Ligature Risks and Preventing Inpatient Suicide - Compliance with the CMS and TJC Standards

Suicide prevention and protecting patients from harm or strangulation continue to be a major focus of accreditation surveys. Suicide is the third most frequently reported sentinel event. The Centers for Medicare and Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients who are suicidal. Any hospital that receives Medicare/Medicaid payments, which are most hospitals in America, must implement these changes for all patients.

CMS tag numbers 144 in patient rights and tag 701 in facility services discuss what units need to be ligature resistant. It covers what patient assessments must be done and what should be in the environmental assessments. It discusses education and policy and procedure requirements.

Joint Commission has multiple requirements to ensure compliance with their standards. These will be discussed and include psych hospitals, behavior health units, general acute care inpatient units, and emergency departments.

Resources will be provided along with tools to assess patients to determine if they have suicidal ideations will be included.

• Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations
• Discuss that the Joint Commission has requirements for hospitals to follow to prevent patients from self-harm, including hanging or strangulation
• Describe that CMS recommends education in orientation when policies change and every two years
• Recall that CMS has proposed guidelines.

CMS Hospital Conditions of Participation

• Suicide rates and processed to consider
• CMS definition of ligature risk
• Anchor points and examples
• CMS CoP manual
• Deficiency reports
• Tag 144 – patient safety and rights
• Policy and procedure requirements
• Education recommendations
• Competency requirements
• Patient assessment
• Correction of environmental risk
• Tag 701 and Environmental assessment

Joint Commission

• Requirements to prevent suicide
• Requirements for outpatient and residential treatment centers
• Recommendation for psych unit, psych hospital, and general acute care settings including emergency departments
• Sentinel event reduction doors and soft suicide prevention doors
• Ceilings, beds, and toilets
• Shower curtains                    
• SAFER matrix and when at risk for getting RFI
• EC.02.06.01 EP 1 requirements
• Dedicated versus non-dedicated spaces
• Suicide risk reduction
• ED and safe rooms
• TJC ligature risk FAQs
• NPSG 15 January 2023

Resources and tools of the trade

• Behavioral Health Design Guide
• Suicide Prevention Resource Center
• VA/DoD Clinical Practice guidelines
• Suicide prevention guidelines for training
• Patient health questionnaire PHQ-9 and 3
• ED-SAFE screeners
• Patient safety secondary screener
• ED Suicide Behavioral Questionnaire SBQ-R
• Environmental Assessment
• C-SSRS Columbia Suicide Severity Rating Scale
• SAFE-T Assessment
• Suicide Prevention Decision Support Tool and more
• NY patient safety standards guidelines

• All healthcare providers in the hospital's behavioral health unit
• All healthcare providers at Psychiatric hospitals
• All healthcare providers in hospital emergency departments
• All healthcare providers on hospital units where suicidal patients may be treated
• Hospital risk managers
• Patient safety officer
• CEO, COO, CNO, and nurse supervisors
• Chief medical officers
• Director of maintenance and facility services
• Environmental Services
• Security
• Director in charge of environment of care requirements and staff
• Quality improvement coordinator
• Compliance officer
• Director of Regulatory Affairs
• Nurse educator
• Clinic and outpatient managers
• All department directors/nurse managers such as ED, ICU, CCU, Med-surg managers, outpatient, etc.