Have you seen The Joint Commission’s latest FAQs on ligature risks? In January, TJC published three new FAQs on this topic. One is particularly noteworthy since it involves somewhat of an easing of TJC’s original position. So, let’s cover that one first.

Ligature Risk: Drop Ceilings

Question: “Are drop ceilings allowed in corridors and common areas on an inpatient psychiatric unit?”

Answer: “Yes, drop ceilings are allowed in corridors and common areas where staff are regularly present as allowable by the facility’s safety risk assessment. These areas do not need to be in constant view of staff but should be a part of the standard safety rounds conducted by staff (for example, 15-minute patient safety checks, shift-to-shift environmental rounds, and so on).

Drop ceilings in areas that are not fully visible to staff (for example, a right-angle curve of a corridor) should be noted on the risk assessment and have some additional steps taken to make it more difficult for a patient to attempt to access the space above the drop ceiling (such as gluing or clipping tiles), which would allow staff to hear or see the patient’s suicide attempt and prevent the attempt from occurring.”

So, the current TJC position is that corridors and common areas with drop ceilings are not required to be in constant view of staff. These areas need to be included in the standard safety rounds conducted by staff. Again, this is an easing of the November 2017 TJC requirement. At that time, TJC indicated that drop  ceilings were acceptable in hallways and common patient care areas as long as all aspects of the hallway were fully visible to staff.

The current position on drop ceilings is pragmatic and welcomed by the field. TJC staff discussed this topic at the recent Consultants Forum we attended at Joint Commission headquarters.

TJC staff reported they had encountered inpatient facilities with a staff person dedicated to monitoring a hallway 24/7 purely because it had a drop ceiling. It makes much better sense for facilities to incorporate this into their routine safety rounds.

Prohibited Items

Question: “Has The Joint Commission identified any specific items that should not be allowed to be brought on an inpatient psychiatric unit?”

Answer: “No, The Joint Commission does not determine the items to be prohibited from an inpatient psychiatric unit. Items that are prohibited to be brought into organizations, due to the risk of harm to self or others, should be determined by the organization. Compliance with such safety measures is based upon organizational policies/procedures, individual care plans, and applicable state rules or regulations.”

The important point here is you must define your process for control of potentially harmful items. Depending on the setting, this could include sharp objects, shoestrings, belts, and even pencils.

So, be sure you have a policy and a procedure for how this issue is handled. Also make sure all staff know what your policy is. And, of course, make sure the policy is consistently implemented. That’s what surveyors look for.

Ligature Resistant Products

Question: “Does The Joint Commission recommend specific ligature-resistant products?”

Answer: “No, The Joint Commission does not recommend products. Organizations are required to do the following: 

• Comply with TJC’s Recommendations for Suicide Prevention in Healthcare Settings 
• Conduct a risk assessment of the environment 
• Determine which products to appropriately install (based on manufacturers’ instructions) 
• Ensure that the products are functioning properly to maintain ligature resistance”

No surprise. TJC is, understandably, not in a position to recommend specific products.

The message here is the organization must do its homework. First step is the environmental risk assessment. Next comes the research into the “best practice” products on the market.

“Best Practice” Products and Design Guides

Looking for design advice and the best products on the market? Here are some excellent resources and product guides we always recommend to clients:

• Design Guide for the Built Environment of Behavioral Health Facilities
• Patient Safety Standards, Materials and Systems Guidelines Recommended by the New York State Office of Mental Health
• Dept. of Veteran Affairs – Office of Construction & Facilities Management Design Guide – Mental Health Facilities

Ligature Risks: Curtains on Bathroom Doors

TJC also discussed the topic of curtains on bathroom doors at the Consultants Forum meeting. Many facilities have replaced their bathroom doors with curtains to eliminate ligature risks. This has proven a workable solution for most.

However, TJC emphasized that organizations must address the risk of patients using these curtains for self-harm. Essentially, you must be able to show how you’ve evaluated the risk of the curtains (e.g. for suffocation) and have minimized that risk. Best approach is to include it on your environmental risk assessment along with your mitigation strategy.

Evaluation of Ligature Risks on Mock Surveys

When we conduct our TJC mock surveys, we closely scrutinize ligature risks and the facility’s environmental risk assessment. Our engineer also takes a deep dive into these areas when he does his Life Safety & Environmental Reviews.

Ligature Risk FAQS on TJC Website

TJC has published all the FAQs related to ligatures and suicide risk reduction on its website.  Just click on the Hospital or Behavioral Health manual and look under the Environment of Care chapter. It’s a handy way to reference all the guidance TJC has provided the field on this important topic.