Ligature risk: The presence of unmitigated ligature risks in a psychiatric hospital or psychiatric unit of a hospital is an immediate jeopardy situation. Additionally, this also includes any location where patients at risk of suicide are identified. (A701 Interpretive Guidance 482.41(a) October 17, 2018 revision)
The guidance refers to psychiatric hospitals or units within a hospital – but take note that surveyors have been applying this to all areas of a hospital where patients with emotional or behavioral issues are cared for (Emergency Department, Med/Surg Unit, etc.).
CMS S&C Memo: 18-06- Hospitals DATE: December 08, 2017 “The hospital Patient’s Rights Condition of Participation (CoP) at § 482.13(c)(2) provides all patients with the right to care in a safe setting. Psychiatric patients requiring medical care in a non-psychiatric setting (medical inpatient units, ED, ICU, etc.) must be protected when demonstrating suicidal ideation. The protection would be that of utilizing safety measures such as 1:1 monitoring with continuous visual observation, removal of sharp objects from the room/area, or removal of equipment that can be used as a weapon”.
482.13(c)(2) Interpretive Guidance: “In order to provide care in a safe setting, hospitals must identify patients at risk for intentional harm to self or others, identify environmental safety risks for such patients, and provide education and training for staff and volunteers”. “Psychiatric patients requiring medical care in a non-psychiatric setting (medical inpatient units, ED, ICU, etc.) must be protected when demonstrating suicidal ideation or harm to others. The protection would be that of utilizing safety measures such as 1:1 monitoring with continuous visual observation, removal of sharp objects from the room/area, or removal of equipment that can be used as a weapon”. “A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures. The most common ligature points and ligatures are doors, hooks/handles, windows, and belts or sheets/towels. The use of shoelaces, doors, and windows increased over time”.
Terminology matters when speaking to the surveyors. If staff say they have a ligature free or ‘safe’ room, surveyors will expect to see a totally ligature free environment. If the organization cannot create a ligature free environment, staff need to speak to the fact that they make the room ‘safer’ for the patient with behavioral or at-risk self-harm ideations. Safer rooms can be created by removing anything not medically necessary for patient care. The recommendation is to use a1:1 direct observation, when possible. Ensure that when staff create a ‘safer’ space that the steps they took are documented clearly in the medical record. Care settings must be made as safe as possible for patients with self-harm/behavioral conditions or the facility will face an immediate jeopardy/immediate threat to life situation. Review the risk assessment, processes and tools that are being used – TODAY!