And now, I would like to introduce our speaker to get us started. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. And we are so thankful that you're here with us this morning. Laura, we invite you to go ahead and get us started. Great. Thank you very much, Lindsay, and welcome, everyone. So glad everyone could join us on this morning. We're talking about an issue that it's kind of hard to address in the fact that this is something that might occur to our patients that we really didn't want to have happen. And that is, of course, where they have found an item and then they pose the risk of ligature to themselves or even to others that might result in suicide. I always want to include my disclaimer that the information I'm providing today is just that. It's informational only. It is not intended to serve as legal advice or establish any attorney-client relationship. So please consult with your in-house counsel, your legal representative for advice, and especially if there's any particular state law that might apply to the subject matter at hand. So I just want to do a brief introduction on the topic itself. Now, surprisingly, U.S., the United States, has the highest suicide rate of all the wealthy nations and they account for almost 14% of deaths per population within our country. We spend 17% of our GDP, our gross domestic product, on health care. You would think that, okay, we would be a little bit more in the positive side. So it's very interesting to see some of those rates. This happens to be the one that I was able to tap into. This is the most recent one that I could find. So you can see we're up there. The 23 report from CDC showed it is one of the leading causes of death. It is not the, but it is one of the leading causes. And the number of suicides, the deaths, have increased by 2.6 between 21 and 22. And males make up less than what the females do. I've got that graph there that would show the difference in the number of years across the timeframe. And again, 23, 22, those were provisionals. The suicide rate since 2000, we did have a slight decrease in 2020, which in a way is kind of surprising given what was going on in 2020. But unfortunately, they are now starting to come back up. What are the factors? What are the risk factors in our patients? Well, they may have had a previous attempt. Of course, the history of depression, other mental illnesses that would contribute to them feeling like they have to end their own life. Serious illnesses such as chronic pain. You may have known of someone who maybe had a debilitating disease and it was so awful and the pain that they suffered from it was so bad that they felt that they could not go on and did end up losing their life. Maybe they're having some legal problems that are potentiating these. Perhaps they are impulsive. Aggressive tendencies will lead to them ending their own life. Of course, we're all very familiar with job and financial problems or loss that could result in severe depression. Substance use can also lead to it. Maybe there's something in their past, childhood experiences or other PTSD issues that can result in this. And then violence, victimization or other perpetration. Something that has led them to believe it just can't go on. Now, I've got one here. This is a very interesting map and I call it interesting because it shows the rate by the CDC according to each state. My state of Colorado, it's up there. I was really surprised. I thought that we would have been a little less, but that was very interesting and Montana and Wyoming had the highest age-adjusted death rates. So it's not just where you live sometimes that you think you have the lowest rate. As far as prevention, these are the most recent statistics. Every 12 minutes, someone does end up taking their own life. Every single suicide, we have 25 attempts. And each year, almost a million department ER visits are made by someone who is even just thinking of ending their own life. It is the 10th leading cause of death. This is from SAMHSA. They put out a great information and it talks about suicide prevention. They also, by the way, have information available for healthcare providers who are having also the issues with severe depression. We never want to see certain headlines as it relates to us. This was back in 23, where we had a teen who died by suicide. She was inpatient at the behavioral health unit. Now, this was the second attempt, a second attempt that this patient had before, unfortunately, it was a completed suicide. And nurses, we face the same issues. We have a higher-than-average suicide risk because just of what we're going through and the pressures put upon us. And it's not just nurses, it's also physicians. Here this article did mention from Medscape, physicians, they have the highest suicide rate of any profession. So unfortunately, we did see a slight spike in this. There was some information out there that showed there was a spike during COVID, where they were just, everyone was so overwhelmed that they just couldn't do it anymore. Now, I want to just, this happens to do with inpatient suicides. In 22, they did note the risk of suicide in psychiatric hospitals was 50 times higher than in your general population. And that really can be a complex, increase your complexity for assessing the risk and really no consensus on how to stop it. What should be in place in order to stop it? The rate of inpatient suicides, Joint Commission did an analysis, they took 27 states and brought it together. There were 16 inpatient suicides and 30 that did go up almost, almost double between one year of 2014 to 2015. 34 of them occurred during their inpatient psych hospitalization. 70% were because of hanging. And what they found was that the door, the handle, or even a hinge was the most common fixture used. So how are we going to do this? Well, one of the other things they noted was care transition. And what are the best ways to decrease that rate when the patient is transitioning from inpatient, really supervised, monitored care to when they're going to go back into the general public. And they showed some best practices to help with that because they found that there usually is an after an attempt where they come into the emergency department. Okay, what brought them in? What led them to want to try to hurt themselves? And now they're going to be going home. So they do have some information guides. It really is very helpful for your families and your patients to try and get them through this next phase of their recovery, hopefully. Well, we did want to talk about the CMS conditions of participation. It is in what's called the state operations manual. Those of you who've had an opportunity to listen, you're probably very familiar with this section because what we're trying to do today is avoid this. That's where you get the statement of deficiencies, where you have to provide a plan of correction when you're at the condition level. And of course, no one ever wants to get that notice of involuntary termination from your Medicare and Medicaid agreement. So how does this all work with those conditions of participation? So the regulation itself, the law, starts in the federal register. And then CMS has the responsibility to do a couple things. One, they have to put out a transmittal to their surveyors and to the general public that, hey, this is a new regulation. CMS has to develop interpretive guidelines and survey procedures on what that regulation says. In other words, what's the rationale behind it and what are the surveyors supposed to do once they're on site? And then they're to update the manuals. And there are two main manuals we're going to be addressing today. One is the Appendix A, that's for acutes, and then Appendix W for critical access hospitals. Overall, there are three types of surveys. We have the certification, where you're just getting started. A validation, where perhaps they came back and see what was going on, or your joint commission, and they want to just make sure, yes, everything is still following along with what joint commission with your deemed status. And then a complaint survey that hopefully no one ever has to face. There are multiple changes that have occurred. And one thing you want to do is, I would subscribe to the federal register. So if you're in compliance, you might want to keep that handy. You'll usually get emails about every week that will tell you this is new, this is different, and of course, you want to make sure the most recent manual. The first started in 86. Multiple updates, and surprisingly, within a four-year period of time for acute hospitals, they put out three new manuals. Your most recent manual came out in April of this year. Critical access hospitals, yours hasn't been updated too as frequently. In fact, your last update was 2020. If there is a new manual, I'll show you how to find what's called the transmittal page, because that's a quick way to find out what was new, revised, or deleted. And I would suggest you check the survey and certification site monthly, just to keep up when they do send out new memos. And I have all these links here for you to copy-paste if you'd like them. So as far as the manuals, again, we're going to be talking about A. Now, AA is for psychiatric hospitals. They have weaved those requirements together now. For psychiatric hospitals, they really, really focus more in that appendix on care of the patient, as opposed to the overall processes and environmental setup, which is what we're going to be talking about a lot today. And then W, that's for your critical access hospitals. There are a few other ones you might want to keep handy, and that would be Q in particular. That is immediate jeopardy. If CMS comes out or Joint Commission comes out and finds something that poses an immediate risk of harm or danger or death to a patient, they're going to come visit you within two days. And then as far as the manual for your individual hospitals, again, this is for Appendix A. You will see where it says transmittals. That's once you get into the website. That link, once you click it, will take you to that transmittal page. But you really want to focus and make sure you keep an eye on that red lettering that shows the revision date. Again, it was last updated in April of this year. Criticals, yours has not been updated since 2020. So this is what that transmittal page will look like when you do click on the blue lettering. It will tell you the issue date and what was changed. So again, it's a really quick way to get to the meat of it. And that just happens to be an example of what that one would look like when you get there. The memo page, again, good way. I check it monthly just to keep up with what has changed. Some of it won't apply because it talks nursing homes. It might be end-stage renal