CMS Updated Guidelines on Ligature Risk

On July 17, the Centers for Medicare & Medicaid Services (CMS) issued revised instructions for state surveyors to evaluate ligature risk in hospital settings. This guidance explicitly addresses measures aimed at safeguarding patients vulnerable to self-harm or harm to others within their surroundings. In response to the American Hospital Association's (AHA) recommendations, the guidance emphasizes that hospitals can exhibit adherence to specific patient safety protocols by conducting thorough patient evaluations, ensuring sufficient staffing and supervision in units, and proactively addressing environmental hazards through comprehensive risk evaluations.

Hospitals and healthcare professionals need to keep their eyes on the required elements to evaluate comprehensive risks. Let's delve into this article and grapple with the latest CMS guidelines on ligature risks.

What is Ligature Risk?

Different bodies have demonstrated ligature risk in different ways as, according to Health Facilities Management, individuals contemplating suicide or self-harm face heightened danger if their surroundings contain easily accessible "ligature-risk points." These points are described as anything that can serve as a potential anchor for cords, ropes, or other materials used for hanging or strangulation, such as ceiling pipes, shower rails, and radiators.

The New England Healthcare Engineers' Society (NEHES) offers a more specific definition, characterizing a ligature point as a stationary location where a ligature can be fastened, looped around, or secured by any means capable of supporting the individual's weight, either completely or partially.

CMS has also clarified the ligature risk policy and defined it as follows: "A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges, and closures."

In 2016, CMS encouraged The Joint Commission and state agencies to enhance their evaluations of ligature risks for patients experiencing suicidal thoughts. However, CMS did not offer specific written guidance on the required changes. Consequently, hospitals received directives to remove ligature risks without clear instructions on which areas of the hospital needed to be ligature-free or how to achieve this while simultaneously administering treatment for the underlying physical and mental disorders prompting the patient's hospitalization.

However, the utmost priority is ensuring the well-being and safety of psychiatric patients and the dedicated staff who attend to their needs. The Centers for Medicare & Medicaid Services (CMS) are currently formulating extensive interpretive guidance on ligature risk. This initiative aims to furnish clear direction and guidance for Regional Offices (RO), State Survey Agencies (SAs), and accrediting organizations (AOs).

CMS Guidelines: What Hospitals Need to Know

Medicare-certified hospitals are required to ensure patient safety under the Medicare Hospital Conditions of Participation. This means creating an environment that patients would reasonably consider safe, addressing not only physical safety but also emotional well-being, respect, and dignity. Ligature risk management aims to provide tailored environments and monitoring based on each patient's medical and psychiatric needs. It's recognized that some patients may require more restrictive settings and closer monitoring.

Hospitals are not expected to have the same ligature risk setup throughout their facility. Instead, they should focus on individual patient needs identified through clinical and psychiatric assessments. When addressing deficiencies or adverse events, hospitals should target specific issues rather than applying universal solutions. For instance, if a ligature risk is found, such as a window being misused, it doesn't mean all windows need replacement. Surveyors should delve deeper to understand underlying causes like inadequate monitoring or patient assessment.

Issues related to ligature risks should be addressed within relevant areas of compliance, such as Patient Rights, Physical Environment, Nursing Services, or Quality Assurance and Performance Improvement (QAPI), depending on the specific non-compliance identified.

Prevention Against Ligature Risks: Steps Hospitals Should Take

Patients with suicide or violent behavior risks receive care in hospitals. While all risks can't be eliminated, hospitals must show how they identify and reduce risks in line with standards. They should primarily focus on these three elements that are listed below:

• Patient Assessment

Various patient screening tools exist to identify self-harm or harm to others, but CMS doesn't endorse any specific tool. Hospitals should select tools appropriate to their patient population, care setting, and staff proficiency. For instance, post-partum units may require different screening strategies than emergency departments. All psychiatric patients must be screened for suicidal thoughts to ensure safety. Hospitals treating behavioral health issues should also conduct such screenings. Hospital policies should outline when such screenings are necessary.

• Staffing/Monitoring

Hospitals must offer comprehensive education and training to all staff on identifying patients at self-harm risk, environmental safety factors, and mitigation techniques. This includes direct employees, volunteers, contractors, and others involved in clinical care. Training should align with staff roles and patient demographics. CMS mandates initial training during orientation and updates with policy changes. Ongoing training every two years is recommended to ensure staff competence and adaptability.

• Environmental Risk

All hospitals must establish an environmental risk assessment strategy alongside patient risk assessments to ensure safe patient care. Strategies may vary across hospitals and units, tailored to specific care environments and patient demographics. Each unit should undergo appropriate risk assessments, acknowledging potential risks associated with patients at risk of self-harm or harm to others.

The CMS guidelines on ligature risks underscore the imperative of patient safety, emphasizing tailored approaches to risk management. Hospitals must adopt comprehensive strategies aligned with patient needs, staff training, and environmental assessments to mitigate risks effectively and ensure safe care delivery.