Ensuring patient safety is a high priority for any hospital. In situations where patients may be a danger to themselves, hospitals must take additional measures to mitigate a potential tragedy. Alarmingly, suicide accounts for an estimated five to 15 patient deaths per 100,000 admissions in general hospitals and regulatory agencies have taken notice of this concerning trend.

In 2016, a Sentinel Event Alert from The Joint Commission required hospitals to have a strategy for detecting and treating suicide ideation of patients in all settings. This included any unit or area where a behavioral health patient might be treated. This year, CMS went a step further by requiring hospitals and clinics to ensure there are no ligature risks in areas specifically designated to treat behavioral health patients. Ligature risks are any potential objects that patients could conceivably use in an attempt to hang themselves. In addition, areas that may be used to treat them on a temporary basis must also have a mitigation strategy in place to eliminate ligature risk.

“This new CMS requirement affects all hospitals and clinics across the country,” said Diana Scott, MHA, RN, CPHQ, senior director of accreditation advisory services at Vizient. “A behavioral health patient can show up in any hospital’s emergency department, regardless if they are specifically set up to treat them. Because of that, virtually every hospital is included under the umbrella of non-designated space. Organizations must assess the environment in which they would be caring for those patients and identify and address the ligature risks that exist in those areas.”

Ligature risks range from certain types of medical equipment or peripheral items like IV tubing, hospital bed type, ceiling tiles, door hinges and doorknobs. While not related to ligature risks, even windows are evaluated as a potential hazard. In addition, Scott says the bathroom typically presents the largest area of risk. From plumbing pipes and handicap grab bars to faucets, soap dispensers and paper towel dispensers, it may seem as if there’s no end to the list of potential ligature risks.

“Obviously, the concern of ligature risk was not top of mind when these rooms were designed, many of which were not originally designated for behavioral health patients,” Scott said. “Depending on what needs to be removed or replaced, the financial implications to the hospital can rise substantially.”

To achieve compliance in non-designated areas for behavioral health patients, the most frequently used mitigation strategy is to require a one-to-one observation by a trained staff member for each suicide/self-harm risk patient.

With the potential for representatives from CMS, the state or an accrediting organization to arrive without notice to gauge risk, every organization needs to address this issue sooner rather than later. And while the primary focus will be on evaluating designated areas for care, Scott notes that surveyors may also take a very close look at any potential non-designated care areas that could be used in the event of an emergency.

“To evaluate whether the hospital is compliant, surveyors look at the policy or protocol applicable to providing care for these patients in a designated or non-designated temporary space,” Scott said. “But they also evaluate it in motion. This could include interviewing staff, directly observing the interaction between a patient and a provider or evaluating the competencies of the individuals who would be carrying out the risk assessment.”

If a hospital is cited with a high-risk deficiency, it has 45 days to correct the issue or devise a plan that shows how the risk(s) will be mitigated while the permanent correction is being implemented. If that doesn’t happen, the hospital receives a second level deficiency citation. This time, it only has 30 days to achieve compliance. As a last resort, the hospital could temporarily close their designated space for the duration of renovations to make it risk-free or refrain from treating patients in designated areas until a permanent correction was implemented. Ultimately, the hospital can lose its accredited status and Medicare certification if the risk goes unaddressed.

Compliance requirements are currently being reviewed by CMS, and they may consider granting cited facilities an extension to make physical modifications. Clearly, any substantial amount of renovation would take longer than 45 days. In the meantime, however, it’s important for hospitals to take action as quickly as possible.

“Leadership needs to have a heightened awareness of the suicide risks associated with the physical environment connected to behavioral health patients that come through every organization,” Scott said. “It’s not something that has historically been top of mind, as we have previously depended on close patient assessment and surveillance. However, the focus has shifted: the expectation is that organizations must be vigilant in assessing and monitoring these patients, but also must minimize opportunities in the physical environment for self-inflicted harm. Leaders need to be aware of the regulations that could affect them and their patients in an adverse manner if their facilities aren’t upgraded to a ligature-resistant status and mitigation strategies aren’t implemented.”

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Published: September 12, 2017