Every hospital needs to attend this webinar. It is now a hot area and there is a lot of survey activity around the 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 is 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 inpatient 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 its standards. These will discuss in detail and include psych hospitals, 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 areas 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.
CMS Hospital Ligature Risks
Resources and tools of the trade
(A.D., B.A., B.S.N., M.S.N., J.D. CPHRM, CCMSCP, CC)
Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal, patient safety, and risk management issues and writes numerous publications. Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, emergency department patient safety, and risk, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, implementing a falls program, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year. She was the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program.