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Use risk assessment for ligature concerns when choosing beds for geriatric patients


May 1, 2018

Be able to show a thorough risk assessment along with a plan for intervention if surveyors question the use of some hospital beds on behavioral health (BH) units that also serve geriatric patients.

Ligature risk has become a high-profile issue for CMS, The Joint Commission (TJC) and other accrediting organizations (AO) with both TJC and CMS in the last six months issuing new and clarified guidelines for hospitals on how they expect to protect patients from self-harm.

Those protections include removal of ligature points from the physical environment where BH patients are treated. Standard side rails on hospital beds are often cited by surveyors as a key point through which a rope, bed sheet or other item can be looped for hanging. TJC officials have said they may cite Environment of Care standard EC.02.06.01 for ligature concerns.

According to a CMS survey-and-certification letter issued in December, S&C Memo: 18-06- Hospitals, “Clarification of Ligature Risk Policy,” a ligature point is “anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.” That includes handles, coat hooks, pipes, shower rails, radiators, bedsteads, window and door frames, ceiling fittings, hinges, and closures.

You must minimize risks
While not all ligature risks can be eliminated, CMS writes, hospitals are expected to show how they identify patients at risk for self-harm and the steps they are taking to minimize those risks, including changing the physical environment as needed. If a ligature risk is found by surveyors, facilities will have 60 days to enact a plan of correction.

Bed rails are often mentioned in CMS inspection reports citing ligature risk, according to the Association of Health Care Journalists database HospitalInspections.org, and more than one hospital has faced a ruling of “immediate jeopardy” (IJ) because of it. An IJ ruling can mean the loss of accreditation and a hospital’s ability to bill Medicare.

In addition, ligature risk is becoming one of the top reasons TJC rules an immediate threat to life, which is similar to a CMS IJ ruling.

Geriatric patients pose a particular quandary for hospitals when those patients are also on their behavioral health units, says Ernest E. Allen, ARM, CSP, CPHRM, CHFM, a former Joint Commission surveyor and presenter of the HCPro webinar, “Suicide Prevention in Hospitals: Reduce Risk and Comply with Joint Commission Requirements” last November.

Geriatric patients, different concerns
CMS expectations don’t distinguish between geriatric units and adult units, says Allen.
“In regular adult units, you have a much younger population and they are a much higher risk” for self-harm, he says. In geriatric units, a lot of the patients have dementia. Because of that they may be at risk for self-harm, but much less so than the younger patients, he says.

For example, he says that CMS is concerned about patients climbing up and pushing through tiles in a ceiling to find a sturdy point from which to hang themselves. While that’s a legitimate concern, he points out that it’s less of a danger in a geriatric unit.

“With geriatric patients, many of them are elderly, 70, 80, 90 years old, and many of them are not very ambulatory, many are in wheelchairs,” he says. “CMS should consider them less of a risk. That patient can’t even stand up or climb on the bed or try to get into a ceiling tile to hang themselves. They can barely walk, let alone get up on these things.”

The specialized equipment used with geriatric patients poses a problem, notes Allen. The rails and bars of motorized medical beds, which can be raised and lowered to help patients get in and out of bed, can be considered ligature points, as can the rails and handles of a wheelchair.

“In most regular adult units, those beds are close to the floor, secured, non-electric, without any ligature points,” he says. “But when you use a medical bed for geriatric patients, there are ligature points. You need a metal rail to keep patients from falling onto the floor.”

Some geriatric BH units put the beds in the lowest position and place a thick mat on the floor by the bed, to avoid the use of bed rails. Beds with the frame sitting on and secured directly to the floor also are an option and are often used in adult behavioral units, he notes.

But the issue with older geriatric patients, he says, is that “several patients have mobility issues and have difficulty getting out of a low bed. With the population getting more obese, it is also a back-injury issue to staff trying to help life a patient out of bed.”

Solutions can be expensive
Regardless of the patient population, TJC wants all those rails eliminated, says Allen. While there are beds available with solid plastic rails, “ordering all new beds for a unit? That’s $4,000-5,000 each. That’s a huge expense.”

Some hospitals have chosen to go through with such expenses rather than risk problems on survey that threaten their accreditation.

For instance, a hospital system in northern Texas decided to slowly replace beds used for geriatric patients in BH units with the specialty beds with solid rails.

“We have been phasing in the newer ligature resistant beds. We have purchased the last of them this year, so all of those rooms will have the solid rails,” says the hospital’s accreditation officer, Tammy Owens.

But that doesn’t always solve all of the problems. “Something else to consider about the beds is the electric motor,” Owens notes. “The cords are standard length cords,” which can be used by a patient to hang himself.

“We have decided that we will have the beds in the lowest position and remove the cords,” says Owens. “It was the only way to really eliminate the cord as a ligature tool.”

Meanwhile, MetroHealth System in Cleveland is implementing a $1.3 million renovation of its behavioral health inpatient unit to meet expectations from TJC, according to The Cleveland Plain Dealer. The hospital is replacing a variety of equipment, including cabinets and toilets, as part of the renovation.
Hospital leadership chose renovation now even though the building is going to be replaced in three or four years, after a new facility is completed.

“To be extra careful, we are deciding to redo the entire areas in which there are ligature risks,” Akram Boutros, president and CEO of MetroHealth, said during a January board meeting. “Unfortunately, all of that work is going to be torn down when we tear down the current hospital but I think, in the meantime, it is an appropriate thing to do for patients.”

Other hospitals may have to make the choice between spending money or treating those specialty patients.

TJC: Assess risk in special cases
Most psychiatric units and geriatric units either lose money or break even for their hospitals, says Allen. Telling facilities they need to pay perhaps hundreds of thousands of dollars on a “money-losing unit can be a burden. Some hospitals have said they might have to close our units down because they won’t be able to afford the compliance costs.”

In any case, “it’ll make it costlier to operate a psychiatric unit, to comply 100% with this,” he says.

Both CMS and TJC have said they are still refining their expectations on ligature risk and protecting patients from self-harm. Allen says he is hopeful CMS will make allowances for geriatric units.

But that’s not the case now. And what CMS says, goes, warns Allen.

“[CMS] should distinguish between geriatric and regular adult psychiatric units, but you really don’t have much choice,” he says. “CMS is a big threat. Either finish this in 60 days or we cut off your funding.”

TJC, in the meantime, has stated that geriatric patients may offer different challenges. In the answer to a frequently asked question (FAQ) posted online, TJC officials respond that the best action is a good risk assessment.

The FAQ notes that there is equipment that is necessary for the safe treatment of BH patients that also poses a risk — “i.e. medical beds with side rails on a geriatric unit.” In those instances, hospitals must consider the patient’s risk for self-harm, and implement “appropriate interventions” to reduce or eliminate that risk.

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