Suicide is the third most frequently reported sentinel event. Suicide prevention and protecting patients from harm or strangulation is a major focus of accreditation surveys. CMS has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients who exhibit suicidal behaviors. Any hospital that receives Medicare and/or Medicaid payments must implement these changes for all patients. 

CMS tag number 144 in patient rights and tag number 701 in facility services discuss what units need to be ligature resistant. These tags cover patient assessments, environmental assessments, education and policy, and procedure requirements. The Joint Commission has multiple requirements to ensure compliance with their standards regarding ligatures and suicide prevention. These standards will be discussed to include psychiatric hospitals, behavioral health units, general acute care inpatient units, and emergency departments.  

Learning Objectives

• Recite 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 hospitals must follow to prevent patients from self-harm, including hanging or strangulation.
• Describe that CMS recommends education when policies change and every two years.
• Recall that CMS has recently updated guidelines.

Speaker: Laura Dixon, BS, JD, RN, CPHRM