disease or lab. So just make sure that when you do see a new one that crops up, it is applicable for your hospital. That's just what it happens to look like. And we're going to be covering a memo that came out on our topic. On deficiency reports, I did mention nobody wants to get that notice of a deficiency. We can access that data. So if you're looking to find out what's going on in your community or your state, what are they focusing on? This is one way you can do it if you're trying to do some benchmarking. It has all of the hospital's acute and critical access. It has the tag numbers. It is updated quarterly. And so you can get the most recent. It may take them a month or two to catch up. So from October to December, it came out in late January. And the way you would tap into that is where it says Certification and Compliance. Go to the hospital. Scroll to the bottom of that page where you'll see the full text statements. It is an Excel format. They come in two Excel sheets. One is from 2010 to 2016. And the next one is 2017 to current. Because there was so much information. And essentially, this is what pops up. So if you do want to do a search, make sure you put in by tag number the letter of your particular facility, A for hospital, W for criticals, and the four-digit number. If you simply put in a three-digit number, you will get the wrong information. Why were hospitals cited? This is what I was able to pull off of some of those past deficiencies. Well, we didn't train our staff for those who are highly suicidal. Didn't have a one-to-one sitter, again, for one who was very suicidal. Absence of appropriate policy and procedures. They didn't follow their own policy when it was in place. They didn't use evidence-based tool to assess a patient who was suicidal. Behavioral health unit was not ligature resistant. Not enough staff to monitor highly suicide patients. No environmental risk assessment. Gowns had ties at the back. And this was on a suicidal patient who was in an inpatient psych unit. Suicidal patient had a bed with side rails. And we're going to talk about why these were cited as we go through. Zippered mattress. What they could do is take that mattress cover off and suffocate themselves. Slippers had leather shoelaces. Doors between the bedroom and bathroom, not resistant. Again, on a psych unit. They didn't have identified hazards within the environment that were immediately corrected. They knew they were there, but they didn't take actions or steps to correct them. Toilets had exposed plumbing. Again, in a psych hospital. And then finally, bed. There were loops on the end that were not of ligature resistant quality. In other words, they didn't break away. And it just was a risk for the patients. Tamper-resistant electrical boxes were still present. Unsafe hinges. No solid ceiling in the behavioral health. Unsafe shower curtains. Plastic bags in a trash can on a behavioral unit. Now, if you go back to the initial slide as this program started, you will see most of these issues within that patient. She was sitting in a behavioral health unit. The gown had ties on it. The sink had an exposed pipe that she could have wrapped something around it. And then there was a plastic bag in the trash can. And it's interesting if you just walk around sometimes and peek in, you'll start to identify these areas that a surveyor would also list it. All right. Let's go ahead and start here. Now, I want to talk about ligature risk for self-harm. This is in the patient rights section. It's tag 144. And just so you know, in appendix W for your critical access hospitals, you do not have a corresponding section. However, you still have to provide a safe environment for your patients. So if you're starting to see an uptick, you're a critical access hospital, and you're seeing an uptick in your behavioral health patient admissions, this could be kind of beneficial for you to listen to what they found in an acute hospital as to what some of the deficiencies were, what some of the requirements are. Lindsay mentioned we do have a few questions. Participation is voluntary. And so, Lindsay, I believe this is our first question. It is. I'll go ahead and get that one up here on my screen. Okay, you should all see this one now that says, we assess all patients to some degree for risk of suicide. Yes, no, only those with a history of suicide attempts, or possibly you are not sure. And if you did miss the introduction, we, again, as Laura just mentioned, we'll have several of these questions throughout the presentation. And we will also pause to address any questions that you have for Laura up to that point in the presentation. So you should see that Q&A option there at the bottom of your Zoom window. So if you do have any questions for her as we go throughout the presentation, go ahead and be typing those questions into that Q&A option so we can address those in a timely manner. Or if you don't see that Q&A option there at the bottom of your Zoom window, you can, of course, utilize the chat to type in your questions as well. Question here, what age group is the question referring to, Laura? Is it just in general? Oh, any age group. And that's a very good, any age group. Any age group. And it's really, it's kind of sad. I guess it's the best word I can come up with. When you see, you know, someone as young as six, seven, eight, nine coming in and have had a suicide, an incomplete suicide attempt. It is, it's disheartening, I guess is the best word to put. As far as, you know, what are these poor kids going through? Okay, I'll go ahead and share those results. Okay, great. Excellent. Okay. So what we're going to talk about today is some of the requirements that CMS has put out. But first, let's start with the ligature risk. It's in tag one. It's in that, again, A144. And it's, what it's saying is that patients, we have to give them and give them care in a safe setting. So what does that mean? Well, that means we have to look at patients and identify those who might harm themselves or others. And then, okay, what's in our environment that could pose a risk for patients, especially to harm themselves? Of course, then we have to give education and training to our staff, and that's volunteers also. Whether it's, it could be someone delivering the food tray, or it could be, you know, a new nurse that's come on board to find out, okay, what education do we need to provide to this person so they're aware of how to assess a patient? And then, of course, take steps to correct those environmental risks. And we know that those who are at risk can be inpatient or at our outpatient locations. It doesn't have to be a locked behavioral unit. The interpretive guidelines are saying what we need to do is really identify those at risk for intentional harm. Look at our environment. Are there any safety risks? And if so, take them out of there. If you can't take them out, then mitigate the risk. Cut that risk down. They do mention having enough staff to support mitigation, education, and training. And, of course, they want to see a policy and procedure on how you're going to do that. How are you going to do the education? How are you going to evaluate your environment? And as you noted, one of the issues was we weren't following our own policy, so we want to make sure we're doing that. I did mention non-psych units. You may have those patients with behavioral health needs. They may be coming out of ICU after an incomplete attempt. They may be coming up from ER because the behavioral health unit is full. You may get those. So we still have to look at those areas that could pose a risk for intentional harm. Those patients who do require medical care, we have to evaluate them, monitor, of course give the care they need when especially they're demonstrating that suicidal ideation or potential harm. Okay, maybe you've got a bedside nurse who is on a step-down unit. Perhaps they don't have the expertise a behavioral health nurse would. Is there a resource that non-behavioral health nurse can go to? In other words, how would we identify this harm? Look at that and do an individual suicide assessment on the behavioral health patients. Because you just want to make sure that, yes, indeed, we are tracking them. And you may want to do them for all patients. They do provide definitions for us. I would take the definitions that CMS provides in the interpretive guidelines and add them to your policy and procedure. Because once they look at it, they'll recognize that language. So they do define either a risk or a point as anything that can be used to be wrapped around, to hang, or strangulate. And it doesn't have to be themselves, by the way. It can be harming staff or others. So it can be a cord, a rope, a bra strap. And they even list out some of them of what those ligature risks could be. It could be the closures on a door. This is the ligature point where they put them into place. The radiator, they can use that to tie something around it. A window frame, a door frame. Even shower rails or curtains can be utilized. Pipes can be also utilized. As far as the material itself, again, I mentioned the bra straps. It can be even a phone cord, a phone charger cord, a phone cord. Rubber strips from door sealing, that's what you're looking at here. That's a picture of the insulation from a window that a behavioral health patient had torn out and used it as a ligature on themselves. Shoelaces, belts, the usual things we would think that a person would utilize. They do have a couple checklists if you want to do a walk around and see what's available in rooms, maybe a patient brought in. By the way, if a patient's family is bringing in clothes, you check the clothing also to make sure like a robe belt is not there, that you have taken that away. And then as far as within a room. So this is your standard room that you probably run into. And this was a nice review that a surveyor kind of pointed out. A safety surveyor had to come in and do this. And these are just some of the issues and areas of exposure where there's multiple on the bed itself. There could be ligature points, they can tie it around that foot rail. They could be used as a weapon, some of the furniture. Baseboard as a weapon risk, I guess they would have to rip that thing out of there to do it, but nonetheless. Of course, we know medical equipment can be used, the IV poles can be used as a weapon. Light fixture, curtain can be used as a ligature, just normal things you would see in a hospital room that you wouldn't even think twice about because they've been there for so long. And again, the point I mentioned, that's a fixed point where that ligature can be tied around, wedged, anything to keep it in place, but yet bear the weight of a patient, whether it's in whole or in part. In some of the courtrooms