Suicide is the third most frequently reported sentinel event. Suicide prevention and protecting patients from harm or strangulation is a major focus of accreditation surveys.
The Centers for Medicare & Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients who exhibit suicidal behaviors. Any hospital that receives Medicare and/or Medicaid payments must implement these changes for all patients.
CMS tag number 144 in patient rights and tag number 701 in facility services discuss what units need to be ligature resistant. These tags cover patient assessments, environmental assessments, education and policy, and procedure requirements.
The Joint Commission (TJC) has multiple requirements to ensure compliance with their standards regarding ligatures and suicide prevention. These standards will be discussed to include psychiatric hospitals, behavioral health units, general acute care inpatient units, and emergency departments.
The webinar will provide resources and tools that can be used to assess patients to determine if they have suicidal ideations.
Laura A. Dixon, BS, JD, RN, CPHRM
Laura A. Dixon 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, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.
Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, 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, Dixon holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.
At the conclusion of this session, participants should be able to:
Discuss that the Joint Commission has requirements hospitals must follow to prevent patients from self-harm, including hanging or strangulation.
Describe that CMS recommends education when policies change and every two years.
Recall that CMS has recently updated guidelines.
By attending Ligature Risks and Preventing Inpatient Suicide: Compliance with the CMS and TJC Standards Webinar offered by Georgia Hospital Association, participants may earn up to 2 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit.