Understanding ligature risks and improving patient and staff safety


Subject Matter: Article | Topics: Codes and standards

Spotilgiht 9/26/17 The number of suicides continues to increase in the United States, and is now the tenth leading cause of death, according to the Centers for Disease Control and Prevention. The Centers for Medicare & Medicaid Services (CMS) is increasing its focus on ligature and self-harm risks, and some health care facilities have been cited for hazards that could contribute to patient self-harm or suicide in behavioral health areas. Although inpatient suicides are a relatively small percentage of the overall number of suicides, the reason some patients are in a behavioral health inpatient setting is to help protect them from self-harm. Health care facilities should work to protect patients from self-harm hazards.

Currently there are not any specific regulations that clearly explain physical methods to lessen these risks. CMS is currently working on creating increased clarity and guidance regarding what constitutes a ligature or safety risk in a behavioral health setting. In the meantime, the Joint Commission and other accrediting organizations have been instructed to use their judgment in identifying ligature and safety risk deficiencies; the level of severity for those deficiencies; and the approval of the facility’s corrective actions and mitigation plans. CMS expects to develop its guidance over the next six months.

Although there is currently no specific CMS requirement related to these issues, citations are being issued under the general requirements of K-100. Joint Commission Standard EC.02.06.01, EP1, specifies that interior spaces must meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.

To help members understand the possible patient and staff safety risks, ASHE has developed a resource listing potential ligature points and other self-harm concerns for behavioral health areas. The list is categorized by room type and contains items that are known to pose specific ligature or self-harm risks. This list is not exhaustive, but provides an idea of what surveyors may be looking for in behavioral health areas. For example, toilets can be used as an anchor point for and, if damaged, can be used as a weapon. The tops of doors can be used as anchor points by tying a knot in a rope or sheet and lodging it over a closed door; door tops should be monitored or cut to eliminate ligature opportunity.

Members can download the list and use it to record their facility’s mitigation efforts for these potential hazards.

Download the Checklist