Ligature Risks and Preventing Inpatient Suicide: CMS CoPs & TJC Resources (ODW5023)-Ligature Risks and Preventing Inpatient Suicide CMS CoPs & TJC Resources Recording

Video Transcription

Video Summary

Laura Dixon, an expert in risk management and patient safety with over 20 years of clinical and legal experience, presented an in-depth webinar on ligature risks in hospitals, focusing on suicide prevention. She emphasized the importance of compliance with CMS conditions of participation and Joint Commission recommendations to ensure a safe care environment for behavioral health patients, particularly those with suicidal ideation or incomplete suicide attempts.<br /><br />Dixon highlighted that the U.S. has one of the highest suicide rates among wealthy nations, with males at four times higher risk than females, and that suicide is a leading cause of death across age groups. She underscored various risk factors, including mental illness, chronic pain, substance use, financial or legal difficulties, and past trauma. Importantly, she noted that patients are at high risk both during hospitalization and after discharge, requiring thorough assessments and safety planning.<br /><br />Key compliance challenges include performing comprehensive suicide risk and environmental ligature assessments, training all staff—including those outside behavioral health units—on suicide prevention protocols, and maintaining environments that are "ligature-resistant" rather than "ligature-free." Practical adjustments include using tamper-resistant fixtures, securing potential ligature points like door hinges and bathroom plumbing, and providing appropriate patient attire to minimize risks. One-to-one patient observation and use of safe rooms were stressed as vital interim safety measures when environmental modifications are pending.<br /><br />Dixon also reviewed various validated suicide risk screening tools and the need for clear policies on patient monitoring, staff education, and follow-up care after discharge. She stressed timely correction of deficiencies identified during surveys, adherence to state laws, and continuous quality improvement. The presentation included multiple resources and practical guidance to implement effective suicide prevention strategies in different hospital settings, ultimately aiming to reduce inpatient and post-discharge suicides through comprehensive risk management.

Keywords

risk management

patient safety

ligature risks

suicide prevention

CMS compliance

Joint Commission

behavioral health

suicide risk assessment

environmental ligature assessment

staff training

ligature-resistant environments

post-discharge care