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Healthcare Facility Compliance 13 items

Behavioral Health Unit Ligature Risk & Safety Audit

Environmental and clinical safety audit of psychiatric and behavioral health units focused on ligature-resistant design, self-harm risk mitigation, and suicide screening.

The Joint Commission EC.02.06.01CMS 42 CFR 482.13(e)NPSG.15.01.01FGI Guidelines

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Ligature-Resistant Environment

  • Are all patient rooms, bathrooms, and common areas on the locked psychiatric unit free of ligature attachment points (fixtures, door hardware, grab bars)? *
  • Are ligature-resistant door hinges, alarms, and top-of-door sensors installed on patient room and bathroom doors? *
  • Are shower heads, water controls, and plumbing designed to be ligature-resistant? *
  • Is a current environmental risk assessment (ligature risk assessment) documented and hazards mitigated or on a corrective plan? *

Contraband & Hazard Control

  • Are patients and their belongings searched for contraband and dangerous items on admission and after off-unit trips? *
  • Are cords, belts, sharps, glass, and plastic bags controlled and secured on the unit? *
  • Are medications administered under direct observation to prevent cheeking and hoarding? *

Suicide Risk Screening & Assessment

  • Is every patient screened for suicidal ideation using a validated, evidence-based tool on admission? *
  • For patients who screen positive, is a suicide risk assessment completed to identify severity and drive interventions? *
  • Is a documented, individualized safety plan or mitigation plan in place for at-risk patients? *

Observation & Staffing

  • Are levels of observation (e.g., one-to-one, close observation) ordered, documented, and consistently maintained per risk? *
  • Are staff trained to conduct and document observation rounds at the ordered frequency? *
  • Is staffing on the behavioral health unit adequate to safely manage acuity and observation demands? *

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