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As many of you know, the surveying of ligature risks in psychiatric hospitals has almost taken on a life of its own over the past four months.  So, in follow-up to our June article on ligature risks, we’re providing some timely feedback from clients about how this issue has been reviewed during recent surveys. We’ve had six psychiatric hospital clients surveyed since the March 1 announcement from TJC on this topic, and the scrutiny on it has been intense. Four of the six received scores of High Risk and Widespread Scope on the SAFER matrix for these issues as well as Condition Level findings for the CMS Physical Environment CoP which results in a Follow-up Survey. (The other two hospitals are newly constructed buildings with state-of-the-art environments in terms of safety risks and had no problems in this area.) Here’s a summary of the issues cited for the four hospitals:


  • Non-ligature resistant door handles on seclusion room bathroom; non-ligature resistant push button on sink
  • Non-continuous door hinges
  • Door hinges (although continuous) had been trimmed on top during installation creating a ligature point
  • Gear style hinges (although continuous) were surface installed and demonstrated not to be ligature resistant
  • Shower handrails, shower controls, shower heads, soap dispensers, towel hooks, and toilet paper dispensers non-ligature resistant
  • Suspended ceiling with two missing tiles; pipe accessible above
  • Removable toilet seats (Note: TJC has instructed surveyors to no longer cite toilet seats since there is no evidence of this being a ligature risk.)
  • School unit restroom: non-continuous door hinges; non-ligature resistant sink spigot and door handles

Patient Rooms

  • Non-ligature resistant door handles
  • Hospital style beds
  • Spring hinges on corridor side of doors creating ligature point from inside of room
  • Suspended ceilings – tiles held in place by clips; one tile pushed out of place so clips cited as not an effective mitigation strategy
  • Electrical outlet and light switch covers had tamper proof screws but covers were nylon; could be bent out enough to create a ligature point or allow access to energized parts
  • Air conditioning units with open vents and removable covers; potential ligature points or could be broken up to create sharp instruments; allowed access to potentially hazardous internal parts

Other Locations

  • Hallways: non-ligature resistant handrails (including hallway alcoves) and non-ligature resistant door hinges
  • Treatment Rooms: wire shelving; cabinet door handles and drawer handles, coat hooks
  • Conference Rooms: closet door hinges, blind closures, door handles, plastic garbage bag
  • Day Rooms: magazine rack, air vents on AC system, computer cables, closet hinges, and door handles, non-institutional sprinkler heads, suspended ceiling system with lay-in tiles, computer cords, Plexiglas cover on window not secure
  • Kitchen/eating area: cabinet hinges, locks on storage closets, non-institutional sprinkler heads, suspended ceiling system
  • OT Room: strings on window blinds, cabinet hinges, door handles, locking mechanism on art cabinet doors, toilet plumbing in OT bathroom
  • Ball style door handles on office doors (accessible to patients) and on soiled utility room door
  • ADT swipe mechanism at entrance to unit
  • Cables on water cooler and computer
  • Magazine racks, water fountains
  • Patient gowns with strings
  • Non-secured outdoor area for fresh air breaks (accompanied by staff); risk of elopement

In terms of responding to these observations by surveyors, the hospitals often took immediate action and rectified the situation during survey whenever possible. This included, for example, replacing non-continuous hinges with continuous hinges, replacing handrails and door handles, and removing other items that were deemed to be a ligature risk. These actions were duly noted by the surveyors in their reports. When the risk could not be immediately rectified, the surveyors wanted a mitigation plan; i.e. what the facility would do until the long term fix was in place. These mitigation plans included actions such as closing off showers and bathrooms, implementing increased patient supervision, and staff supervising bathroom access. These mitigation plans were also included in the survey reports.

Several of the hospitals made the point to the survey team that these same conditions had existed during previous surveys and not been cited as noncompliant. As one CEO put it, “This wasn’t a problem on our last four surveys. So, why is it a problem today?” The response from surveyors was that the directive from CMS is clear and they must cite every single ligature risk they observe.

So, the pendulum seems to have swung to somewhat of an extreme position on this issue. TJC has heard this sentiment from its customers and is aware that there needs to be a reasonable, consistent approach to surveying ligature and self-harm risks. Toward that goal, they have convened an Expert Panel to provide input on this topic and develop recommendations for suicide risk reduction as well as consistent guidance for surveyors and the field regarding ligature and self-harm risks. The panel will also be addressing how these requirements should be applied in non-hospital behavioral health settings. Included on the panel are hospital leaders and representatives of CMS, the Veterans Administration, SAMHSA, and TJC. It’s hopeful that the panel’s recommendations will result in a more consistent and evidence based approach to this important topic. Meanwhile, it’s more critical than ever that hospitals be prepared to show surveyors a comprehensive, documented risk assessment as well as detailed mitigation plans for any risks that have been identified but not yet been eliminated.

For more information on how ligature risks are surveyed, view the FAQ posted on June 1, 2017, on the TJC website. In addition, we will be sure to keep you updated on this challenging topic as it continues to unfold.