Ligature Risk and Assessments as a Hospital Priority

The Centers for Medicare and Medicaid Services (CMS) regulations cover a wide range of expectations in the provision of safe, quality patient care. On July 17, 2023, CMS released a memorandum highlighting the requirements for ligature risk and assessment in hospitals. Psychiatric hospitals encounter heightened ligature risks due to patient population considerations, as well as medical hospitals whose physical environment naturally presents unique challenges in caring for patients with medical and psychiatric needs. While ligature risk and related assessments with corresponding actions are not new to healthcare organizations, the CMS memorandum clarifies three key elements: patient assessment, staffing/monitoring, and environmental risk.

When considering ligature risk in your organization, how thoroughly is your organization addressing ligature risk and assessment in an ongoing and persistent manner?

In the memorandum background, CMS reiterates the importance of providing a safe environment for patients that also needs to include emotional well-being. Components of emotional health and safety are listed as respect, dignity, and comfort. To appropriately provide comprehensive health and safety, organizations should approach the mitigation of ligature risk in a focused way according to individual patient needs and specific to the organization rather than a one-size approach that may miss unaddressed risks like process issues. CMS provides an example of a door used as a ligature point. Organizations should evaluate the extent of needed environmental modifications, such as changing out all doors as in this example, while also pinpointing the root causes and contributing factors of an adverse event that require other corrective actions for patient safety and quality. To accomplish this, it is critical to conduct a credible and thorough root cause analysis that uncovers the true root causes of an incident rather than stopping at superficial reasons that do not reach far enough in correcting and preventing harm.

As noted, there are three key elements for consideration:  

Patient Assessment

When choosing the appropriate patient assessment tools, evaluating and implementing the tools that best fit your patient population’s needs and risks is essential. Policies and procedures need to outline the screening and assessment processes of patients needing behavioral health treatment and patients receiving primary medical treatment. Evidence-based resources and best practices are available through organizations such as the National Action Alliance for Suicide Prevention. For psychiatric hospitals and units, how does your organization screen all patients for suicidal risk? In acute medical hospitals, how are patients being seen and treated for behavioral health conditions screened for suicidal risk? What is the suicide risk assessment process for patients who screen positive?


Under this element, CMS details the expectations of training and education for staff, including contracted personnel and volunteers. Effective suicide prevention initiatives call for well-informed training and education that covers elements like the assessment process, identification of patients at risk, environmental factors, and how risks can be mitigated. As with assessments, training and education needs to reflect the needs of the patient population. There is an expectation for training and education to occur upon hire, when policies and procedures change, and at least every two years post-orientation training per CMS.

Leadership rounding can be instrumental in assessing compliance with staffing and monitoring related to ligature risk and assessment in the following ways:

  • If a patient is assessed at high risk for suicide, is the patient being monitored at a heightened level per policy and procedure? If 1:1 monitoring calls for the monitoring staff to be within arms’ length away, how is the staff positioned in relation to the patient?
  • A root cause analysis sometimes points to staffing inadequacy as a causative factor. Is the number, experience, and/or pattern of staffing a proximal cause of the event?
  • During the leadership round, assess staffing effectiveness, including staffing numbers and complement of staff according to acuity. Is there anything that needs to be addressed for safety, quality, and prevention of an adverse event? What is the mechanism for staff communicating staffing needs to be addressed during their shift?
  • Use the leadership round as an opportunity to follow up on new education and training. Ask staff if they have any questions or need additional resources. Do they have any concerns about the design of a new process? What are their insights on how to improve safety for patients and staff?

Environmental Risk

Environmental risk assessments also need to reflect the particular elements of the environment of care in an organization. For example, how do ligature risks differ in an emergency department versus a psychiatric unit? It is critical to include the specific elements of the environment that can lead to patient and staff harm if not modified and/or consistently mitigated. An environmental risk assessment needs to be routinely referenced, reassessed, and revised accordingly at regular intervals when the physical environment changes. In addition:

  • During leadership rounds, bring your organization’s environmental/ligature risk assessment to the rounds. Ask staff how a particular issue, such as a door or medical cords, is mitigated. How are new ligature risks added to the risk assessment for mitigation? During mock surveys, we have noted gaps in staff awareness of the mitigation plan and staff not having the mitigation plan readily available for their awareness of safety strategies.
  • In rounding through the patient care area, has a balance been found between an appropriately safe environment versus an overly restrictive one? Is the environment safe, as well as respectful, comfortable, and one that facilitates healing?
  • Instead of global actions, what are the individualized and targeted actions to keep the environment safe based on patient population and other considerations?


Managing ligature risks can be challenging for healthcare teams, requiring ongoing vigilance and staff engagement. Hospitals can demonstrate regulatory compliance through patient assessments, adequate staffing, consistent monitoring based on assessed risk, staff training and education, and mitigation of risks within the environment. Implementing insights from environmental risk assessments and root cause analyses can be instrumental in achieving a safe, healing environment for patients and staff.

You can find current and past CMS memorandums at the website - Policy and Memos to States and CMS Locations. Healthcare organizations are encouraged to read the full content of this memorandum and discuss the information with your team.


CMS Memorandum Dated July 17, 2023: Ligature Risk and Assessment in Hospital

To learn more about how we can assist with Accreditation and Regulatory Compliance contact the Courtemanche and Associates Team at 704-573-4535 or email us at


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