Home Events Ligature Risks and Preventing Inpatient Suicide: Compliance with the CMS and TJC Standards

Ligature Risks and Preventing Inpatient Suicide: Compliance with the CMS and TJC Standards


Date: 7/18/23

9:00 – 11:00 A.M.  Central time


Registration fees:     $225 per facility   |   Non-Members Registration Fee:  $350 per facility


Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.


Suicide is the third most frequently reported sentinel event. Suicide prevention and protecting patients from harm or strangulation is a major focus of accreditation surveys. The Centers for  Medicare & Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients that exhibit suicidal behaviors. Any hospital that receives Medicare and/or Medicaid payments must implement these changes for all patients. CMS tag number 144 in patient rights and tag number 701 in facility services discuss what units need to be ligature resistant. These tags cover patient assessments, environmental assessments, education and policy, and procedure requirements. The Joint Commission (TJC) has multiple requirements to  ensure compliance with their standards regarding ligatures and suicide prevention. These standards will be discussed to include psychiatric hospitals, behavioral health units, general acute care inpatient units, and emergency departments. The webinar will provide resources and tools that can be used to assess patients to determine if they have suicidal ideations.


At the conclusion of this session, participants should be able to:

  • Recite that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations.
  • Discuss that the Joint Commission has requirements hospitals must follow to prevent patients from self-harm, including hanging or strangulation.
  • Describe that CMS recommends education in orientation when policies change and every two years.
  • Recall that CMS has proposed guidelines.


Laura A. Dixon most recently served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities,  practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

This speaker has no real or perceived conflicts of interest that relate to this presentation.




Jul 18 2023


9:00 am - 11:00 am

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