Additional FAQs: Suicide Risk Reduction Recommendations

The November 2017, January 2018, and July 2018 issues of Perspectives published suicide risk reduction recommendations from an expert panel convened by The Joint Commission. On October 9, 2018, The Joint Commission convened the sixth expert panel to further address questions related to these recommendations. The following set of Frequently Asked Questions (FAQs) is intended to clarify the panel’s recommendations to reduce the risk of suicide in health care settings.

For questions related to the FAQs or the suicide risk recommendations please contact the Standards and Interpretation Group (SIG) via the Standards Online Submission Form.

QUESTION: Are dropped ceilings allowed in corridors and common areas on an inpatient psychiatric unit?

ANSWER: Yes, dropped ceilings are allowed in corridors and common areas where staff are regularly present as allowable by the facility’s safety risk assessment.  These areas do not need to be in constant view of staff but should be a part of the standard safety rounds conducted by staff (for example, 15-minute patient safety checks, shift-to-shift environmental rounds, and so on).

Dropped ceilings in areas that are not fully visible to staff (for example, a right-angle curve of a corridor) should be noted on the risk assessment and have some additional steps taken to make it more difficult for a patient to attempt to access the space above the dropped ceiling (such as gluing or clipping tiles), which would allow staff to hear or see the patient’s suicide attempt and prevent the attempt from occurring.

QUESTION: Has The Joint Commission identified any specific items that should not be allowed to be brought on an inpatient psychiatric unit?

ANSWER: No, The Joint Commission does not determine the items to be prohibited from an inpatient psychiatric unit. Items that ore prohibited to be brought into organizations, due to the risk of harm to self or others, should be determined by the organization. Compliance with such safety measures is based upon organizational policies/procedures, individual core plans, and applicable state rules or regulations.

QUESTION : Does The Joint Commission recommend specific ligature-resistant products?

ANSWER: No, The Joint Commission does not recommend products.  Organizations are required to do the following:

  • Comply with the Recommendations for Suicide Prevention in Healthcare Settings (see the previously fisted Perspectives articles)
  • Conduct a risk assessment of the environment
  • Determine which products to appropriately install (based on manufacturersinstructions)
  • Ensure that the products are functioning properly to maintain ligature resistance P

 Perspective’s, January 2019, Volume 39, Issue1

1 reply
  1. BHFC says:

    NOTE: Behavioral Health Facility Consulting LLC. advises its clients to consider corridors that are NOT directly observable from the Nurse Station to be considered Level III areas. Corridors that are directly observable from the Nurse Station may be considered Level II as long as there will ALWAYS be staff present and the facility’s Risk Management and Safety Committees review the conditions and determine that this level of risk is appropriate for the patient population being served, staffing levels being provided and other considerations.

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