Updated CMS Ligature Risk Guidance

The Centers for Medicare & Medicaid Services (CMS) recently issued an update to the State Operations Manual used by surveyors on protecting patients from ligature risks. While the update noted that the primary focus was on psychiatric hospitals and hospitals with psychiatric units, it was also clear that all hospitals (not just those with psych beds) caring for patients with psychiatric conditions must identify patients at risk for intentional harm to self or others and mitigate environmental safety risks. The guidance outlines:

  • how patients should be identified,
  • steps to take in implementing an environmental risk strategy,
  • the type of training that should be provided to staff, and,
  • the timeline for corrective action.
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