Joint Commission Recommendations for Ligature-Prevention Safeguards

PUBLISHED: Aug 10, 2018
Relevant to: Behavioral Health, Critical Access Hospitals, Hospitals

Recently StayAlert! reported that the U.S. Centers for Medicare and Medicaid Prevention (CMS) is planning to adopt and incorporate recommendations from a Joint Commission-convened panel that addressed environmental safeguards to reduce suicide risk. Today’s notice takes a closer look at Joint Commission’s recommendations.


In response to the continued occurrence of suicide within healthcare facilities, as well as disagreement between TJC surveyors and state agencies on what constitutes a ligature risk and what mitigation strategies are acceptable, TJC convened a panel of experts to develop recommendations to assist both providers and surveyors in understanding adequate safeguards to prevent suicide in the healthcare setting.

The panel developed 13 recommendations for inpatient psychiatric units, general acute care settings and emergency departments. A summary of the recommendations is provided below.

Note that in their report on the recommendations, TJC uses the term “ligature-resistant” because the expert panel determined that it is not possible to remove all potential ligature risks and a “ligature-free” environment is not a practical expectation.

Summary of TJC Recommendations:

For inpatient psychiatric units including psychiatric hospitals and general/acute care settings:

  • Patient rooms, patient bathrooms, corridors, common patient areas must be ligature-resistant. However, the following do not need to be ligature-resistant and will not be cited by TJC for ligature risks:
  • Nursing stations with an unobstructed view (i.e., a patient self-harm attempt can be easily seen and interrupted)
  • Areas behind self-closing/self-locking doors
  • Doors between patient rooms and hallways must contain ligature-resistant hardware including, but not limited to, hinges, handles, and locking mechanisms.
  • Health care organizations should not be required to have risk-mitigation devices installed to decrease the chance that the top of a corridor door will be used as a ligature attachment point.
  • Transition zones between patient rooms and patient bathrooms must be ligature-free or ligature-resistant.
  • Patient rooms and bathrooms must have a solid ceiling.
  • Drop ceilings may be used in hallways and common patient care areas as long as all aspects of the hallway are fully visible to staff and there are no objects that patients could easily use to access the drop ceiling and get access to ligature risk points in the space above the drop ceiling.
  • The medical needs of patients with serious suicidal ideation should be carefully assessed/balanced to determine the optimal type of patient bed utilized to meet both medical/psychiatric needs.
  • Patients with suicidal ideation requiring medical beds with ligature points must have mitigation plans/safety precautions in place.

According to TJC, the general medical/surgical inpatient setting does not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment. Recommendation for the general medical/surgical inpatient setting include:

  • Fixed ligature risks, including bathroom fixtures and doors, will not be cited on survey in these areas.
  • When a patient with serious suicidal ideation requires admission to a general acute inpatient admission, all objects (that can be removed without adversely affecting the ability to deliver medical care) that pose a risk for self-harm shall be removed. should be removed.
  • Mitigation strategies must be implemented and documented, including:
  • One-to-one monitoring
  • Careful assessment of objects brought into the room by visitors
  • Protocols for transporting patients to other parts of the hospital

According to TJC’s recommendations, Emergency Departments (ED) do not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment. Recommendations for EDs include:

  • Fixed ligature risks, including bathroom fixtures and doors, will not be cited on survey in these areas.
  • There must be policies and procedures for keeping patients with serious suicide ideation safe in the ED, including:
  • Use of safe-rooms that are ligature-resistant
  • Use of 1:1 monitoring
  • Removal of objects that pose risk for self-harm
    • Note: While TJC does not require the use of “safe-rooms” in the ED, the following is required:
      • Patient screening for suicidal ideation
      • Secondary screening for patients with suicidal ideation
      • Environmental risk assessment of the immediate vicinity for patients with suicidal ideation
      • Protocols for monitoring patients with suicidal ideation including bathroom use, visitors, transport
      • Staff training on management of patient with serious suicidal ideation
  • Patients with serious suicidal ideation receive reliable monitoring and intervention when necessary

Included with today’s notice is a link to the TJC recommendations and links to several example policies related to the recommendations.

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