TJC & CMS News Blog
Information for

A hot topic at the annual Behavioral Healthcare Conference in Chicago this month was TJC’s update on how they are surveying ligature risks in psychiatric hospitals and psychiatric units of med/surg hospitals. As readers know from our newsletter articles and their own experiences, the findings in this area have been ramping up for the past six months.

The information shared at the conference was presented by the TJC Engineering Department and Standards Interpretation Group. It included the most recent recommendations drafted by the expert panel on suicide reduction formed by TJC. This panel met for the third time on October 11 and its recommendations will be disseminated to the field once approved by CMS.

The following were key points addressed during the presentations.  These apply to inpatient psychiatric units in both psychiatric hospitals and general/acute care settings:

Patient room doors on hallway

  • Must have ligature resistant hardware: hinges, handles, latching hardware.
  • The top of the door is a risk. Top-of-door alarms not currently required; include tops of doors on risk assessment with mitigation strategies; educate staff.

Patient room bathroom doors

  • Must be without ligature attachment points: door, hinges, handles.
  • Possible strategies: soft suicide prevention door, sentinel event reduction door, removing the door.


  • Drop ceilings not allowed in patient rooms and patient bathrooms.
  • Drop ceilings allowed in hallways and common areas with the following requirements:
    • Hallway is visible to staff at all times with an unobstructed view.
    • If common area door is self‐locking and self‐closing and continuously monitored by staff while occupied by patient(s).
    • Drop ceilings in these areas are included on risk assessment with mitigation strategies and staff education.

Medical Beds

The solution for this one is left more to the judgment of the hospital and should be based on patients’ clinical needs. TJC guidance was as follows:

  • Limit medical beds to only patients that meet the requirments.
  • If there is a medical and ligature resistant need, a medical bed may be utilized with appropriate mitigation strategies for the patient.
  • Same concept for medical equipment.
  • Educate staff on risks within the room.

Toilet Seats

  • TJC’s position is that toilet seats are not a significant risk for suicide or self-harm attempts as determined through data collection and evidence based research.
  • Toilet seats are consistent with a ligature risk‐free environment. TJC recommends (to CMS) that they not be cited on surveys. They also are not required to be noted on a risk assessment.

A major message from the presentations (and one we are driving home with our clients) is the critical importance of working with your clinical team on the mitigation strategies you are using related to ligature risks. We are all familiar with the typical response that we conduct suicide risk assessments, put patients on special observations, do 15 minute rounds, etc. However, you need to really drill down on those strategies and make sure that:

  • These polices/procedures are written and clearly understood by staff.
  • Staff have been thoroughly trained and you have assessed their competence in implementing these strategies.
  • There is ongoing supervision by managers and leadership oversight to ensure these procedures are consistently implemented.

Surveyors will be asking staff about this when they tour your units. They will want answers that match your policies and they will want documentation of the staff training, competency assessment, and leadership oversight.

From our end, we will continue to keep you posted on new developments related to the surveying of ligature and self-harm risks. Feel free to contact us with any questions about your survey preparation and how best to prepare your hospital for this scrutiny.