BriggsNetNews

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

CMS posted QSO-23-19-Hospitals this morning (July 17, 2023). 

Medicare-certified hospitals have a regulatory obligation to care for patients in a safe setting under the Medicare Hospital Conditions of Participation at §482.13(c)(2). The intention of this requirement is to specify that each patient receives care in an environment that a reasonable person similarly situated as the patient would consider to be safe. Additionally, this standard is intended to provide protection for the patient’s emotional health and safety as well as his/her physical safety. Respect, dignity, and comfort would also be components of an emotionally safe environment.

The focus of ligature risk management should be to place patients in an environment, with appropriate monitoring, reflective of their specific medical and psychiatric needs. Based on their clinical evaluation, some patients may require both a more restrictive environment and an increased level of monitoring than other patients. Therefore, it is not expected that hospitals have the same ligature risk configuration throughout their facility, but rather focus on the specific needs and risks of individual patients, based on their clinical or psychiatric assessment. Similarly, corrective actions implemented in response to deficiencies or adverse events should focus on appropriately addressing the findings or failures, rather than universal remedies. For example, the attempted use of a door as a ligature point does not mean all patient doors in the hospital need to be replaced. Instead, surveyors should investigate further to determine whether the failure could have been the result of something more basic to safe patient care, such as insufficient monitoring and/or patient assessment and evaluation. All contributing factors should be considered before corrective action is initiated.

Patient safety issues related to ligature risks identified should be cited at the appropriate CoPs (for example, Patient Rights, Physical Environment, Nursing Services, QAPI, etc.) depending on the specific types of non-compliance identified.

Patients at risk of suicide (or other forms of self-harm) or who exhibit violent behaviors toward others receive healthcare services in both inpatient and outpatient locations of hospitals. Although all risks cannot be eliminated, hospitals should be able to demonstrate how they identify patients at risk of self-harm or harm to others and the steps they are taking to minimize those risks in accordance with nationally recognized standards and guidelines. The potential risks include, but are not limited to, those from ligatures, sharps, harmful substances, access to medications, breakable windows, accessible light fixtures, plastic bags (for suffocation), oxygen tubing, bell cords, etc.

Hospitals should consider three main elements in ensuring patient safety related to ligature risks:

• Patient Assessment
• Staffing/Monitoring
• Environmental Risk

The QSO provides information for all the above elements.

Resources to Improve Quality of Care:

Check out CMS’s new Quality in Focus interactive video series. The series of 10–15 minute videos are tailored to provider types and aim to reduce the deficiencies most commonly cited during the CMS survey process, like infection control and accident prevention. Reducing these common deficiencies increases the quality of care for people with Medicare and Medicaid.

Learn to:

• Understand surveyor evaluation criteria

• Recognize deficiencies

• Incorporate solutions into your facility’s standards of care

See the Quality, Safety, & Education Portal Training Catalog, and select Quality in Focus.