Ligature Risk Made Practical: How to Run a Survey-Ready Environmental Risk Assessment
Step 1: Define your scope (so your assessment is defensible)
Document the “who/where/when”:
Population served: adult MH, adolescent RTC, detox, co-occurring, etc.
Care model & supervision: routine checks, line-of-sight, 1:1, awake overnight, etc.
Spaces covered: bedrooms, bathrooms, common areas, group rooms, corridors, outdoor areas, storage/utility access, etc.
Trigger events: baseline, after renovation/changes, after incidents/near misses, and at a defined interval (e.g., quarterly or semiannual).
Why it matters: Joint Commission expectations focus on thoughtful evaluation of the environment and having a plan/resources that guide staff.
Step 2: Build an interdisciplinary team (and assign ownership)
Minimum recommended roles:
Clinical leadership (Program/Clinical Director)
Nursing leadership (DON/designee)
Facilities/Maintenance
Safety/Risk/Compliance or QAPI lead
Direct care staff representative (they see what actually happens)
Document:
ERA lead/owner
Recorder (photos, tool completion, action log)
Approver (sign-off authority)
Step 3: Use a standardized Environmental Risk Assessment (ERA) tool (consistency is everything)
Your form should be simple but complete. Include:
Assessment fields
Area/room ID
Hazard description (ligature point / anchor point / tool-access / blind spot)
Risk rating (Likelihood x Severity)
Current controls (rounding, supervision, restricted items)
Mitigation plan (engineering + administrative)
Interim controls (if fix is delayed)
Owner + target date
Verification method (photo/work order/audit)
This directly supports the NPSG expectation to identify environmental features that could be used to attempt suicide and take action to minimize risk.
Step 4: Walk the environment using a “patient pathway” lens
Assess like a patient, not like a contractor. Ask:
Where are individuals alone or less observable?
Where do escalations occur?
What can be improvised (cords, clothing, bags, linens, furniture)?
What breaks/loosens over time (hinges, hooks, dispensers, door hardware)?
High-yield areas in residential:
Bathrooms (privacy + fixtures)
Bedrooms (door/closet hardware, windows, blinds/curtains)
Door hardware (hinges, closers, handles)
Common areas (TV mounts, cables, cords, furniture)
Storage/maintenance access (tools/cords/chemicals)
Important nuance: Joint Commission’s standards FAQs note there is no “height requirement” for ligature risk—low anchor points can still be used.
Step 5: Risk-rate consistently (and define what triggers urgent action)
Pick a simple method and stick to it.
Example (1–3 scale):
Likelihood: 1 unlikely / 2 possible / 3 likely
Severity: 1 low / 2 serious / 3 life-threatening
Risk score = L x S
Define response thresholds:
6–9: urgent mitigation + interim controls immediately
3–4: mitigation plan with timeline + interim controls as needed
1–2: monitor / maintain controls
Surveyors care less about your math and more about whether high-risk findings trigger timely mitigation and documented interim protections.
Step 6: Apply mitigation in the right order (engineering → administrative → interim controls)
1) Engineering controls (preferred)
Ligature-resistant/reduced hardware (where clinically appropriate)
Breakaway shower rods/curtains
Tamper-resistant fasteners
Furniture replacement/modification
Remove/modify anchor points where feasible
2) Administrative controls
Observation adjustments (line-of-sight, increased frequency)
Bathroom/bedroom protocols
Contraband checks + restricted items management
Staffing plan adjustments during higher acuity
3) Interim controls (documented, time-limited)
If a fix will take time, document what you’re doing today.
Example:
“Room 8 bathroom hook identified; interim control: supervised bathroom access for high-risk individuals served; work order #____; completion by ____.”
Joint Commission FAQ guidance also highlights observation expectations in areas with ligature risk for individuals at high risk (e.g., the need for continuous observation with immediate intervention capability in certain contexts).
Step 7: Convert findings into an action log that QAPI tracks until closure
This is where programs win or lose surveys.
Your Ligature Mitigation Action Log should include:
Finding / location
Risk score
Mitigation type (engineering/administrative)
Interim controls (if any)
Owner
Target date
Work order reference + vendor notes
Verification (photo/inspection/audit)
Closure date + sign-off
Bring the action log to QAPI until all high-risk items are closed. This turns “assessment” into a living safety process.
Step 8: Train staff to recognize and report ligature hazards
NPSG materials emphasize training and competence for staff caring for individuals at risk for suicide.
Training should be practical:
What are common ligature risks in your building?
What changes over time (missing screws, loosened fixtures, improvised cords)?
“Stop-and-call” triggers: what requires immediate escalation
Documentation expectations (rounding, hazard reporting, interim controls)
Step 9: Audit and re-assess (prove your system works)
Minimum cadence:
Routine environmental rounds with a ligature lens
Leadership spot checks
Re-assessment after incident/near miss
Re-assessment after renovation/environment change
For non-inpatient settings (residential/PHP/IOP), Joint Commission FAQs address expectations for environmental risk assessments—so documenting your cadence and triggers is especially important outside of “typical inpatient psych unit” framing.
What surveyors will want to see (your “ready binder” list)
Have these available:
Most recent ERA (signed/dated)
Action log + evidence of closure (work orders/photos)
Policy/procedure that links environment + supervision + response
Staff training roster + competency validation
Rounding/observation policy and sample documentation for high-risk individuals served
Need a second set of eyes before survey?
Book a 30-minute Ligature Risk Readiness Call and we’ll review your current ERA, mitigation log, and rounding process and map out the fastest fixes.