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The Joint Commission puts new emphasis on ligature risks

Healthcare FMs and real estate executives should know that ligature risks have become a significant concern of The Joint Commission during the last year. Michael S. Bernstein, Life Safety Code Surveyor for The Joint Commission, offered tips and resources to help secure your facility at the NYC: 5th Annual Hospital, Outpatient Facilities & Medical Office Buildings Summit.

The event, held Sept. 17 at the New York-Presbyterian Hospital, was sponsored by Corporate Realty, Design & Management Institute and the Health Care Institute of IFMA.

Bernstein explained via email after the event why the new emphasis: “A facility was surveyed, it had ligature risks identified during survey, and before they could be mitigated there were two successful suicides. This occurred in the 1st quarter of 2017.”

Here are the tips and resources Bernstein offered at the conference:

  • If we find significant ligature risk, it can be called immediate threat to life!
  • The U.S. Department of Veteran’s Affairs has good guidelines for behavioral health. Look to them for guidance.
  • Survey evaluations will include: Patient Room, Solid Ceiling, Bed, Light Fixtures, HVAC Vents, Tamper Proof Screws, Sprinkler Heads, Bathroom Fixtures (plumbing, toilet paper dispensers, paper towel dispensers, etc.), Grab Rails, Full-size doors and hardware, Curtains (Privacy, Window Treatment, and Shower), Medical Gases, Medical Devices.
  • Survey evaluation will include: Common Areas: Therapy Room, Day Room, Restrooms/Bathroom, Laundry Room.
  • Scoring may vary depending on the situation: Immediate Threat to Health or Safety vs. Condition Level, Identification prior to the survey, Mitigation plan and implementation, Plan of correction.
  • Guidelines to help with Ligature: State rules and regulations and “Guidelines for Design and Construction of Health Care Facilities,” 2014 edition Evidence-Based Guidelines: “Design Guide for the Built Environment of Behavioral Health Facilities” National Association of Psychiatric Health Systems (NAPHS). “Patient Safety Standards, Materials, and Systems Guidelines, New York State Office of Mental Health (OMH). “Mental Health Facilities Design Guide,” Department of Veterans Affairs (VA), Office of Construction & Facilities Management. “Designing Environments for Alzheimer’s Disease.