Patient suicide ranks among the top three sentinel events, reports The Joint Commission (TJC), prompting regulators to focus heavily on ligature risks this year. If many suicide attempts are impulsive, TJC reasons, then reducing environmental risks and opportunities for self-harm is vital for curbing the suicide trend in healthcare settings.

With that in mind, surveyors are taking a hard look at ligatures: potential hanging or choking points in healthcare facilities. Patients who have been identified as potential risk to themselves or others, will use any item or ligature point within a room to accomplish harm. Additionally, some accreditation organization surveyors have gone to extremes to validate a point of view by utilizing floss, hang it over a door hinge and say, “That’s a ligature point.” Although that last example may be extreme, the fact is accreditation organizations are being extremely meticulous, which means healthcare facilities must ensure they are prepared for this type of scrutiny.

Any observable ligature risk, no matter how small, is an immediate Recommendations for Improvement (RFI) when observed in an inpatient psychiatric area, to be corrected within 45 days or less depending on the severity or the total number of issues identified. Given what’s at risk — people’s lives — ligature RFIs are never appropriate for time extensions, said the TJC at this year’s ASHE conference.

Put simply, when surveyors walk into your healthcare facility, they’ll assess:

• Has this facility identified and assessed ligature risks?
• What plans have they developed to eliminate those risks?
• What is their risk assessment process?
• Is staff aware, trained and well equipped to act on these plans and improvement processes?

In a recent alert, TJC outlined minimum expectations for ligature risk mitigation plans:

• Leadership and staff are aware of current environmental risks.
• Patient’s individual risk for suicide or self-harm is identified, followed by appropriate interventions.
• At-risk behavior is assessed on a recurring basis.
• Staff is properly trained to identify patients’ level of risk and intervene properly.
• Suicide and self-harm mitigation strategies are incorporated into the Quality Assessment/Performance Improvement (QAPI) program.
• Policies and procedures are in place, and staff knows what immediate action to take when a patient is deemed at risk for suicide.
• If equipment poses a risk but is necessary for treatment of psychiatric patients, those risks are considered in the patient’s assessments, and adequate interventions are implemented to minimize those risks.

TJC notes that psychiatric patients may pass through or spend time in non-behavioral health units like emergency rooms, so ligature risks must also be addressed in those areas. “Any physical risks not required for the treatment of the patient that can be removed, must be removed,” stated TJC, and patients should remain under surveillance if risks remain in the environment.

As you take steps to counter ligature risks, keep in mind this is so much more than a compliance issue. You wouldn’t see regulators emphasize ligatures if those risks hadn’t enabled tragedies in facilities like yours. Help ensure no patient harms him or herself under your watch.

Larry Lacombe is the vice president of Program Development and Facilities Compliance at Medxcel Facilities Management, specializing in facilities management, safety, environment of care, emergency management and compliance. Medxcel Facilities Management provides healthcare service support products and drives in-house capabilities, savings and efficiencies for healthcare organizations.

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