here in Colorado, in the visitors' bathrooms, they have taken out the coat hooks because they found on certain occasions, all those who were there, again, facing legal issues, would go in and try and hang themselves with those coat hooks. So that's why they've taken them out in a lot of the court areas here. And it can be a loop, a noose, anything, again, to hurt the hang or strangulate the patient. Doesn't have to hold their entire weight. They mentioned as far as on the sinks with the pipes, the drainage pipes, well, how could that be? They can tie it around and then just drop their weight to the floor. Doesn't have to be a hanging from a shower curtain rod. And then they do have some other areas, some examples of what could be. The shower head, I don't know how that could hold a weight, but it could. Door hinges, I think sprinkler heads are a little small, but nonetheless, CMS has identified it. And then the window or door handles. As far as what we have to do, follow those nationally recognized standards to minimize that risk so that they can't do it, that they can't cause self-harm. Anti-ligature fixing, those are designed. They either impede or prevent putting a ligature in there. And it's also designed to break away. That after a certain amount of pressure, could be 10, 20 pounds, it automatically snaps off and nothing can be there. So what do you want to take into account? What do you want to consider? Well, of course, your dedicated behavioral health unit. But again, as I mentioned, you may get those patients from the ED or the ICU, CCU, where they've had an incomplete attempt. Those are non-dedicated areas. So that may not be so tightly monitored or controlled. But if you do get one, have and do an environmental risk assessment. Use that multidisciplinary team. And CMS does make a good rationale for that because sometimes what we would see, oh, that's a risk, we have to get rid of it. But then your safety personnel comes along and says, wait a minute, that's a fire suppression issue. We have to have that place. All right, then how can we do to minimize the risk or mitigate that risk? Same with housekeeping. You know, we have to get rid of this equipment here because it does pose a risk that the patient would get ahold of a mop and hurt themselves. But then housekeeping goes, wait a minute, we have to have these mops here under infection control and what our requirements are for cleaning. That's why it helps to have that multidisciplinary team. Look at short-term, long-term fixes based upon your risk assessment. Some of these may cost some money, some financial outlay. And so that's one thing you have to take into consideration. Also look at who's taking care of your patients. Are they competent to take care of them? You know, you've got some really good people who are great at behavioral health and taking care of patients. Others may be not so great. That's just not one of their fortes. So again, look at the competency of staff. Train anyone, anyone who interacts with a patient who has had incomplete attempt because they need to be on the lookout for is this patient going to harm themself when my back is turned? Because that could be lab radiology, housekeeping, dietary, volunteers. Just make sure they're aware that just kind of keep an eye on this individual. Look at the bathroom. What's in there that they could harm themselves? And as I mentioned, we do still have to watch our visitors. They could be very well-meaning. Oh, he loved these shoes and they were so comfortable on his feet and there were shoelaces in them. Probably not a good idea. Same with the bathrobe, something as simple as the bathrobe. Now they did, I want to point out something in identifying patients who are at risk. In the old guidelines as of 2021, this used to say must, it is now should. So they did change it. You should do a patient risk assessment. How you do that, what your strategies, that's up to you and how you're going to do that patient risk assessment. There are multiple tools out there to help you identify if you have a patient at risk. And of course, appropriate to their population, your setting, how good is your staff? Or the age of the patient. Again, do you have a pediatric patient? So what they're saying now is you should implement an environmental risk strategy because it may not be the same. You may have something totally different in ED that you would have say on a mother-baby unit. Could be the same thing given postpartum depression. Same, it could be something different when you have a short-term surgical area as opposed to again, your behavioral health unit. But it has to be specific to that unit and the patients you anticipate being there. Now, of course, it doesn't mean that if you don't normally care for a suicidal patient, you shouldn't do an assessment, but rather make it appropriate to what you have. Because again, you could easily get those patients in. You may want to look at a specific tool, make your life a little easier. They've done the work, it's out there. Document, take credit for your assessment because CMS may want to look at it. They may want to see what assessment tool did you use? They do mention the VA environmental assessment tool. I have it in the appendix for you because you can assess for safety risk in all type of environments and care settings. It also talks about the National Action Alliance for Suicide Prevention. That is another tool. Again, whichever tool you decide to use. Make sure staff is also trained on how to use it. So what do we have to look at? What are some of the risks? I did mention the housekeeping cart. We do have to look at that because it may not just be the mop. It could be the broom handle itself that could be used as a weapon. Cleaning agents to harm themselves, take it and drink it. Again, what's brought in from your patients. And I'm sorry, the visitors. Light fixtures, windows, call lights, handrails, power cords, shoelaces. Again, all of these items that have been touched on before. And they also mentioned a not enough staff. Now there are two different types of ligature components. One is ligature-free or resistant. And then there's ligature-safe. Ligature-free or resistant, that's essentially the same level. This is for behavioral health hospitals and psych units. Those dedicated units. It does not apply to other non-psych departments. However, we know that you may be boarding patients, psychiatric patients in your emergency department until a bed becomes open. And these could be ones that are at risk for self-harm. So identify those who are at risk and take steps to mitigate those environmental safety risk. They did again, put out a memo July of last year, 23. And it talks about the three main elements so that we can keep patients safe related to these risks. And also how can you show compliance when the surveyor shows up? And there are three main components. Patient assessment, that was part of the question. Do you assess your patients? Staffing and monitoring, keeping an eye on our folks. And then the environment itself. So that happens to be the memo, what it looks like. So overall, they don't expect hospitals to have the same ligature risk configuration throughout the facility. They know that. Look at this needs and risk of your individual patients, whether it's clinical or psychiatric assessment. If you have a patient who did have an incomplete attempt and it is now on the step-down unit, they're going to have clinical needs along with that psychiatric assessment. Take those actions in response to any deficiency or adverse events. No, we never wanna have that adverse event. That's a hard lesson to learn. But nonetheless, keep an eye on those. Focus on what's appropriate based upon those findings or maybe the gaps you found in care rather than doing an overall universal remedy. Because again, it may not be, number one, financially feasible. And number two, you may not have the resources to put into it. And that includes bodies to do some of this stuff. So starting with the patient assessment, when the surveyor comes around, you should be able to show how you found those patients who are at risk, whether it's to themselves or to others. And then what'd you do to minimize those risks? Taking into account what are nationally recognized standards and guidelines. In the memo, they reiterated all of those potential risks that we've already talked about, whether it's their O2 tubing or it's a plastic bag that happens to be in the trash can. As far as the screening and tools appropriate to the population, where you're at, your staff competency. But patients do need to be screened. All patients in psych hospitals and those in the units. Those in acute care, if they've been evaluated and treated for any behavioral health conditions, that's the main reason that they happen to be there. Or maybe there's those per hospital policy that you are going to assess. They do have resources. They talk about recommended standard of care for patients with suicide risk. Again, I mentioned that Action Alliance. This particular alliance, they advanced two goals. One, promote suicide prevention. That's a core component of healthcare. And then promote and put into effect effective practices to assess and treat those who think, yeah, indeed we are at risk. So let's say you get a patient in who lives in a violent domestic abuse sort of situation at home, but they're in there for mother baby. That's a patient you might wanna give strong consideration to assessing. It's like at risk for self-harm because they may feel trapped, unable to do anything about it. So that's one thing. Maybe it's not an actual behavioral health patient, but somebody who's at high risk. They talk about staffing and monitoring. That was the second component. Of course, enough education and training so the staff can identify such patients and then mitigate them. What are those risks that is posed? And this includes contracted per diem agency. Doesn't matter what type of staff. We have to make sure they're appropriately trained. And of course, to all new staff on orientation. If you're changing or updating the policy and procedure. Now they do mention ongoing at least every two years after that initial training. And you're probably doing this if you're having your annual skills lab. That's an excellent opportunity to do it. And it's also a good way to evaluate is there a gap in training when perhaps your patient population is starting to change. And then our environmental risk. Because it could be different in the settings and your units. Of course, we have to make sure we're still giving care to the patient population, but make it appropriate to your unit. And again, that you may be taking care of patients who are at risk for self-harm. And then suicidal ideations. Those who are in your hospital, but