Update on Ligature Risks, Suicide Prevention, Restraints and Seclusions

Update on Ligature Risks, Suicide Prevention, Restraints and Seclusions

March 24, 2021

Noon - 2 p.m. CST

Hospitals must comply with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation. According to CMS and accrediting organizations such as DNV and Joint Commission, the most cited Condition of Participation is Patient Rights. The highest numbers are in the areas of restraints and seclusions followed by care in a safe environment.

According to CMS, ligature risks compromise a patient’s right to receive care in a safe setting. CMS interpretative guidelines have added detailed information on ligature risks and the requirements for patient care of suicidal patients to prevent strangulation and these patient care and environmental expectations will be discussed. Within the Patient Rights Condition, the regulations governing the appropriate usage of restraints and seclusions account for more than 50% of the Patient Rights regulations. Problematic areas of compliance with be discussed including restraint death reporting requirement. The recent 2019 changes to restraint requirements will be explained.

This webinar is a must attend for anyone involved in quality assessment and improvement, direct patient care, compliance, risk management and other staff responsible for survey preparation.

Target Audience:

This program is intended for all hospitals including general acute hospitals, critical access hospitals (CAH), psychiatric hospitals, hospitals or CAH with psychiatric units and anyone involved with compliance regulations and standards, including but not limited to CEO, CMO, CNO, physicians, nurses, quality improvement staff, risk managers, compliance officers and legal counsel, Joint Commission liaisons, safety officers, behavioral health and psychiatric staff, Emergency department staff, and other interested staff.

Learning Objectives:

  • Describe the CMS requirements for providing care in a safe environment for all patients, specifically those patients who are suicidal or in need of behavioral health services.
  • Explain what an immediate jeopardy citation means to the hospital
  • Explain the implications of a Condition Level deficiency
  • Discuss the CMS adoption of the TJC (The Joint Commission) Suicide Panel recommendations of the comprehensive ligature risk interpretative guidelines
  • Explain the specific guidance that surveyors utilize in determining compliance with providing care in safe environment
  • Discuss physical environment issues
  • Discuss potential issues with personal belongings
  • Provide examples of IJ and COP level deficiencies relating to patient safety
  • Explain CMS definitions of restraints and seclusion
  • Describe which restraint regulations which are at greatest risk for citation and how to prevent
  • Explain requirements to utilize restraints
  • Explain which deaths while in restraints must be reported to CMS
  • Describe the internal log requirements for restraint deaths

Registration Pricing:

  • Member (charge per connection): $149
  • Nonmember: $179

You are allowed one connection/viewer per member registration. Additional line connections will be billed accordingly. If you would like to gather as a group, select the group rate for unlimited attendees/connections to the webinar. Simple instructions with a link to the webinar will be sent when you register and again the day before the webinar. A recording of this program is also included in the cost of registration.


Nancy Ruzicka, RPh, MBA, MJ, CHC, Ruzicka Healthcare Consulting LLC

Nancy Ruzicka Nancy Ruzicka has experience teaching and assisting hospitals and other healthcare facilities in understanding applicable Federal and State laws, rules, regulations and interpretative guidelines. Her experience also encompasses teaching all levels of healthcare staff in understanding compliance and HIPAA requirements.
Ruzicka’s previous experiences include Director of Integrity & Compliance and Privacy Official at Mercy Medical Center, Des Moines; Director of Regulatory Compliance at UnityPoint Health and over twenty years of experience with Iowa Department of Inspections and Appeals.
She received her MJ in Health Law, MBA and BS in Pharmacy from Drake University, Des Moines. She is certified in Healthcare Compliance (CHC) and maintains her Iowa pharmacy license. Ruzicka Healthcare Consulting, LLC has an outstanding reputation for providing solutions through consulting, education, and mock surveys. They focus on current needs and challenges related to regulatory compliance and accreditation. Ruzicka Healthcare Consulting, LLC brings expertise in regulatory, compliance, and accreditation in a customized client focus for proven results.