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Use checklist to help staff clear areas to protect at-risk patients


November 17, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

While The Joint Commission (TJC) clarified that it does not expect all patient care rooms in general acute or emergency department settings to be ligature free, your staff still needs to remove possible items for self-harm from a room if the patient occupying it is considered to be at risk.

Ligature risk tops the list of problems cited by TJC surveyors under one of the most frequently cited standards, EC.02.06.01, on establishing a safe and functional environment for patients. TJC cited ligature risk in at least 12 immediate threat to life decisions during 2018, according to Jennifer Cowel, RN, MHSA, president and CEO of Patton Healthcare Consulting in Naperville, Illinois, and a former TJC executive.

Those decisions are usually a result of widespread ligature risks, incomplete environmental risk assessments, and a lack of a mitigation plan to address the ligature risks, as well as failures to conduct or to fully complete suicide risk assessments, said Cowel during an HCPro webinar, “Preventing Suicides and Eliminating Ligature Risk in 2019,” that is now available on demand.

For general acute inpatient and emergency room settings, do a risk assessment of rooms and customize a checklist for staff to use when clearing a room for an at-risk behavioral health patient, said Cowel.

Make sure staff on the unit are not only aware of the checklist, but have seen it, know what’s on it, and know when to implement it, advises Cowel.

TJC has published a number of revised or new frequently asked questions (FAQs) to clarify expectations, in addition to articles in a number of TJC publications. And CMS has said it will follow TJC as it revises its own expectations on suicide risk and patient self-harm.

To meet physical ligature risk requirements for general acute inpatient and emergency room settings, remember you may still need to implement 1:1 monitoring with a trained observer in addition to removing certain items from the room, said Cowel.

Here are five things Cowel says to remember about requirements for these settings, which are different than those for inpatient psychiatric units:

  • General acute inpatient settings do not need to be ligature resistant at all times. Ligature risks including bathroom fixtures, doors, and other fixed items such as TV mounting brackets and ceiling-mounted lift equipment will not be cited on survey in these areas.
  • However, if the patient has serious suicidal ideation—also known as “high risk”—your staff must be prepared to:
  1. Remove all objects that pose a risk
  2. Implement mitigating strategies and 1:1 monitoring
  3. Assess objects brought into the room by visitors
  4. Implement protocols for transporting off unit
  • Like acute inpatient settings, emergency departments also do not need to be ligature resistant, and fixed ligature risks, including bathroom fixtures and doors, will not be cited on survey.
  • However, at-risk patients must be either:
  1. Placed in a “safe room” that is ligature resistant or that can be made ligature resistant
  2. Kept in the main area of the emergency department, with 1:1 monitoring and removal of all objects that pose a risk and are not medically necessary
  • Patients with serious suicidal ideation must be placed under 1:1 continuous monitoring, with 360-degree viewing; continuously monitored video is allowed as long as a qualified staff member can immediately intervene when called for (which should also be in hospital policy).

Patton Healthcare provided a suicide risk checklist that hospitals can customize for their own use.
The checklist includes not only what things should be removed if not medically necessary but also what areas, closets, or cabinets nearby should be locked.

The checklist can be found at https://www.accreditationqualitycenter.com/resources/suicide-risk-room-checklist and is available online as a Word document for customizing.

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