outside the psych unit, we still have to keep them protected. So what does that mean? Maybe it's one-to-one monitoring with continuous visual observation, taking things out of the room, equipment, unnecessary equipment that you can take out of the room that could be used as a weapon. Some hospitals, they do have safe rooms within say their emergency department where they can put a psych patient. And we understand, and I also understand, sometimes those rooms, you're boarding patients because there's no place to put them. I see this also in critical access hospitals where the psych units and the behavioral health hospitals, they don't have a bed yet. And these patients still show up there and they have to put them somewhere. So that's why we still maybe have to keep an eye on whether the room's close to the nurse's station or whatever it is. So here's our second question. I'll have Lindsey put that up. Okay, I'm gonna actually read this first part and then I'll put the question up here for you. This says, hospital C is a general hospital that at times may receive a patient with self-harm ideation. Such patients are admitted to one med-surg floor and all staff on that floor have been trained on safety measures with such patients. No other staff are similarly trained. And then the question here, will that be a possible citation for hospital C? And let's get that up here for you to see your options. Okay, yes, no, or not sure. And it looks like we've had one question come in, Laura. It says that our risk screening starts with a depression screening. Those patients with a positive depression screen are further evaluated for suicide ideation. Is this the same as completing suicide screening? It probably will. You'll probably be okay because then you're going to identify it. And again, those who are doing those screenings, really, we have to give them some education and training for some other red flags that might trip it off as far as what might pose a risk for self-harm. By the way, your behavioral health nurses, if you have that luxury, good resource to help train those who have patients on non-behavioral health units because they are really good at picking up on clues and cues on what can happen. So you're good to start with your depression screening if that is negative. It never hurts death. Ever thought about harming yourself? Very simple question. In fact, even when I've gone to my primary care physicians and some of the specialties, that's just a routine part of their question. Have you ever thought or had feelings you wanted to harm yourself? Okay, I'll go ahead and end this poll here and share those results. Okay, so it could be, yeah, good, good. Not sure, it could be a citation. It depends because then if all of these folks are coming to one floor and all the staff's been trained, well, what happened if they're full? Nobody else was ready to take care of them. Nobody could take care of them because they just, they weren't comfortable with it too. So that's why we have to have staff trained on how we identify patients at risk and what's going on in our environment. When I worked in pain management, we had patients who were depressed because they were in chronic pain and we had to make sure we went in and looked at the room because we did have a patient who helped themselves to some of the equipment that we just normally stored in the room, which were extra needles. I know, not a good idea, but we did it at that time. There were plastic bags because sometimes we would have to empty out the laundry bag and swap it out. And we had to go back in and do a revisit when that one patient took those needles out of the room. And again, I mentioned this includes everybody who might have patient contact, whether it's your per diem staff, your employed staff, doesn't matter. And again, they recommend every two years for this training. On correction of the environmental risk, well, you establish that timeframe is going to be established by your regional office, could be your crediting organization, whether it's joint commission, DNV, doesn't matter which one it is. Now, when it is not reasonable to have compliance within that timeframe. So let's say CMS, the state comes in and says, you have 60 days to complete this risk and mitigate it, get it fixed. And you know, that's going to involve, oh my goodness, I've got to go out and get, first off we have to get funding, then we have to go get bids and we have to choose a contractor. Well, now you're up to almost 90 days. If you need an extension, only CMS can grant that to you because those deficiencies for ligature risk don't qualify for any waivers and just be prepared, they will not grant them. So if you have, and CMS says, no, we want this thing fixed. They may say, you cannot take care of patients until that is fixed. I want to give you the heads up that might occur, but some of them understand this is a financial outlay and things take time to get them fixed. Some are pretty simple. Some again, may take some structural reconfiguration. As far as in the plan of correction, you do have 60 days. Once you get the report, follow-up surveys, they're going to come back and visit. They want to make sure they are done. And we know that they do take time. It can be a burden, whether it's approval, funding, getting the bids, et cetera. And then just time to complete them. Now, do you have enough of the materials to make those changes? As far as immediate jeopardy, I mentioned that at the beginning. Those that don't pose an immediate jeopardy, those are expected to be corrected within that timeframe that CMS has said. And that includes when you've removed the immediate threat to patients. And those, again, these are not immediate jeopardy. They do expect you to have interim safety measures in place as part of your plan of correction. And that start, the period starts when the hospital is notified of that deficiency. And again, only the state agency or accrediting organization can ask for more time from CMS to correct that deficiency. That's why it's always good to stay on good terms with your state agency or accrediting organization. As far as mitigation of these safety measures, you may have to bring in extra staff. So that could be a one-to-one sitter if you can't get that mitigated in time or fixed in time. They also talk about other nursing protocols from the American Psychiatric Nurses Association, good research on one-to-one monitoring that can have some adverse events, especially if you have a paranoid patient or an agitated patient when somebody's constantly standing there or sitting there watching them. It can add to that paranoia and just make their condition overall worse. So again, for requesting an extension, what you have to do is make sure that your plan of correction has been accepted, that you've got a mitigation plan, at least in place in the interim, why you can't meet that correction within the timeframe, what's the effectiveness of your mitigation plan. Yes, it's working. We have one-to-one sitters. They're constantly there. And now we're getting the bids in place. And then they want updates on that plan of correction. So that may be in 30 days. Okay, we've got the bids out and we've accepted this bid. Anticipated start of construction is here. And another 30 days. Okay, construction has started. They're 20% through it. That's what they want to see is how are you progressing? And again, if you're gonna go to any accrediting organizations, Joint Commission, DNV, if you don't have them, that goes to your state agency, Department of Health, whoever it happens to be from your state that would do the survey. Again, then they send it to the regional office or central office and the central office will respond. They will copy the requesting organization and the regional office within 10 working days. And you have to, again, give those progresses, electronic progress reports on a monthly basis. And they want copies. They want documentation to support what you're doing, invoices, communication with vendors saying, hey, this is where we're going. That could be emails. So they do want confirmation that yes, indeed, this is being worked on. As far as the overall survey procedure, and this is again under tag 144, don't be surprised if the surveyors kind of stand around and watch. Because what they're doing is first off, they're looking at the environment. They may bring a safety engineer in with them when they're doing these types of surveys. Because what they're looking for is just things we see every day. The housekeeping cart. Are they unattended for any certain amount of time? And on a particular unit. They want to see your incident is posing these risks. Then they want to talk to your staff. Are staff trained to identify risk in the care environment? And if so, how do they report those findings? So they may go up to a nurse and say, have you done your safety risk assessment for your environment here? Did you see anything? Yeah, I did see a couple of plastic bags in the wastebasket, okay. What was your next step? What are you required to do at that point? That's what they want to see. Is staff and trained to observe, identify and then resolve or take steps. They also of course want to see your policy and procedures. And they will interview your staff at the same time. How do you define continuous visual observation? One-to-one. What's a one-to-one observation? They want to look at your policy. What do you do to curtail unwanted visitors? Contaminated materials that could pose a risk. Unsafe items. Again, like I mentioned, having the needles in that room was not a good idea. And so that's one thing you just kind of have to look at. So having that multi-type group, the assessment team to come around from different disciplines, it's a big benefit. They'll see things you see every day and don't see anymore. They want to look at your security efforts. How do we protect a person from suicide or self-harm? These again, they are looking at nationally based standards. And you have to of course have enough security to protect the patients and keep them safe. Now, whether or not you employ or contract with security, nonetheless, they still have to be trained on what to look for and how to respond appropriately. Next area I want to talk about is the building and the environment itself. And that is tech 701, again, in the cube. And critical access don't have other than that you have to provide a safe environment for patients. So please listen to this section also because it'll be ahead of the game in doing so. So as far as your buildings, they wanna make sure the overall condition of the hospital is developed and maintained so it's safe and provides a safe and wellbeing of the patients. In other words, it can be everything from slip and falls, believe it or not, to again, the