Ligature Risks and Preventing Inpatient Suicide: Compliance with the CMS and TJC Standards
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Speaker : LAURA A DIXON
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When : Tuesday, March 18, 2025
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Time : 03 : 00 PM EST
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Laura A. Dixon, BS, JD, RN, CPHRM
Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.
Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.
Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.
As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.
Suicide prevention and protecting patients from harm or strangulation continues to be a major focus of accreditation surveys. Suicide is the third most frequently reported sentinel event.
The Centers for Medicare and Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients that are suicidal. Any hospital that receives Medicare/Medicaid payments, which are most hospitals in America, must implement these changes for all patients.
CMS tag numbers 144 in patient rights and 701 in facility services discuss what units need to be ligature resistant. It covers what patient and environmental assessments should be completed. It discusses education and policy and procedure requirements.
Joint Commission has multiple requirements to ensure compliance with their standards. These will be discussed and include psych hospital, behavior health units, general acute care inpatient units, and emergency departments.
Resources will be provided along with tools to assess patients to determine if they have suicidal ideations will be included.
Areas Covered
Introduction
- Suicide rates and processes to consider
- Conditions of Participation manual
- Recent CMS memo on inpatient ligature risks
- Deficiency reports
- Tag 144 – patient safety and rights
- Policy and procedure requirements
- Definitions of ligature and anchor points
- Education and training of staff
- Patient assessment
- Correction of environmental risk
- Tag 701 and Environmental assessment
Joint Commission
- Introduction and SAFER matrix
- EC.02.06.01 EP 1 requirements
- Dedicated verses non-dedicated spaces
- Recommendations for Inpatient setting
- Recommendations for general acute care setting
- Sentinel event reduction doors and soft suicide prevention doors
- Ceilings, beds, and toilets
- Shower curtains
- Suicide risk reduction
- ED and safe rooms
- Video monitoring
- NPSG 15January 2024
Tools of the trade
- Behavioral Health Design Guide
- Patient health questionnaire PHQ-9 and 3
- ED-SAFE screeners
- Patient safety secondary screener
- ED Suicide Behavioral Questionnaire SBQ-R
- Environmental Assessment
- C-SSRS Columbia Suicide Severity Rating Scale
- SAFE-T Assessment
- Suicide Prevention Decision Support Tool
- ASQ Screening tool
Learning Objectives
- Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations
- Discuss that the Joint Commission has requirements for hospitals to follow to prevent patients from self-harm including hanging or strangulation
- Describe that CMS recommends education in orientation when policies change and every two years
- Recall recently updated guidelines from CMS
Who Should Attend
- All healthcare providers on the hospital behavioral health unit
- All healthcare providers at Psychiatric hospitals
- All healthcare providers in hospital emergency departments
- All healthcare providers on hospital units where suicidal patients may be treated
- Hospital risk managers
- Patient safety officer
- CEO, COO, CMO, CNO, and nurse supervisors
- Director of maintenance and facility services
- Environmental Services
- Security
- Director in charge of environment of care requirements and staff
- Quality improvement coordinator
- Compliance officer
- Director of Regulatory Affairs
- Nurse educator
- Clinic and outpatient managers
- All department directors/nurse managers such as ED, ICU, CCU, Med-surg managers, outpatient, etc.
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$200.00
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