The New York Times/Redux

Off the Books During the 2015 inspection of the Robbinsville fulfillment center, Fagan’s team also identified 26 injuries over four months that were left out of official recordkeeping logs. Her interviews with employees confirmed that supervisors were discouraging workers from reporting injuries. Federal regulations require that companies record all work-related injuries that involve days away from work, transfer to light duty, a significant diagnosis from a doctor, or any medical treatment beyond first aid. The reports inform the Bureau of Labor Statistics’ industry injury rates and are meant to function as an internal corporate metric for improving safety standards. Accusations of faulty recordkeeping at Amazon are not confined to Robbinsville. An OSHA inspection of an Amazon facility in Kenosha, Wisconsin, found that the warehouse failed to record 15 injuries in a 28-day period in October 2015. At least three anonymous complaints to OSHA between January 2016 and August 2018 in Carlsbad, California; Lebanon, Tennessee; and Phoenix, Arizona, explicitly referenced management’s failure to keep accurate injury logs. Four current and former EMTs interviewed as part of Type and The Intercept’s investigation also said colleagues or supervisors pressured them to keep injuries off the books, though some said they refused to do so. An Amcare staffer in Ohio described recommending that an employee with a shoulder injury be referred to an outside specialist. His boss tried to convince him to wait longer and continue treating the pain before sending her out for treatment. “How can someone with zero medical credentials argue that? That’s negligence,” said another on-site medical representative who was involved in the incident. An EMT in Pennsylvania said she saw a colleague tell a patient with a suspected concussion to go sit in a dark room instead of going to the doctor.

Employees at the Amazon fulfillment center in Robbinsville, N.J., on Nov. 27, 2017. Photo: Victor J. Blue/Bloomberg/Getty Images

The “Justification Process” Interviews with Amazon employees in medical and safety manager roles suggest that the company managers discouraged both on-site medical representatives from seeking outside medical care for warehouse workers and safety managers from recording legitimate injuries in compliance with federal law. Around the time that OSHA was investigating the fulfillment center in Robbinsville, New Jersey, David Troutman, the on-site medical representative in Phoenix, Arizona, got a call to assist an employee who had turned cold and clammy. He said he remembered maneuvering the man into a wheelchair and checking his blood sugar. It was dangerously low, he recalled. Troutman asked the man if he was diabetic. The man, who by that point had lost his ability to speak, nodded and groaned. Troutman said he wanted to call an ambulance, but another Amcare staffer worried their manager would question their decision to send the man to the hospital. Troutman and his colleague argued, then eventually administered oral glucose and allowed the man to sit in the Amcare clinic for two and a half hours until he regained the ability to speak. “In a typical situation, 911 gets called,” Troutman said. “They’re going to start an IV.” In early 2016, another employee came to the clinic with chemical burns on their hands, Troutman recalled. This time, Troutman sent them to the county hospital — the nearest medical center that could treat chemical burns. The next time he saw his boss, Troutman said, he was questioned about the burn victim. His supervisor claimed that since the hospital had ultimately deemed the burns “superficial,” Troutman had made the wrong call by sending the employee to the hospital. Shortly thereafter, Troutman was placed on a job improvement plan, and he was let go at the conclusion of the exercise. The whole thing was “a way to throw you under the bus legally,” Troutman said. Former Amazon employees have alleged instances of inadequate medical care similar to the incidents Troutman describes in disability discrimination, harassment, and retaliation complaints filed with California’s Department of Fair Employment and Housing. An employee at a fulfillment center in Eastvale, California, who sustained a back injury in July 2018 filed a complaint alleging that he was treated with ice for two weeks at Amcare and then told that he must return to his regular duties, despite the fact that he had not yet seen a doctor. He missed work because of the pain and was fired. Another injured employee requested to go to the emergency room in 2016 and was denied, in apparent violation of the company’s safety protocols. A third employee claimed they were treated for a back injury with Icy Hot and terminated for requesting medical care. In all three cases, the employees were issued right-to-sue letters by the DFEH.

“Some safety managers would say, ‘We need to write one on every one, and if it gets through, it gets through.’”

