Accreditation

Surveyors on the lookout for suicide hazards

Briefings on Accreditation and Quality, November 1, 2017

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CMS and Joint Commission are cracking down on potential ligature and self-harm risks

Annually, there are 460,000 emergency department visits that occur following cases of self-harm, and the patients treated during those visits are six times more likely to make another suicide attempt in the future. Nationally, suicide is the 10th leading cause of death, a fact that hasn't gone unnoticed by CMS or The Joint Commission.

While last year The Joint Commission issued a Sentinel Event Alert to hospitals urging them to do a better job of identifying suicidal ideation in patients, this year the accreditor is doubling down, issuing specific warnings in Joint Commission publications and FAQs outlining concerns about ligature, or hanging, risks.

A complete reassessment of the physical environment of the areas where patients with behavioral or mental health problems are cared for could be in order, say consultants and accreditation managers with recent experience in the issue.

The Joint Commission warns that a finding of significant risk could spur a call for an immediate threat to life designation, which could threaten your hospital’s accreditation. That and a renewed focus on the physical environment by CMS might require building or equipment changes, warns at least one consultant.

Joint Commission refocuses on mitigation

The handles on the box springs of patient beds in residential areas. The caulking along the wall of otherwise-solid grab bars in showers. Any loops that might hold mattresses onto a bed frame. All of those and more have been cited as potential ligature risks by The Joint Commission and CMS surveyors in the last few months as they have stepped up inspections in the physical environment for suicide hazards in hospitals.

As of March 2017, Joint Commission surveyors have been putting special focus on suicide, self-harm, and ligature observations in psychiatric units and hospitals. Surveyors are documenting any and all observations of ligature or self-harm risks in the environment during the survey. They’ll also evaluate whether the facility has:

•    Identified these risks before
•    Planned to deal with these risks
•    Conducted an effective environmental risk assessment process

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