ligature hazard. And that includes routine and preventing maintenance testing. Your building, of course, it has to be built so we minimize risk to everyone, visitors, patients, employees, and that safety features that we're following nationally recognized guidelines and standards. So we have to make sure it meets our accessibility standards such as ADA. Can we get in there? We wanna watch for any age related features, whether it's a geriatric patient, are we keeping them safe from wandering or abuse by other patients? And consistent again with our national standards. Age related risks, they can include anything from access to meds, furniture can pose a hazard or harm to a patient, medical equipment, they do mention in their increased risk of falls, and security of the inpatient and outpatient areas. So again, we're still keeping an eye on harm, self harm to a patient. So have adequate security. So of course, we don't have allotment and we don't have abduction because we could also have injury, unauthorized access to units by a person to go in and harm another individual. They do mention the International Association for Healthcare Security, they have security guidelines that could be utilized. So again, we wanna prevent unauthorized access, inappropriate discharge and non-clinical rooms. Now, why would you think that would come up here? Patients, if they have access and can walk around, we don't want them accessing, if there's a history of self harm, electrical rooms, HVAC rooms where there's all this piping that could go on and same with the ventilation. We don't want them harming ourselves. And especially if we have any unmitigated ligature risk. Now, if those exist in a psych hospital or unit, then that's immediate jeopardy. So again, if it's an unmitigated ligature risk, you have to find, these must be referred to the health and safety surveyors and the surveyors are going to dig deeper because if they find it just walking around and you happen to have behavioral health patients on your unit and they're not mitigated, then you could also be cited under tag 144. So you get two citations under 70A and 144. So here's what the surveyor is going to look at. First up, they want to see your most recent environmental risk assessment. You choose the extent and who does it. Maybe again, you want that multidisciplinary team. They want to make sure that you've identified any risk or things that keep you awake at night, whether it's age related, maybe it's something with your security, suicide or other forms of self harm. They will determine if you have identified them in the assessment and do you have a plan to mitigate them? Do you have a plan to take care of them? So let's just say that they come on site, their usual unannounced survey and they're walking around and for some reason, you've managed to have the luck of the draw, you get a few more of those behavioral health patients who are coming out of ICU and they need med surge care still. And you happen to have three or four in a particular area. Are they in one area so you can efficiently take care of them? And that the staff are, they're pretty up to speed on what needs to be done. And if so, maybe one of those patients decided to harm themselves. Well, you've taken steps to mitigate that since that occurred. And CMS shows up the next day. As long as you can show you have identified it, you're taking steps to mitigate it, you're doing what you can, you probably are gonna be okay in that respect. But if you don't take steps, you don't do anything about it, you might get a citation based upon that. So look at when they happen and jump on it, get it taken care of or addressed as soon as practicable. Well, that's CMS. Now I wanna go to Joint Commission on Ligature Risk because they have what they call elements of performance. It's essentially some of the standards by CMS. And these are expectations to determine if you are in compliance. And if you're out of compliance, again, you will be cited with a requirement for improvement. Each of the requirement for improvement, it's placed in that safety team matrix, how likely it is to cause harm to this. Some of you may be familiar with that. It's no harm, very few patients do, high harm, multiple patients. It's that multicolored grid. That's a safety matrix that they're talking about. Any non-compliance for suicide risk, you have to put corrective actions into place. Non-compliance, that's rated high because they'll look at the number of occurrences. Could it be condition level from CMS? And this is what that safety matrix look like. Again, is it immediate threat or limited? And that's what they're looking at when they put it on that matrix. So environment of care. I've got the number four there, have and maintained a safe functional environment. Sounds very familiar to tag 144. The environment is constructed, arranged and maintained, 701. So that we have safety, you can still take care of patients, diagnosis and treatment and special services for your community. Now, it doesn't specifically mention suicide prevention. They put that into something under the National Patient Safety Goals. Under Joint Commission, their standards, you have to be a member of Joint Commission to get those. The National Patient Safety Goals, no, anyone can access those. And that's why Joint Commission keeps it so everyone has access to that information and those goals. Again, this is what they put them at. So as far as your interior spaces, again, we're talking about the location. Interior spaces, we meet the needs of our patients and they're safe and suitable. Now they do delineate between inpatient psych units and general acute patient settings. And again, these align with 144 and 701. So I'm gonna start now, just go right to the National Patient Safety Goals on patient suicide risk. It's number 15. It's probably one of the longer ones under National Patient Safety Goals, but they really see this as crucial. And over time, it hasn't changed too much. Which brings me to my third question, Lindsay. Let's go ahead and get that one up here on your screen. Excuse me. And this one says, our facility conducts a ligature risk assessment yearly. Yes, no, do not have a need for such an assessment or possibly prefer not to answer. I don't see any pending questions at this time. So make sure that you are typing in any questions that you may have particular to your organization. So Laura will make sure that we have time to address those. And for anyone who's had the very unfortunate consequence of finding a patient who has used a ligature, my condolences. That's a horrible thing to have to walk in and see. Okay, looks like we've gotten some good responses. I'll go ahead and end this and share those results here. Okay. Great, great. It's good that those of you who are doing that assessment, again, for your facility. Now, what they did is for suicide, CM, excuse me, Joint Commission did come up with a revised definition. They put it in their Sentinel Event Policy. It went into effect January of this year. The old definition focused on inpatient settings that were staffed around the clock, or a person who did complete a suicide within 72 hours after being discharged. Well, the revisions clarified the expectations. And what they did was they worked with some of these healthcare organizations and Joint Commission on their Office of Quality and Safety because what they're really doing is they are strongly encouraging hospitals who are Joint Commission accredited to report sentinel events to Joint Commission. So they have a new definition now. It's one caused by self-inflicted injuries or injurious behavior. Any of the following apply. Happened in a course when they're in the hospital, seven days of discharge or either inpatient or from the ED while they're receiving or within seven days of getting behavioral healthcare services. Could be a day treatment, could be intensive outpatient program, residential or group home, or even a transitional support living. They expanded the scope of when they considered this to be a reportable event. So what this goal did, and essentially what it's saying, reduce the risk for suicide. So what you do is you identify safety risk in your population, in other words, your patient assessment, like the memo says, because if it happens while it's in a staffed around the clock setting, they know this is a frequently reported event, sentinel event. And that's why it is so important to identify these individuals at risk, whether they're under a care or following discharge. And they feel that identifying those patients, is a huge step to protect those who are at risk. So as far as the assessment, this is for psych hospitals and psych units within a general hospital. This is the only one that applies to these, this element of performance. You do an environmental risk assessment. You look at features there that they could use to harm themselves to attempt suicide. And then you take steps to minimize it. Take away those anchor points or hinges or hooks or whatever it happens to be. Now, as far as non-psych units that are in general hospital, I'm going to have that patient there. You have procedures to mitigate the risk of suicide for those who are at high risk. And again, that could be one-to-one monitoring, taking those things out of the room, just like CMS had mentioned. Look at what's brought in by well-meaning visitors and watch the transport when they're going to part of the hospital so that they can't grab onto something and hide it until they harm themselves. Now, non-psych units, this is non-psych units. You don't have to be ligature resistant where psych units, psych hospitals need to be. That's a requirement, they must be. But still assess your clinical areas. What can be used for self-harm and get rid of it, hide them, put them away, whatever it is while the patient's there. Put a checklist so staff know what do I need for this patient and what can come out because then they don't have to guess. As far as psych patients and suicidal ideation, the elements of performance two through seven, and we're going to go through these, they apply only to patients in psych hospitals and those who are in general hospitals where the reason for admission is a behavioral health condition. Three through seven, that's for all patients who've had any expression of suicidal ideation during the course of care, whether it's admission or while they're inpatient. So the first one, EP2 says screen all your patients for suicidal ideation. Those who are being treated and evaluated for behavioral health unit, again, this is for those psych hospitals. That's the reason they are there. Use that screening tool. Now, joint commission, they do recommend suicidal ideation, validate the tool starting at age 12 and above. So they have lowered that. A couple