The topic of ligature risks in inpatient psychiatric settings has been a significant challenge for the industry over the past several months following TJC’s increased scrutiny of this issue since March 1st.

The latest development is that TJC has now published official recommendations on ligature risks in healthcare settings. These Recommendations Regarding Environmental Hazards for Providers and Surveyors were released in a preview communication on October 25th and subsequently published in the November issue of TJC Perspectives. As part of this communication, TJC has formally defined the term “ligature resistant” as “without points where a cord, rope, bedsheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.”

So, if you operate inpatient psychiatric units (either in a freestanding psychiatric hospital or in a med/surg hospital) we urge your leadership team to carefully study these recommendations and take action on each of them. The following is a summary of the TJC recommendations as well as our suggestions for actions to take now:

Recommendations for Inpatient Psychiatric Units

Note: We have confirmed with TJC that these recommendations also apply to inpatient detox/rehab units.

Areas Required to be Ligature Resistant

Inpatient psychiatric units must be ligature resistant in patient rooms, patient bathrooms, corridors, and common patient care areas. In addition, the transition zone between the patient’s room and the patient’s bathroom must be ligature resistant or ligature free.

Actions to take now: If you have not yet installed ligature resistant features in all your bedrooms and bathrooms, do this ASAP. Until these physical plant solutions are in place, include each of these risks on your environmental risk assessment and describe the mitigation strategies you are using to prevent patients from harming themselves in these areas. For the bathroom doorways, consider curtains, slanted top doors, or other products available in the product guides.

Areas NOT required to be Ligature Resistant

Nursing stations with an unobstructed view (so that a patient’s attempt at self-harm at the nursing station would be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature resistant.

Actions to take now: Make sure those doors that are supposed to be self-locking and self-closing actually do so. We often walk by activity rooms where “patients are never alone without staff” yet there is a patient sitting in the room and the door is open.” Ongoing vigilance is critical.


Doors between patient rooms and hallways must contain ligature resistant hardware including hinges, handles, and locking mechanisms. Even with ligature resistant hardware on the door, the top of the door itself is considered a ligature risk since there have been instances of suicides and suicide attempts by means of a ligature between the top of the door and the door frame. This top-of-door risk can be addressed by installing top-of-door alarms. However, TJC is not recommending these as a requirement since their effectiveness has not been widely proven. Rather, hospitals should note these doors on their risk assessment and describe their mitigation strategies (e.g. observations rounds, environmental rounds, etc.)

Actions to take now: Determine if you want to use top-of-door alarms and, if so, do some research on the products available. If not, make sure the tops of doors are listed on your environmental risk assessment and describe your mitigation strategies.


Patient rooms and patient bathrooms must have solid ceilings. Drop ceilings are not allowed in these rooms. Drop ceilings are allowed in hallways and common patient care areas IF all aspects of the hallway or common patient care area are fully visible to staff and there are no objects that patients could easily use to climb up to the drop ceiling to remove a panel and gain access to ligature points above the drop ceiling. Drop ceilings in areas that are not fully visible (e.g. alcoves) should be included on the risk assessment and have appropriate mitigation strategies (e.g. tile retention clips, gluing tiles in place.)

Actions to take now: Survey the ceilings in your hallways and common areas and decide where you will allow drop ceilings (if at all.) If you plan to use tile retention clips, make sure they are sturdy enough to secure the ceiling. Some have been shown by surveyors to pop easily out of place.

Medical Beds

TJC is not as prescriptive in this area as it is in others. The recommendations state that hospitals must determine the appropriate type of medical bed needed to meet both the medical and psychiatric needs of the patient. For patients who are determined to need a medical bed that has ligature points, there must be appropriate mitigation plans and safety precautions in place.

Actions to take now: If you clearly need to use medical beds with ligature points for your patients, research the “best practice” beds available in the design guides and benchmark with other hospitals about their choice of medical beds.

Now that we have covered inpatient settings, what about behavioral health settings that are not inpatient psychiatric units such as PHPs and residential settings? First, be clear that the recommendations above do not apply to these non-inpatient behavioral health settings. However, what does apply is that the organization must complete an environmental risk assessment and make determinations regarding any environmental risks identified and how these should be addressed for their population. This is required by standard EC.02.01.01 and is now frequently being cited by behavioral health surveyors if the organiztion has not completed this type of environmental risk assessment. In addition, the expert panel convened by TJC reviewed the topic of ligature risks in these other settings at their October meeting. Their recommendations are forthcoming and will be communicated to the field as soon as they are finalized. We will keep you posted on those.

As you work to implement the TJC recommendations, the following are some resources for products and design guidance for inpatient psychiatric settings:

Design Guide for the Built Environment of BH Facilities (Facility Guidelines Institute)

New York State Office of Mental Health Environmental Safety Product Guide

VA Design Guide for MH Facilities

Monarch Achieves Gold Standard of Joint Commission Accreditation