Description
There is a lot of survey activity around prevention of suicidal patients from harm or strangulation. The Joint Commission announced that this is one of the four top areas of focus.The Centers for Medicare and Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self harm from patients that are suicidal. Any hospital that received Medicare, which are most hospitals in America, must implement these changes for all patients.
CMS tag numbers 144 in patient rights and tag 701 in facility services discusses what units need to be ligature resistant. It covers what patient assessments must be done and what should be in the environmental assessments. It discusses education and policy and procedure requirements.
Joint Commission has 16 requirements to ensure compliance with their standards. These will be discussed and include psych hospital, behavior health units, general acute care inpatient units, outpatient units and emergency departments.
Resources will be provided. Tools to assess patients to determine if they have suicidal ideations will be included.
Detailed Outline:
CMS Hospital Ligature Risks
- 15 pages proposed guidelines for 2021
- Tag 144 and 701
- Deficiency reports
- What is a ligature risk? CMS definition
- Anchor points and examples
- Policy and procedure requirements
- Education recommendations
- Competency requirements
- Patient assessment
- Environmental assessment
- Correction of environmental risk
- Design guide for creating safe rooms
- Things to do to reduce ligature risk
- Documentation requirements
- Ligature resistant requirements
Joint Commission
- Requirements to prevent suicide
- Requirements for outpatient and residential treatment centers
- Recommendation for psych unit, psych hospital, and general acute care settings including emergency departments
- Sentinel event reduction doors and soft suicide prevention doors
- Ceilings, beds, and toilets
- Shower curtains
- SAFER matrix and when at risk for getting RFI
- 02.06.01 EP 1 requirements
- Dedicated verses non-dedicated spaces
- Suicide risk reduction
- TJC ligature risk FAQs
- TJC sentinel event alerts on suicide and SEA 56
- NPSG 15 changes July 1, 2019
Resources and tools of the trade
- Suicide prevention resource center
- VA/DoD Clinical practice guidelines
- Suicide prevention guidelines for training
- Design guide for built environment of behavioral health facilities
- Patient health questionnaire PHQ-9 and 3
- ED-SAFE screeners
- Patient safety secondary screener
- ED” Suicide Behavior Questionnaire SBQ-R
- Environmental Assessment
- C-SSRS Columbia Suicide Severity Rating Scale
- SAFE-T Assessment
- Suicide Prevention Decision Support Tool and more
- NY patient safety standards guidelines
Objectives:
- Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations
- Discuss that the Joint Commission has requirements for hospitals to follow to prevent patients from self harm including hanging or strangulation
- Describe that CMS recommends education in orientation, when policies change and every two years
- Recall that CMS has proposed guidelines
Intended Audience:
- All staff, nurses, physicians and providers on the hospital behavioral health unit
- All staff, nurses, physicians and providers at Psychiatric hospitals
- All staff, nurses, physicians, and providers in hospital emergency departments
- All staff, nurses, physicians and providers on hospital units where suicidal patients are taken care of such as ICU, medical-surgical units, OB and post-partum, and outpatient areas
- All hospital risk managers
- Hospital legal counsel
- Patient safety officer
- CEO, COO, CNO, and nurse supervisors
- Chief medical officers
- Director of maintenance and facility services
- Biomedical engineering
- Materials management
- Environmental Services
- Security
- Director in charge of environment of care requirements and staff
- Quality improvement coordinator
- Compliance officer
- Director of Regulatory Affairs
- Board members
- Nurse educator
- Clinic and outpatient managers
- All department directors/nurse managers such as ED, ICU, CCU, Med-surg managers, outpatient, etc.
- Anyone who is responsible to ensure compliance with the CMS hospital conditions of participation and the Joint Commission standards