of years ago, it was 14. Now they've dropped it to 12. Number three, use an evidence-based process so you can do that assessment. So again, it's consistent and we know what to ask. Have you thought about harming yourself? How would you do it? Do you have a plan? How much of an intent do they have? Are there any protective factors? Do you have anyone you can go to when you're feeling this way? Now, you can use a single instrument for number two and three to do that assessment because you may want to simultaneously screen them for not only the ideation, but how intent is that ideation? What's the severity of it? They do provide several examples. I've just listed them here. This is on slide number 109. Whichever one you use, fine. And I'm going to talk about those later. If you're going to use them, be consistent. Don't have a smattering of them all over. It's helpful if you have one or two so staff become very good at it. Continuing with these elements, overall risk for suicide is documented and how are you going to mitigate that risk? Follow your policy and procedures. At a minimum, again, training and competency of staff. Guidelines for the assessment. And then keeping an eye on these folks, especially those who are at high risk. They talk in here about counseling and follow-up care because Joint Commission has found and some of any other national guidelines, patients are at higher risk after discharge from the emergency department or inpatient because they don't have that controlled setting. They're not there to keep an eye on them. They don't have that support system sometimes. That's why the seven days, because they figure at seven days, that is a crucial time for a person to then complete that attempt. Follow those policy and procedures on counseling and follow-up care at discharge. Again, I have some examples. That's why they talk about what's called follow-up matters. They found 20% fewer suicides when there is an effective support system. 43% occur within one month of discharge. 91% of those lifeline services, they had that follow-up. And the website, there are many evidence-based articles that do include, and that's that follow-up matters. Now, as far as having that hotline, that phone system, you're not required to have one. You just have to have a process, some way to tell the patient, hey, if you get into trouble, here's who you call. And don't hesitate to call. That's why we're here, why they are there. Number seven, they talk about monitoring what you put into place. How good are your policy and procedures? Are they working? Staff following them. How are you gonna improve your compliance if not? So here's just some examples. We have a patient, comes into ED. They got a fracture because they were attempting suicide. The admission risk assessment wasn't required by joint commission, but they were aware the patient was suicidal. So what do you wanna do? Well, now we know as they recover, what is their ongoing risk to continuing or completing that suicide? Maybe you have a patient who comes into ICU for detox. They recover, but why are they drinking? Why are they taking these drugs? What's the underlying issue that they feel they have to do that? And we have a person who's in active labor. Perhaps they have a severe history of postpartum depression after a previous child. When I was working in nursing, in Iowa, we had a patient who severe postpartum depression and psychosis. And shortly she was getting ready to be discharged. So we went in to do her discharge. She's not there, can't find her. So it turns out the police found her walking along a roadside. Now this happens to be in the middle of winter. And those of you who've had the luxury of experiencing some of the Midwest winters know they're cold and they last forever. Well, she's out there barefoot carrying this little baby just wrapped in a small blanket. And we're able to get her back in. But had we known her previous history, we could have taken steps to assess her a little bit more clearly. There was no sequelae with the baby. Baby was fine, so was she. But that's something we learned we had to now start keeping an eye on. What's this woman's history with any previous pregnancies? Now, here are just some suggestions. You don't have to do these. Just some items that I picked up in some articles that I've read. Assessment triage. Again, any thoughts of hurting themselves or others? Use sitters if you feel you've got a patient at risk. And by the way, tell the patient why that person is out there. So you've answered some questions. We're concerned for your safety and your wellbeing. And they're just here to make sure you're safe and everything's gonna be okay. Maybe a safe room for those patients, those especially admitted outside your behavioral health unit. A lot of you probably put them in rooms close to your nurse's station so you can keep a closer eye on them. You may wanna think about doing a failure modes effects analysis for suicidal patients, particularly if you're starting to see an uptick in those admissions. Check, do that facility assessment. And again, under CMS, you're now required to do it. And again, you're not required to have your own crisis hotline. Just how do they access one if they need one? So I've got some recommendations. These are inpatient psych units. This is from a joint commission report that they talk about how do we do that? First off, they give you a definition of ligature resistant. And again, it's very similar to what CMS now has. That's the point where something can be tied or looped around it to sustain that point of attachment to end up in self-harm or loss of life. They do recommend the following for inpatient psych unit areas be resistant. And again, inpatient. This is a recommendation. Just keep an eye on this may be required now that you're a psych hospital or unit. Rooms, bathrooms, corridors, and common patient areas, resistant. And again, psych units and psych units and your general acute care. Nurses station and locked areas. Nurses station, you have to have an obstructive view. You have to be able to do a 360 to see this. And especially any areas that are behind self-closing or locking doors. You do not need to be ligature resistant if the nurse can see the patient and an attempt was made. So you're in a general unit and the nurse can see the patient in that area. Again, you don't have to be ligature resistant. Again, this is ligature resistant rather than ligature free because they understand nothing. Maybe impossible to take all these points out and still take care of patients. Doors and hardware. In the inpatient psych unit, general acute setting or psych hospital. These are the areas between the patient rooms and the hallway. Ligature resistant hardware. That could be handles, hinges, locking mechanism. Again, inpatient rooms, you have to have the roller. You cannot use the static lock for patient rooms. You're not required to have a risk mitigation device to decrease the chance. Somewhere along the line, this was a couple of years ago, one of the surveyors said, oh no, you have to have it and the hospital got cited. Well, then they went back to evaluate and said, no, you don't have to do that. In other words, over the top of the door as a corridor door, as a ligature attachment. I said, you don't have to have that anymore. Otherwise, there are several devices. They decrease the top of the door being used. Now they talk about laser beams. I think that's a little expensive more or less and maybe not practicable, but something that you can keep an eye on those. And again, these are the corridor doors because that could be a false alarm. Staff could be distracted. And really there's nothing to show out there in the real world, so to speak, that you have to have that. So again, joint commission isn't requiring it, neither CMS. And describe what you're gonna do on your mitigation strategy. You're just gonna keep an eye on it, keep staff monitoring it, leave the doors open during the day. As far as between the room and the bathroom, this is where it gets a little bit more interesting. It's called the transition zone. So you've got a couple options. Take the door off. Okay, that's one. You can put an alarm on the door or a special door so that it breaks away if a certain amount of pressure is being put on it. Staff, you can also deny access unless someone is with them to just, again, if it's not feasible to make a different door on there. So someone has to go with them. That can be a little difficult if you're already running short on staff. Now, some states say you cannot take the door off because it's a privacy issue. Virginia, Florida, and Massachusetts are the three states that say you cannot remove the bathroom door because we have to ensure privacy. Surveyors, they will look into your specific state law and see if that does apply to you. So an option is a soft-sided prevention door. It does take away the anchor points. Very calming artwork. There's a couple examples I'll show you as I go through here. Otherwise, sentinel event reduction door or saloon doors, and they are designed to do just that. No anchoring points on any of the four sides, and there's universal continuous hinge. It can be attached to a doorframe. It eliminates those gaps, essentially, is what it does. So that's an example of what one of those looks like. This was developed by the VA, and it is shatterproof. You can clean it off. There's tamper-resistant hardware, and the hinges come off after 20 pounds of pressure. Otherwise, in the rooms, in the bathroom, in the patient rooms, you must have a solid ceiling. No drop ceiling in your patient rooms or in the bathrooms. You can have a drop ceiling in the hallway or common areas, but the following have to be in place. One, no furniture so a patient can climb up onto it, and then just the ligature point. You have to have a clearly visible hallway. They have to be included, the drop ceiling, if you're going to have them, they have to play part of your risk assessment and a mitigation plan. So if you're starting to find that one, you're a little short on staff and maybe you've caught patients trying to do this, that there's a mitigation plan to stop that. Do you use a shower curtain or not? So there was an FAQ that they put out because they do know this is a risk. The expectation is that the current they are, the curtains are on your risk assessment. Just they are noted and they're there. You're aware of them. And here's our mitigation plan, especially if you have that high risk patient who's in there taking a shower. Otherwise installed, inspected and maintained and tested according to what the manufacturer recommends so that there's functioning and breakaway features. Now these next two, they're not part of the recommendation. I do want to bring them up. And that's your