January 03, 2018 | | Comments 2
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CMS memo defines ligature risk and clarifies expectations

A new CMS memo creates a definition of a ligature risk, a time frame for correcting them, and 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 more comprehensive guidance on ligature risks. The agency says it expects to have the update done in six months. Until then, accrediting organizations (AO) are allowed to use their own judgment on ligature risks. That includes the definition of a ligature risk, plans for correction, how deficiencies are ranked, and how long a facility has to correct the problem. Facilities should double-check with their AO’s ligature risk and self-harm requirements.

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Filed Under: Patient Safety

About the Author: Brian Ward is an Associate Editor at HCPro working on accreditation, patient safety, and quality news.

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  1. Hello,

    I am a COTA on the Behavioral health Unit at St. Joseph Hospital in Fort Wayne, IN. We have moved our unit to another floor and I have been tasked to find frames for artwork that do not present any ligature risks. Any ideas or impossible tasks.

  2. Hello,
    Artwork is important to patient satisfaction. For a behavioral health unit it needs to be secure to the wall and not a ligature risk. Instead of glass, a plastic type surface that does not shatter should be used.
    There are some ligature free picture frames that can be found online. It would it be okay for a facility to use one of these IF they tested it once it arrived (to see if it was as safe as advertised) and documented the result.
    So yes, order one and test it. If it passes, document your findings and then order more as needed and install on the walls.
    It is not required to have an outside inspector come in to approve. It it is important to have all of your paperwork from your risk assessment and the manufacturer’s information as to why it is safe for behavioral health units. Then have the documentation available to show the state, CMS or Joint Commission on your next survey.

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