Healthcare Facility Compliance 12 items
Ligature-Risk Environmental Scan
Environmental scan of behavioral health and general-acute areas for ligature and self-harm risks, mitigation, and monitoring for at-risk patients.
TJC EC.02.06.01CMS QSO ligature guidanceTJC NPSG.15.01.01
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Fixtures & Hardware
- Are doors, hinges, and handles in psychiatric patient areas ligature-resistant? *
- Are bathrooms free of ligature points at fixtures, grab bars, shower heads, and plumbing? *
- Are beds, furniture, and fixtures free of anchor points or fastened to prevent use as ligature points? *
Contraband & Access
- Are cords, tubing, plastic bags, sharps, and other contraband controlled in patient areas? *
- Are drop ceilings, exposed pipes, and HVAC returns assessed and mitigated? *
- Is patient property searched and hazardous items secured per policy? *
Risk Assessment & Monitoring
- Is a validated suicide-risk screening completed for behavioral health patients? *
- Is a documented environmental risk assessment maintained with a mitigation plan for identified risks? *
- Are appropriate levels of observation (e.g., 1:1) provided for high-risk patients in non-ligature-resistant settings? *
Staff Readiness & Review
- Are staff trained to recognize and respond to suicide and self-harm risk? *
- Is the ligature-risk environmental assessment reviewed and updated on a defined schedule? *
- Are self-harm and suicide events reviewed to identify environmental contributors? *
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