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CMS memo defines ligature risk and clarifies expectations

Hospital Safety Insider, December 14, 2017

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The new memo creates a definition of a ligature risk, a time frame for correcting them, interim guidance for surveyors, plus requirements for requesting a time extension for a plan of correction taking longer than 60 days. CMS says that while not all ligature risks can be eliminated, hospitals are expected to show how they identify patients at risk and the steps they are taking to minimize those risks.

According to the S&C Letter 18-06, a ligature risk (or point) is “anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.” That includes handles, coat hooks, pipes, shower rails, radiators, bedsteads, window and door frames, ceiling fittings, hinges, and closures.

CMS is still collaborating with healthcare organizations and patient safety groups on a more comprehensive guidance on ligature risks. The agency says it expects to have the update done in six months.

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