Blog / Focus: Facility Design

Compliance 101: Mitigating ligature risks in behavioral health patient care environments

By Gary Giovinazzo / Special to Healthcare Facilities Today
February 22, 2018

Patient safety is a primary concern for all hospitals and healthcare systems across the country. For the last 12 to 18 months, The Joint Commission and Centers for Medicare and Medicaid Services (CMS) have increased inspection surveys for ligature and other self-harm risks in behavioral health patient care areas.

In March 2017, The Joint Commission issued the following alert:

“Effective immediately, The Joint Commission will place added emphasis on the assessment of ligature, suicide and self-harm observations in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals. This comes at a time when there is national concern about the number of suicides in hospitals.”

Many hospital facilities management professionals manage and mitigate ligature risks on a daily basis. It is up to the facilities team—along with other departments and staff—to understand, identify, and correct physical environment fixtures and objects that may pose a ligature, or hanging, risk to behavioral health patients. 

A complete risk assessment of the physical environment may be required which can include any area where the patient may be moved and treated (e.g., intensive care unit, medical surgery unit, radiology).

Some examples of risks include power cords on medical equipment, call bell cords, hand rails, doors, door knobs, door hinges and hardware, shower heads and curtains, exposed plumbing or piping, paper towel and soap dispensers on walls, electrical switches/receptacles, lighting fixtures, and projections from ceilings. 

The smallest risks must be identified and eliminated. As reported in the Patient Safety Monitor Journal, even loose caulking can introduce significant dangers.

Preparing for inspection surveys

One of the most cited noncompliance standards during The Joint Commission surveys has been EC 02.06.01 ep1: “Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided.”

On December 8, 2017, the CMS issued a memorandum to clarify the standard’s requirements, including material that each facilities team should be intimately familiar with.

To help hospitals comply with the above standard, it’s recommended that several departments, in addition to Facilities Management, develop a Patient Suicide Risk Assessment. 

The purpose of the assessment is to identify potential or real risks to the patient in their treatment environment, as well as corrective action and mitigation plans. The team should be multi-disciplined, and can consist of Behavioral Health, Patient Safety, Quality, Safety Department, and Senior Hospital Administration.

The inspection survey process

The survey will likely be performed in the psychiatric inpatient and outpatient environment, as well as any area the patient may visit. These areas require heightened safety monitoring with continuous observation.

In addition to the ligature risks noted above, surveyors will be on the lookout for:

● Unattended items including utility or housekeeping carts that contain hazardous items (mops, brooms, cleaning agents, hand sanitizers, etc.)

● Sharps, harmful substances, and access to medications

● Oxygen tubing

● Unsafe items brought in by visitors

● Inadequate staffing levels to provide appropriate patient observation and monitoring

Although some risks cannot be eliminated, proactively identifying potential dangers is paramount.

If the surveyor identifies a risk (ligature or other self-harm), the issue must be addressed and corrected immediately as this is an Environment of Care Standard finding. 

This is unlike risks that fall under Life Safety, whereas the facilities manager can request a time limited waiver and correct the issue within an extended period of time. There are no time limited waivers for findings in the Environment of Care Standards.

If the facilities manager is unable to make an immediate correction, the mitigation plan must be implemented, which may include installing temporary enclosures and relocating patients and staff.

Other physical environment factors to consider

Many surveyors find ligature risks or looping potential with interior patient room bathroom doors. Facilities managers can correct this deficiency in a couple different ways:

● Install new door hardware with top sensor monitoring.

● Completely replace the door with an approved door.

Replacement of the doors, including labor, could mean hundreds or thousands of dollars per door. Each facility is unique and there is no one-fits-all approach.

To be certain that your corrections are compliant, send the submittals and specifications to the Authority Having Jurisdiction (AHJ), and obtain their approval in writing prior to placing a purchase order. Keep the signed approval on file in case your corrections are found noncompliant by a different surveyor.

Resource suggestions

Architects designing new healthcare facilities or renovations should follow the Design Guide for the Built Environment of Behavioral Health Facilities by The Facilities Guidelines Institute. This will come in handy when submitting drawings and specifications to the AHJ.

Additionally, certain states have websites outlining approved and rejected materials and equipment for the behavioral health setting. 

I often reference the Patient Safety Standards, Materials and Systems Guidelines (18th Edition) produced by the New York State Office of Mental Health. 

This manual is a guideline to approved and rejected materials, items under evaluation, and items to be used with caution depending on the risk level in New York State facilities. Other states may have similar sites and/or guidelines to assist in proper selection of materials, systems, and equipment.

In closing

Healthcare facilities managers play an important role in fostering patient safety. It is our responsibility to help ensure environments for patients and staff are safe and suitable for care.

Understanding ligature risks and the inspection survey process should be at the top of facilities management curriculum. Any shortcomings could potentially endanger the lives of patients and staff, and jeopardizes the hospital’s accreditation and reimbursements from Medicare and Medicaid programs. 

Our industry must continue to be a knowledge partner for healthcare organizations and the healthcare industry in this area.

Gary Giovinazzo, CHFM, CHSP, CHEP, SASHE is a CBRE Healthcare Practice Leader for an integrated hospital system in New York City. 


See the latest posts on our homepage


Topic Area: Safety

Recent Posts
Recent Posts

Taking on Tornado Season: Is Your Healthcare Facility Prepared?

Scientists predict 2021 could rival 2011 super outbreak


Is UV Germicidal Light Effective in Operating Rooms?

New study shows whether environmental services teams can use UV to disinfect between surgeries


Food Service Supply Chain Issues Prompt Changes

Management team decided to create secondary menus to ensure they had backup plan


Diagnostic Software Delivers Energy Efficiency

Trouble spots included leaky water valves and faulty valve actuators and damper actuators


Case Study: Hospital Design Centers on Patient Healing

Creating uplifting atmosphere was central to inpatient pavilion at Vassar Brothers Medical Center


Post Comment


News & Updates • Webcast Alerts • Building Technologies

All fields are required.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.