Assessing and Mitigating Self Harm and Ligature Risk in the Behavioral Health Environment

Edmund Lydon, MS, CHFM, FASHE – Northeast Hospital Corporation a member of Lahey Health
Geoff Thomas, Facility Manager – Northeast Hospital Corporation a member of Lahey Health
Ed Browne, MS, CHFM, CHC, CLSS SASHE, FACHE – Vice President Support Services, Cambridge Health Alliance

The presentation will discuss patients have the right to receive patient care in a safe setting. Hospital has an obligation to protect patients who are presenting with self-harm / suicidal ideation. The presentation will show a strategy to assess the physical environment for self-harm and ligature opportunities. The presentation will further discuss what does this mean to the facility manager and designer who takes on the responsibility to ensure the physical environment is appropriate for this patient population. The care and safety of psychiatric patients and the staff that provide that care are our primary concerns. Although the Centers for Medicare & Medicaid Services (CMS) is in the process of drafting comprehensive ligature risk interpretive guidance to provide direction and clarity for Regional offices (RO), State Survey Agencies (SAs), and accrediting organizations (AOs) the expectations for improving the physical environment is a required action now under the current published standards of care. These resources will also be explored as part of the presentation. The presentation will discuss that the ligature risk environment has been defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation and that ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures, etc.

The focus for a ligature “resistant” or ligature “free” environment is primarily aimed at Psychiatric units/hospitals. However, hospital emergency departments and general medical units are under scrutiny as well when patients with self-harm ideation are cared for in these clinical settings as well.

This presentation will discuss the current regulatory environment as well as assessing and mitigating self-harm and ligature risk in the behavioral health environment. Inpatient psychiatric hospitals, inpatient psychiatric units in general acute care hospitals, and non-behavioral health units designated for the treatment of psychiatric patients require spaces that meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. Therefore, ligature and self-harm risks must be identified and eliminated. The presentation will discuss the following:

Brief overview of the compliance environment
Performing a risk assessment to identify self-harm / ligature opportunities
What are examples of mitigating the physical environment
Working with architects and contractors

Many of the challenges facing designers and facility managers is understanding what types of building materials (exit signs, lighting, mechanical vents, etc.) are available to meet this required change to the physical environment. Understanding installation challenges and how best to approach the need to make these modifications to physical environment will be discussed. A proactive approach is encourage vs. waiting for the authorities having jurisdiction to identify deficiencies and elevating the hospital into a “risk to life status” requiring mitigation within 60 days or be placed in a condition of participation action plan. Presentation will discuss recent enforcement activities.

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