Webinar: Ligature Risk and Suicide

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*This webinar is part of the SDAHO 2021 Education Package – check with your facility to see if you are registered for the package*

Overview:

This is a hot area and there is a lot of survey activity around prevention of suicidal patients from harm or strangulation. The Joint Commission announced that this is one of the four top areas of focus and their data shows that hospitals are receiving many RFIs in this area. The Centers for Medicare and Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self harm from patients that are suicidal. A 13 page memo was issued and the hospital manual was amended. Any hospital that received Medicare, which are most hospitals in America, must implement these changes for all patients. This webinar will also discuss the CMS proposed 15 page guidelines changes for 2020.

CMS amends tag numbers 144 in patient rights and tag 701 in facility services. This discusses what units need to be ligature resistant. It covers what patient assessments must be done and what should be in the environmental assessments. It discusses education and policy and procedure requirements. If you have a highly suicidal patient and the room is not ligature resistant do you have a 1:1 sitter? Hospitals that do not will need to change their policy and process and budget for this.

Joint Commission has 16 requirements to ensure compliance with their standards. These will discussed in detail and include psych hospital, behavior health units, general acute care inpatient units, outpatient units and emergency departments. The zero suicide campaign will be discussed. The TJC sentinel event alerts on suicide, NPSG 15 and final changes July 1, 2019, and Frequently Asked Question (FAQ) on ligature risk will be covered. This includes one related to whether video monitoring is ever allowed. Again, the Joint Commission announced that this is one of four area of focus so hospitals need to have this issue on their radar screen and be prepared.

Resources will be provided. Tools to assess patients to determine if they have suicidal ideations will be included.

Objectives:

• Recall 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 for hospitals to follow to prevent patients from self harm including hanging or strangulation
• Describe that CMS recommends education in orientation, when policies change and every two years
• Recall that CMS has proposed guidelines

Presenter:

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

Registration:

Registration for this webinar is per connection needed at a facility. This allows multiple staff members to participate in the education using one connection. Prior registration is required to ensure connection information and applicable materials are distributed prior to the webinar. The registration fee for this webinar is $99 per SDAHO Member facility /$149 per non-member facility.