One safety manager who oversaw an Amcare clinic in southern California from 2016 to 2017 said that managers face immense internal scrutiny from their own supervisors if their fulfillment centers report too many injuries to federal authorities. He said his boss pressured him to participate in a system in which managers reviewed each other’s injury reports to justify classifying some incidents in a way that wouldn’t require official documentation. (Reveal and The Atlantic reported on this policy in November, citing the accounts of three former safety managers; Amazon denied the allegation.) “When a doctor states that the employee needs a prescription, time off from work to heal, or restricted duty in their job, then under the OSHA guidelines the incident becomes a recordable incident,” said the safety manager, who requested anonymity because he signed a nondisclosure agreement when he left the company. “In Amazon’s case, they” — safety staffers in his region — “would often override the doctor’s decision that it was a workplace incident based on this justification process.” Amazon put the safety manager on notice that he was at risk of being fired. He described this process as “brutal, painful.” He left the company after one year. An on-site medical representative who worked at an Amcare clinic around the same time described the system: Safety staff would write out “non-recordable justifications,” or NRJs, to accompany injury reports and make the case for keeping the incidents off the official logs. Two regional managers would then have to approve the decision not to record an injury. “Every incident where there was recordable-level criteria, it would be reviewed to see if it could possibly be written up as an NRJ,” the medical technician, who spoke on the condition of anonymity in order not to jeopardize their continuing work as an EMT, said. “Some safety managers would say, ‘We need to write one on every one, and if it gets through, it gets through.’” The Intercept and Type reviewed a copy of a non-recordable justification form and showed it to Kathleen Fagan, the former OSHA medical officer. She said it’s not unusual for companies to review potentially recordable injuries and strike irrelevant incidents from the logs. But, she added, no one is allowed to pressure supervisors or managers to try and find a reason not to record injuries. “OSHA encourages workers (including supervisors/managers) to report this type of harassment to them. That’s a cite-able offense,” she wrote in an email. Both the former safety manager and former OMR said they believe the non-recordable justification process has since been discontinued. Amazon denied that the company actively works to keep injury rates low. “We take an aggressive stance on recording injuries no matter how big or small, which results in elevated recordable rates and makes comparisons misleading,” a spokesperson wrote. “It’s incorrect to assert that we provide Amcare on site in order to discourage associates from seeking care or attempting to keep fewer records—we offer this service to our employees so that they can receive the care they need right away.” Amazon did not respond to Type and The Intercept’s questions about its process of reviewing injury reports to determine if they are recordable, but, in response to questions from Reveal about injury reports, a spokesperson told the reporters that Amazon changed its policies in 2016 to promote greater transparency.

Robotic shelves at the Amazon fulfillment center in Baltimore on April 30, 2019. Photo: Clodagh Kilcoyne/Reuters

“Amazon Could Be a Leader” After its 2015 investigation into the Robbinsville fulfillment center, OSHA issued Amazon a $7,000 fine for the record-keeping violations Fagan’s team uncovered. The fine was paltry compared with Amazon’s billions in profits, but it sent a message. A follow-up investigation in 2017 revealed that the number of injuries recorded at the Robbinsville fulfillment center increased nearly fourfold the following year. A regional safety manager told OSHA the increase in injury rates was a result of over-recording. By the next year, the number of recorded injuries had fallen back to 2015 levels. There’s reason to suspect that the problem of undercounting injuries continues at Amazon fulfillment centers around the country. In the fall of 2017, OSHA launched an inspection of a fulfillment center in Florence, New Jersey, Fagan said, after it received a formal whistleblower complaint expressing concern about multiple incidents at Amcare. The most serious allegation, according to Fagan, involved a temporary worker who suffered a cut to the head while a corporate audit team was inspecting the building. Instead of taking the injured worker to Amcare, managers attempted to hide the person from the auditors. By the time this person was treated, blood had collected into a golf ball-sized protrusion on the worker’s head. (Amazon declined to respond to questions about this incident and others reported in this story.)

Instead of taking an injured worker to Amcare, managers attempted to hide the person from corporate auditors.