OasisLMS

Thursday, May 28 
10 -11:30 a.m.

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 of 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, perioperative services, and pain management. Prior to joining COPIC, she served as the Western region director of patient safety and risk management for The Doctors Company in Napa, California. 

As a registered nurse and attorney, Dixon holds a Bachelor of Science from Regis University, RECEP of Denver, a Doctor of Jurisprudence 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.

This speaker has no real or perceived conflicts of interest that relate to this presentation

Suicide prevention and protecting patients from harm or strangulation continues to be a major focus of accreditation surveys. Suicide is the third most frequently reported sentinel event.

The Centers for Medicare & Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients who are suicidal. Any hospital that receives Medicare and/or Medicaid payments must implement these regulations for all patients.

For acute hospitals, the CMS Conditions of Participation (CoPs) manual includes guidance on ligature-resistant environments under Tag A-0144 (Patient Rights) and Tag A-0701 (Physical Environment/Facility Services). These sections outline expectations for identifying areas that must be ligature resistant and describe required patient risk assessments, environmental risk assessments, staff education, and related policies and procedures.

For Critical Access Hospitals (CAHs), similar guidance appears in Appendix W of the CMS CoPs manual. In addition, 2025 regulatory updates affecting CAHs reinforce requirements related to patient rights, including the expectation that patients receive care in a safe setting.

This program includes a discussion on The Joint Commission National Patient Safety Goals and Recommendations for Preventing Suicide in Health Care Settings. Resources will be provided along with tools to assess patients to determine if they have suicidal ideation.

At the conclusion of this session, participants should be able to:

• Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations.
• Describe that CMS recommends education in orientation when policies change and every two years.
• Explain recently updated guidelines from CMS.
• Describe TJC recommendations for psychiatric and non-psychiatric units.

The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a).  Approved for 1.5 contact hours.