In the July issue of The Joint Commission Perspectives, responses to frequently asked questions from the field were published, relating to the suicide risk recommendations issued over the past several months.
Since we’ve received numerous questions from readers regarding these recommendations, we’re providing a few of the responses in this article. For the full set of FAQs and responses, see the July issue of The Joint Commission Perspectives, available to TJC-accredited organizations on The Joint Commission Connect extranet site.
Question: Can you please clarify the first recommendation as it relates to the nurses station?
Answer: The recommendation states: “Nursing stations with an unobstructed view (so that a patient 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 and will not be cited for ligature risks.” This refers to what can be seen within the nurses station, not what is being seen from the nurses station. If there is an unobstructed view of everything within a nurses station, then patients should not be able to attempt self-harm at the nurses station since this would be easily seen and interrupted.
Question: Can drop ceilings be used in hallways and common patient care areas?
Answer: Yes, drop ceilings can be used in hallways and common patient care areas as long as all aspects of the hallway are fully visible to staff at all times and there are no objects that patients could easily use to climb up to the drop ceiling.
Question: Can curtains be used in place of a bathroom door in an inpatient psychiatric unit?
Answer: If curtains are used in place of a bathroom door, analysis of this risk should be noted on the environmental risk assessment, and the organization must have a mitigation plan for monitoring any high-risk patients near the curtain or area where the risk is present.
Question: What are the requirements for an inpatient substance abuse detox unit?
Answer: Organizations providing inpatient substance abuse detox treatment (as the primary focus of treatment) should follow the recommendations applicable to general acute care inpatient settings, given the complexity of physical health care required to care for these patients. These units do not need to meet the same recommendations as psychiatric inpatient units. As with any patient receiving treatment for mental health, screening, assessment, and reassessment are critical when determining the appropriate level of care. For additional information, see our post on Ligature Risk Recommendations for Inpatient Detox Units.
Question: What does “serious” risk for suicide mean?
Answer: Organizations should use an evidence-based process to conduct a suicide assessment of patients who exhibit suicidal behavior or who have screened positive for suicidal ideation. The assessment should directly ask about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors. After this assessment, patients should be classified as high, medium, or low risk of suicide. The Joint Commission considers “serious” as equivalent to “high risk.” (Please refer to NPSG 15.01.01 for information relevant to screening and assessment of patients at risk for suicide).
Question: Are the recommendations the same for open and/or unlocked psychiatric units?
Answer: The recommendations for a ligature-resistant environment for inpatient psychiatric units (in both a psychiatric hospital and a general acute care hospital) apply to closed or secure/locked psychiatric units in which entrance to and exit from the unit are controlled by unit staff and a patient could not independently leave the unit without supervision. The recommendations would not apply to an open or unlocked psychiatric unit in which patients are able to enter and exit of their own accord.