Archive for: Suicide prevention

Safety Month Showcase: Tips for assessing behavioral health units for ligature risks

By: June 18th, 2018 Email This Post Print This Post

The National Safety Council has designated June as its annual National Safety Month as a way to focus on “reducing leading causes of injury and death at work, on the road, and in our homes and communities.” In accordance with that, HCPro’s safety team will highlight a different healthcare-oriented safety topic each week in the month of June by sharing an excerpt from one of our many books, all available on

The focus this week is on life safety. The excerpt is from Analyzing the Hospital Life Safety Survey, Third Edition, authored by Brad Keyes, CSHP.

In that book, Keyes, formerly of The Joint Commission and currently an HFAP life safety surveyor and independent consultant, provides a practical, strategic approach to the life safety survey process. He walks you through a room-by-room, floor-by-floor analysis of the life safety measures you must have in place to avoid costly citations. The book simplifies Joint Commission standards and CMS requirements and focuses on ways to pass your next life safety survey.

One issue being scrutinized by TJC, CMS, and others right now is ligature risks for suicide, something Keyes tackled in the book excerpt we are sharing this week.

Every behavioral health unit needs to be assessed for potential suicide hanging points. I am an advocate for a process that has a continuous risk assessment, conducted routinely (such as once a quarter), to make sure nothing has been overlooked—every assessment has a chance to uncover something new. The assessment itself simply evaluates any point on the unit where patients could potentially hang or harm themselves without the staff observing it. This primarily concerns the patient’s room and shower area, but could include any other room where patients are not continuously monitored.

Some items that a surveyor may inspect for possible hanging points are:

  • Shower curtains
  • Sink and toilet plumbing pipes
  • Open handrails and grab bars
  • Shower faucets and spray heads
  • Bed rails and grab bars
  • Patient clothes closet doors
  • Doorknobs and hinges
  • Tops of doors
  • Acoustical tile and grid suspended ceilings in areas that are not supervised by staff

If any of these items can support the weight of an individual, then they present a safety risk. A typical risk assessment should be conducted by various stakeholders from the organization, such as the behavioral health unit manager, the risk management manager, the safety officer, the facilities manager, the environmental services manager, the chief nurse, the security manager, and anyone else the organization believes should be included.

The basic assessment should: 1. Identify safety risks, 2. Assess the potential for patient harm, 3. List actions that could eliminate or reduce the risks, and 4. Identify what actions, if any, are to be taken and by whom.

After the risk assessment is completed, everything discussed should be documented and taken to the safety (environment of care) committee for its review and approval. I consider it best practice for the safety committee to vote for approval of the risk assessments since the assessments will then be entered into the committee minutes for everyone to see. This can be very helpful when demonstrating to a surveyor that the assessment was actually conducted. A sample risk assessment template is included in the appendix.

You cannot operate a behavioral health unit without provisions to keep patients from walking off the unit. Therefore, in a hospital environment, you are permitted to lock the exit doors. The LSC refers to locks in this situation as “clinical need” locks. Clinical need locks are permitted in healthcare occupancies where patients require special security measures for the safety of themselves or others.

There must be an adequate provision made for rapid removal of all patients; this could entail a remote control that unlocks the doors or a key carried by staff that can open all locks on the unit. If you choose the latter, then all staff who perform their job responsibilities on the behavioral health unit must carry the appropriate key with them at all times. This includes the clinical staff, obviously, but it also includes support staff such as environmental services, maintenance, food service, etc.

(Editor’s note: Specifics on locking patients rooms, included in the book, were cut from this free digital excerpt for space reasons.)

Some behavioral health units have craft or activity rooms that can be used for patient therapy. These rooms can contain sharp or hot instruments, presenting an obvious potential for patients to injure themselves or others. A thorough risk assessment must be conducted with the same or similar group of people who assessed the unit’s potential suicide hanging points. All utensils and equipment in craft or activity rooms should be accounted for and stored behind locked doors and drawers. Patients should be screened to ensure only suitable individuals enter the room, and patients in the room must be continuously monitored.

If your behavioral health unit has corners or dead-end corridors that are hidden from view of security cameras or nurse stations, these blind spots present possible areas for an attack by an agitated, frustrated, or aggressive patient. Again, an assessment must be made to determine if these risks to staff safety exist, and if they do, then suitable action needs to be taken. AO surveyors are looking for blind spots and are asking what the hospitals are doing about them.

Possible solutions to these problems include:

  • Closed circuit television cameras that are monitored at the nurse station
  • Removing or modifying walls to increase line of sight
  • Eliminating dead-end corridors by installing a wall and a door to keep patients away
  • Personal radio transmitters worn by staff so they can signal for assistance when needed

Surveyors have cited hospitals when they believe the staff is at risk of attack in areas that are not monitored. It is the responsibility of the hospital to ensure the working environment for staff is as safe as possible.

Here are some additional things to consider that could pop up during a survey:

  • Furniture must be assessed to determine if it can be used as a weapon or as a means of breaking a window. Heavy-duty screens or nonbreakable plastic should be considered over the windows to prevent individuals from breaking the window with a chair and jumping out.
  • Remember that electrical cords on patient beds and televisions in common areas can be used as weapons by patients.
  • Many behavioral health units choose to have platform beds rather than standard hospital beds, even if they are manual crank beds instead of electric. This is because platform beds cannot be easily used as a hanging point, unlike standard hospital beds.
  • Be careful where you place the public telephone. The handset of a typical pay phone is rather heavy and can be used as a weapon. Therefore, the telephone should be in a place where it is continuously monitored by staff.

To purchase Analyzing the Hospital Life Safety Survey, Third Edition, please click here. And check back next Monday for a free HCPro book excerpt focusing on a different healthcare safety topic.

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