privacy and shower curtains should be ligature safe. The curtain crack that should also pull off with a certain amount of pressure, non-flammable. You can clean them according to your infection control. And of course, be careful about their vinyl or plastic so that we prevent suffocation because they do talk about the behavioral health type shower curtain. You'll see it's Velcro. It's on there. Just a light amount of pressure will bring it off. So they do have options available for us. And then as far as other fixtures, toilet paper dispenser and rounded covers so they can't use them as an anchor point. Here's an ED room. They had a roll down cover that locked when they had to have those. These were pitchers. They came from Ernie Allen. He was a former colleague with the doctor's company and he allowed us to use these. And then your ligature resistant ceiling. When you look at it, you can understand why they're talking about no drop ceiling because you have to have a special tool in order to get that thing open so that you can continue with maintenance, whether it's pipes, wires, whatever happens to be. The patients can't access them. So it's continuous. It's walled angled. And you have to have that special tool to get it open. Another area that they always talk about are the beds. Medical and psychiatric needs. We still have to keep our patients safe. And that's why we need to balance care with safety. And if they do require a medical bed without ligature, then you're going to have to have a mitigation plan and safety precautions. Here's just an example of what one of those beds would look like. Again, nothing they can tie around. And they're all curved if there is anything so that the ligature would automatically slip off. Whoever thought a toilet could pose as a danger to a patient, but standard toilets, those who have hinges and lids, they haven't found them to be a significant risk. They're not cited. You don't need to note them. But if you're concerned about it, you want to note it and then do your mitigation. Right now, there's only one known case where a patient used that toilet seat as a ligature point and no harm resulted from it. So again, just kind of look at what kind of toilet seats you do have. See if it's something you want to assess or it's not a big risk for you. So that was your inpatient psych unit. I want to talk about the general acute inpatient setting. Again, this is from the Joint Commission Report. And I believe this will be our last of the general questions. Lindsay. Okay, let's go ahead and get that one up here on the screen. I can get this poll right here to work. Here we go. Okay, this one says, one of our challenges has been developing a workable process to follow up with patients who have been discharged following a suicide attempt. Yes, no, or possibly you're not sure. It looks like we have had one question come in as well, Laura, that asks, she missed the comment about room locking mechanisms. Yeah. Asking if you can restate the room locking mechanism and best practices. Yes. So for best practices, and it's really applies to all patient rooms. It's a roller lock. And I shouldn't call it a lock because it doesn't lock. Like when you have your medical gases in those rooms, you have like a deadbolt that goes in there. In patient rooms, you cannot have the deadbolt. It must be a roller that, okay, the door is going to stay closed, but it can't be locked. In other words, the patient can't lock themselves from the inside. That's what they're looking at, are those roller types. So staff can access it. And if you feel you want to take those locks off, okay, but just check your state law as far as any privacy requirements and for the patient. And a lot of the psych units, they've just completely taken the locks off because they don't want to risk it. They don't want to hassle with it. Correct. Okay. We're going to go ahead and end this poll and share those results. Well, good. We're kind of many, many options. All right. So how do we follow up? But before we do that, let's talk about the general acute inpatient setting. Again, these are patients, your med surge units, your step down unit. You are not a behavioral health unit. You don't need to meet the same standards for an inpatient psych unit or hospital, such as ligature resistant. These fixed ligature risk, you will not be cited. And some hospitals, again, they have a safe room if you have patients who have attempted suicide. So as far as equipment and your supplies, we do have to have patient. We have to take care of them, whether it's an IV, maybe it's a cardiac monitoring. We know those pose risk to them because we know we cannot make it ligature resistant. Rather, it has to be ligature safe. That's what it has to be. So if you have a patient with suicidal ideation, take out what you can. If you don't need to have it in there for patient care, monitoring and transporting patients, that may be a sitter one-to-one. And when they mean one-to-one, that's what they mean. They mean one patient, one staff member. Document your strategies that you have done. And again, watch what's brought in by visitors, well-meaning visitors. Look at your protocols for transporting patients to other areas of the hospital. Who's going to watch them while they're waiting for that radiology test to be done? How are you on policy and procedures, monitoring the patient, training of your staff? On joint commission, they will cite ligature risk if all of the following are not routinely done. Education and training for staff. Are they competent on how to care for that patient who is suicidal? One-to-one monitoring if it's serious suicidal ideation. An assessment to determine what has to be in that room and what can you take out. Some of you may just take out all their personal belongings and put them in a locker somewhere to keep them safe until they're ready to go home. Of course, that begs the question, then do you go through it? And check with your in-house counsel. Some of them have said, no, we don't want to go in there. Some will say, yes, we can do it based upon why the patient was admitted. And is there a possibility that an article like a knife could be in there to harm themselves? Joint commission will also cite if we're not monitoring visitors, bathrooms, those who have serious suicidal thought and protocols. So we have qualified staff go with the patient from one area of the hospital to the other. Again, if they've got to go down to x-ray and they're seriously suicidal, someone needs to stay with them perhaps 24, I mean, all the time so they're not going to harm themselves. And the ED, you're not required to be ligature resistant environment. I'm going to repeat that. The emergency department is not required to be ligature resistant. You have two ways. There are two ways to keep them safe. Again, that ligature, maybe you want to have a ligature resistant room, set aside a safe room. So get a patient in, you know where they go. Or again, one to run monitoring, taking things out as you can. Policies and procedures and training and procedures monitoring. So it's done reliably, meaning it's done consistently across the board. You're not required to have a safe room, your decision. But if you don't, again, screen the patients, do a secondary screening. Have they now become suicidal or starting to have these thoughts. A risk assessment for your environment and a protocol to take out what you can for self-harm. If you don't have a safe room, again, how are you going to monitor these patients? That includes going to the bathroom, having visitors, making sure qualified staff can go with the patient from one unit to the other. You don't want to volunteer to go with these folks usually because again, they need to watch them. And being staff trained and competent on how they would address it if they do get a patient in. I did mention the one-to-one continuous monitoring, 360 degree view. So you can see that patient wherever they are in that room. And it must allow for immediate intervention. So if the patient is about to harm themselves, staff can be there and address it right away. As far as video and high risk suicide, there was an FAQ from joint commission on it. You can use video monitoring or electronic sitters if they are at suicide, but not as a long-term intervention. In other words, you can use it as a complement to one-to-one, that's video. So I've got on the next slide, what is the joint commission FAQ on that? So again, can you use that to monitor patients if they're at high risk and they do require one-to-one, then you do have to do that. Someone has to be there. You can use electronic sitters if it is not safe, but as a standalone intervention for one-to-one monitoring, video monitoring won't do it. They have to be able to see them at 360. All right, just some tools of the trade as we start to wrap it up. If you have these pages, starting to look at it, download this. It's free, the Behavioral Health Design Guide. They update it every couple years. I'm expecting one shortly as far as being updated, but again, you can download it. They explain how to create these safe rooms, how to prevent ligature risk and suicide. They help you and other facilities. Maybe you have an outpatient process. How do you physically set up this process and the environment to make it safe? There's also the patient health questionnaire, and it's a depression scale. It's used in your primary care settings. There are nine things they ask them. You can use a shorter version, but if you're starting to get yes answers, then you want to go to the longer one. It's a really good, quick depression assessment, whether it's minimal to severely depressed, and that is again through the SAMHSA, SAMHSA. These are just some of the questions that they do ask in the nine questions. A little interest in what you're doing, or have you ever thought about, it'd be better off dead, and how would you hurt yourself? There's the ED Safe Screener. It's a patient safety tool. Nursing uses this during their primary assessment. Also, with an ED, a positive screen is yes to either ideation in the past two weeks or a lifetime history of attempts. I just wanted to continue to show you what does this look like. Then there's a secondary screener to use when you, or should be done when they are positive on that patient safety screener. Is this when you need to maybe get a mental health professional to work with this patient or start talking to them? Have they had suicidal ideation or a recent attempt in the last six months? Then yeah, that's a clue for the physician. We need to get a mental health consult for this patient. Suicide behavior questionnaire, psychology self-report questionnaire. It helps with adolescents age 13 to 18 for question test that the individual fills out. It talks about future