Ligature and/or Suicide Risk Reduction - Inpatient Psychiatric Units - Ligature Resistant Medical Beds
How many ligature-resistant medical beds does my unit have to have ?
Any examples are for illustrative purposes only.
The Joint Commission has not specified a requirement for the number of ligature resistant beds on any given unit. This will depend on the needs of the patient population. The type of medical bed should be balanced based on the medical needs and the patients' risk for suicide. If medical beds that contain ligature risks are being used within an inpatient and/or designated psychiatric unit, they must be identified on the organization's environmental risk assessment (as per NPSG.15.01.01 EP1). For patients who require medical beds that have ligature points, there must be appropriate mitigation plans and safety precautions in place, including 1:1 observation for patients determined to be at high risk for suicide who have access to the bed(s). Plans to mitigate risk must be documented within the patients' medical record (as per NPSG.15.01.01 EP4). The organization must consider these risks in patients' overall suicide/self-harm risk assessments and implement interventions to mitigate these risks.
The Joint Commission will not advise on the type of medical beds or ligature-resistant beds that should be purchased for patients. These decisions should be balanced based on patient needs. Organizations must evaluate beds and be aware of the ligature and/or other safety risks the bed(s) may present.
In addition, if these medical beds are being used, safety provisions must be considered. Provisions may include, but are not limited to, locking the patient room door where a medical bed is being used when unoccupied, removing a medical bed from the unit if not in use, enacting the safety features of the bed, when appropriate, and/or enhanced environmental and safety rounding. These provisions must be addressed in the organization's environmental risk assessment and/or policies and procedures.
Additional Resource
Suicide Prevention Portal
The Joint Commission has not specified a requirement for the number of ligature resistant beds on any given unit. This will depend on the needs of the patient population. The type of medical bed should be balanced based on the medical needs and the patients' risk for suicide. If medical beds that contain ligature risks are being used within an inpatient and/or designated psychiatric unit, they must be identified on the organization's environmental risk assessment (as per NPSG.15.01.01 EP1). For patients who require medical beds that have ligature points, there must be appropriate mitigation plans and safety precautions in place, including 1:1 observation for patients determined to be at high risk for suicide who have access to the bed(s). Plans to mitigate risk must be documented within the patients' medical record (as per NPSG.15.01.01 EP4). The organization must consider these risks in patients' overall suicide/self-harm risk assessments and implement interventions to mitigate these risks.
The Joint Commission will not advise on the type of medical beds or ligature-resistant beds that should be purchased for patients. These decisions should be balanced based on patient needs. Organizations must evaluate beds and be aware of the ligature and/or other safety risks the bed(s) may present.
In addition, if these medical beds are being used, safety provisions must be considered. Provisions may include, but are not limited to, locking the patient room door where a medical bed is being used when unoccupied, removing a medical bed from the unit if not in use, enacting the safety features of the bed, when appropriate, and/or enhanced environmental and safety rounding. These provisions must be addressed in the organization's environmental risk assessment and/or policies and procedures.
Additional Resource
Suicide Prevention Portal
Manual:
Hospital and Hospital Clinics
Chapter:
National Patient Safety Goals NPSG
New or updated requirements last added: February 01, 2022.
New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: February 01, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: June 27, 2018
This Standards FAQ was first published on this date.
This page was last updated on September 07, 2023
with update notes of: Reflects new or updated requirements
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Reflects new or updated requirements: Changes represent new or revised requirements.