Intense scrutiny on ligature risks continues for inpatient psychiatric units, both in freestanding psychiatric hospitals and inpatient psychiatric units of med/surg hospitals. As the field continues to work toward making these settings ligature resistant, it’s important to know just what is being cited by TJC surveyors these days. Thus, we are providing feedback from recent surveys of our clients so you can use this information to guide your environmental risk reduction efforts. As you will see, in addition to the common findings regarding non-ligature resistant hardware, plumbing, and bathroom doors, there are other, less obvious issues being cited. So, take a look and see if these are potential ligature risk issues for your hospital. All have been cited in 2018 survey reports

• Fire alarm signal box attached to wall
• Heavily framed pictures; need ligature resistant frames
• Weight releasing hooks on door that but the base of the hook stuck out over a ½ inch creating a hanging risk
• Wardrobe doors
• Grills on heating unit
• Sensory room: metal bar with eye hooks; mats with handles; door self-locking but not self-closing
• Drain stopper handle on wall of tub
• Seclusion rooms: beds with restraint holes on side of bed base; metal bar on door had openings in it
• Thermostat on wall
• Hand hygiene dispensers with flat tops in hallways
• Exit signs
• Exit doors with door closers
• Phone cord 24 inches
• Dayrooms: drawers with barrel hinges; refrigerator door handles; power cords and speaker cords; door self-locking but not self-closing
• Laundry room: hoses, cords, shelves, brackets, door self-locking but not self-closing
• Door leading to playground non-ligature resistant

Also, keep in mind that if surveyors identify a ligature risk, they are required by CMS to cite it, even if you have mitigation strategies in place. They will include a description of your mitigation strategies in the survey report but, again, you will still be cited. If the findings for ligature risks are significant enough to cause a Condition level deficiency, TJC must do a follow-up Medicare Deficiency survey within 45 days. The following is a sample of a mitigation plan included in a survey report along with the findings regarding the hospital’s ligature risks:

There were 24/24 inpatient bathrooms, 24/24 patient doors and 2/2 handicapped bathroom/tubs.  The organization states that the replacement doors and hardware are expected to be replaced in the next week.  The clinical mitigation plan includes education of staff regarding ligature risks in patient areas. This has been completed. The staff has the ability to increase a patient observation level at any time for increased suicidal risk.  The staff is educated on the procedure for 15-minute checks which are completed on all patients.  This includes opening closed doors and hypervigilance in bathroom areas.  Staff complete environmental rounds to observe the XYZ units and immediately repair any unit that is in disrepair.  Patients on suicide precautions are monitored more closely in areas with ligature risk.

Also, be aware that surveyors will make a distinction in the report regarding ligature risks they identify but which the hospital had not identified or for which the hospital did not have an adequate mitigation plan. For example:

In the day area of the Child Unit, there was a sink with a spigot and temperature handles which posed a ligature risk.  Leadership stated that the mitigation plan was that a staff person is always stationed in the area. In addition, there was a refrigerator with door handles posing a ligature risk.  Again, it was stated the mitigation plan was a staff member being present.  None of these risks were documented in the environmental risk assessment. One of the interventions used as a mitigation intervention for other risk areas was to place those patients at risk for suicide closer to the nursing station which was located right next to the day area.  No documentation was available regarding the effectiveness of these mitigation plans.

Lastly, as reported in our January issue, there is now a mechanism in place for TJC and CMS to approve corrective actions (for ligature risks) that will take more than 60 days to implement. This longer-term process, however, can only be initiated after the Condition level finding has been made in the survey report and TJC has returned for the follow-up survey. See our newsletter article for details.

We will continue to keep you posted on this important topic over the coming months. There are sure to be new developments in this challenging arena!