anticipation of suicidal thought. These are nice because they really address a specific risk factor. Thoughts, attempts, how often do you have these thoughts? What's the likelihood maybe in a future assist? Then we have our assessment for our environment. It looks at your common areas and what are the safety issues of your building in general? How is your room set up? Are there blinds? Do you have blinds? How do you open the blinds? Is it a cord or is it one of those twist items? Shoelaces, shatterproof mirrors. It really goes into quite a bit on what you want to look at. There's one also called the Columbia suicide severity rating. This is for your outpatient behavioral health settings. They look at identified attempts and really does a good assessment of the full range of ideation and behavior. It's a very popular one. There's three versions of the tool. It talks about recent version that really helps practitioners get a lifetime history. Also, since the last vision, it's a much shorter version of that full version. They have a rating scale. I've talked about some of these as far as SAMHSA safety, the risk assessment. This talks about your past psychiatric history, family history of suicide. Maybe there's a stressor going on. Is there anything going on? Have you lost your job? Any other legal, perhaps, problems? Then again, the safety, that's a suicide assessment, five-step evaluation, and triage from the suicide prevention. It's also screening for mental health. A lot of the health professionals may be using that one. Looks at risk factors, includes access to firearms, family history of suicide, other key symptoms like anxiety, hopelessness, insomnia. There are three levels of risk, of course, high, moderate, and low. There's a suicide prevention decision support tool. This is for your EDs and adult patients who come in. It talks about having that outpatient appointment within that seven days. This does recognize that's their high exposure time for care when they're going to be maybe at higher risk for harming themselves. Then access to firearm, other lethal menu. Don't forget their prescriptions. Did they just recently get some of those prescriptions filled? Then other support tools, follow-up calls with patients who have been discharged. How are you doing? How's your support system? There are six transitional questions. Do they have a plan? What is their intent? Substance use disorder? They do really carry it out. During this call, it really helps them get a gauge for the patient. Are they starting to get aggressive, irritable? Then there's ask, ask screening questions. This is from the National Institute of Mental Health. This is for at-risk use. It's free, the toolkit. You can use it everywhere. It's outpatient primary care. They also have it in many languages, which is really beneficial. Now, with this one, you must have a follow-up plan. If the patient answers yes, okay, great. Now, what are you going to do? There's also the adolescent screener. This is developed for clinical evaluation. Usually, this has to be by someone who's prepared and trained in using this. ED departments, hospitals, they need to be aware of and know and familiar with this particular tool because after it's completed, then the clinician makes a decision about what is their risk for suicide. It has six items of the CAD score because we know that's common for use suicide. Again, you have to be trained to use this one. The suicide ideation worst, by the way, worst is the name of the individual who came up with it. That talks about the intensity of the specific attitudes and behavior. That gets you a little bit more accurate estimate of what their risk is. It's graded on a three-point scale. Then there's a total scale up to 38. Do they have a wish to die? That brings me to my last discussion, which I'm glad we have a little time left over. We've got a 47-year-old, longstanding history of bipolar disorder. Comes to the hospital as a walk-in. Overdosed on tricyclic antidepressants and other medications. He was treated in ED. They stabilized him and were able to reaffirm psychiatric evaluation. Now, of course, there was a shortage of room in their inpatient unit, so they put him on a med-surg unit with a room close to the nurse's station. They give him loafers, thank you, scrubs as his clothes because they thought what he's got with him, there was a belt with it. They said, no, that's too much of a risk, so they sent him home with a family member. On day three, they found him unresponsive. This character, I shouldn't say character, my apologies, this individual, he took the strings from the scrubs and used it as a ligature. Unfortunately, we couldn't get him resuscitated. What areas do you have of concern with this? That was just a pair of scrubs that they grabbed and were able to give to him in order so that he could have clothes on. So, any areas that you have a concern for this one? Those options are there on your screen. Possibly failure to provide safe environment. Was this event foreseeable? Possible citations, ligature resistant, or any others? And if you have any other comments, you can, of course, type those into the chat. And while you're doing that, as Laura, before she goes through our final resources and our closing comments, please make sure that you type in any final questions that you have for her so we can make sure to address those today as well. And I think, Lindsay, you already mentioned that if they have something that comes up after the fact, please get it to you, and I'm happy to follow up with you after the fact. Absolutely. And I will put some information there for you on the chat here in just a moment. Okay, looks like we're getting some good responses here. I'll go ahead and end this and share those results. Yeah, failure to provide a safe environment. Yes. Was it foreseeable? Yes. Yeah, we should have noted this for him. Ligature resistant, absolutely. They knew it. They had these patients. Others, I think everybody's got to give all the credit to the patients. Others, I think everybody's got to give all hit him right on the head. There were several citations, unfortunately, because, again, they knew this patient was going to be very dangerous. The hospital had made arrangements ahead of time for these patients coming to the floor. Now, say, yeah, but we're not behavioral health. Yeah, but you identified these rooms as for behavioral health patients. Therefore, they should have been resistant. So it was a little bit gray in that area, but given that their past history, what they've done in the past, yeah, it should have been resistant. So as Lindsay mentioned, I do want to point out a few additional resources for you. Whatever you decide to use, that's your choice. They want you to make sure it's workable. It's going to be used by your staff and consistently. So that's why I've just got some of the American Psychiatric Nurses Association Suicide Prevention Centers. They have also videos for us. There is the Columbia Scale. A lot of them do use that one. And the ASK Suicide Screening, I noticed there have also been perhaps some of you watching television. They're starting to really promote behavioral health for people, not just those who have a history, but everyone in general. How are you doing? Is there anything you want to talk about? How are you getting along? Can I help you with anything that they're not afraid to talk? And there isn't one for rural suicide prevention toolkit modules that are available. And Joint Commission, they do such a good job on having information and resources for everyone available. So take your time if you wish to look at those resources. I like the one for follow-up. Again, we have found that it's a really hot time for patients when they don't have the support for inpatient and they're alone and things are starting to mount up. That's a high-risk area, though, seven days after discharge. And that's what, you know, if a death does occur seven days after discharge under Joint Commission, they consider it a sentinel event. So, Lindsay, I will send it back to you to see if there's anything else or if you have any final comments. Perfect. Thank you so much, Laura. I did just go ahead and post that reminder there for you all in the chat that you will receive an email tomorrow morning, but just note that it will come from educationnoreplyatzoom.us. And so because it will come from that Zoom email account, it may very well get caught in your spam quarantine folders. So if you don't see that email in your inbox in the morning and you'd just like to go back and access the recording, you can just use the same Zoom link that you're using to join us for today's live presentation to access that recording. And just remember that the link to the recording is live for 60 days from today's date. And then we do have an additional security measure in place to protect Laura's intellectual property here. So you'll need to click on that Zoom link, type in your information, that will prompt an email to come to us for approval of that recording access request. And then we do approve those very quickly, typically within a few moments of receiving the request. We ask that you give us one business day to approve those. And then once we do grant those approvals, you will receive a final confirmation email from Zoom that will contain the link that will take you directly into the recording. Just a special note, if when you click on that final Zoom link, you see what looks like a blank or a white screen at the top, just simply scroll down some and there you should see that option to play the recording. I'm not sure why the format is that way, but it does at times look like it's a blank screen. And unfortunately, or fortunately, it's not. The recording is there at the bottom. And as Laura mentioned, if you do have any additional questions, you can always reach us at education at gha.org. We'll be happy to pass those questions along to her. She is wonderful about being very thorough and timely in her response. We appreciate her for doing so. I know Laura's content information is included here in the slides as well, but we're happy to pass along any questions that you have. And again, that's to education at gha.org. Okay, I don't see any pending questions at this time. So thank you all for joining us today. And as always, thank you so much, Laura, for your time and information that you shared with us. I hope you'll have a wonderful afternoon. We look forward to having you with us for future sessions. Thank you so much, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

Laura Dixon

registered nurse

attorney

risk management

patient safety

suicide prevention

healthcare settings

environmental risk assessments

ligature points

multidisciplinary teams

staff training

evidence-based tools

CMS guidelines