Clarification: Environmental Suicide Prevention

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Date: July 18, 2001 DSL-BQA 01-032 [Supersedes memo 01-027]

To: Hospitals HOSP 14

From: Jane Walters, Interim Chief, Health Services Section

cc: Susan Schroeder, Director, Bureau of Quality Assurance

DSL-BQA-01-027, Environmental Suicide Prevention, dated May 29, 2001, is amended to clarify one technical suggestion concerning ADA compliant grab bars and to clarify the relationship of JCAHO regulation, Medicare regulation, and State authority under the administrative code governing hospitals in Wisconsin, Chapter DHS 124 (exit DHS).

All hospitals in Wisconsin must be in compliance with Chapter HFS 124. Compliance with State law is a requirement for both JCAHO accreditation and Medicare certification.

Both acute care hospitals with psychiatric units and free standing psychiatric hospitals may be deemed to meet the Medicare regulations governing general hospital requirements. Deeming means the hospital is presumed to meet Medicare requirements, not that the JCAHO accreditation exempts the hospital from Medicare requirements. The Two Special Conditions found at 42 CFR 482.61, Special Medical Records Requirements for Psychiatric Hospitals, and 42 CFR 482.62, Special Staff Requirements for Psychiatric Hospitals, are not deemed.

The purpose of this memo remains to clarify regulatory requirements concerning the provision of a safe environment in psychiatric units and psychiatric hospitals. In the course of conducting investigations of inpatient suicides, the Bureau of Quality Assurance has become increasingly aware of environmental conditions that enabled patient suicides. The majority of persons who complete suicide suffer from a treatable mental disorder or a substance abuse disorder or both. Patients of inpatient psychiatric treatment facilities are considered at high risk for suicide; the environment should avoid physical hazards while maintaining therapeutic care. Ongoing assessment of suicidality is a necessary but not complete protection for psychiatric inpatients.

The majority of patients commit suicide via hanging in a bathroom, bedroom or closet. Measures for prevention of suicide through proper physical environmental design are identified in the following recommendations.

• Ceiling systems of a lay-in ceiling tile design should be avoided. Drop ceiling grids, and any plumbing, piping, ductwork or other potentially hazardous elements concealed above a ceiling can be used as a hanging device.

• Sprinkler heads should be a flush mounted design.

• Door-closer devices should be mounted on the public side of a door versus the private patient side of the door. Ideally, the door-closer (if required) should be within view of a nurse or staff workstation. Door hinges should be of the continuous piano style. Door lever handles should point downward when in the latched position. Note that all hardware should have tamper-resistant fasteners.

• Towel bars are not required for American with Disabilities Act (ADA) accessibility compliance, therefore avoiding towel bar installations in private patient rooms is recommended. If provided, towel bars should be designed to not support the weight of the least heavy patient served on the unit.

• Showerheads should be of the flush mounted design. Push-button shower controls are recommended.

• Clothing rods or hooks should be designed to not support the weight of the least heavy patient served on the unit.

• Horizontal or partially inclined utility pipes exposed in private patient areas should be enclosed.

• ADA compliant grab bars are required in 10% of the patient private/semi-private toilet rooms. The remaining 90% are not required to have ADA compliant grab bars installed unless the patient room is used by a patient with disabilities. Reinforced wall areas for future installation of grab bars should be provided or existing wall capabilities should be verified. Grab bars for fully ambulatory patients should be removed. If grab bars are required for a patient, the bars should be mounted with a continuous rail-to-wall attachment.

• Shower curtain rods should be designed to not support the weight of the least heavy patient served on the unit.

• Staff members should adequately supervise ADA-compliant patient areas that include grab bars such as clinic, treatment, occupational therapy and physical therapy areas.

• Seamless floors should be used instead of tile that has sharp corners.

• External breakable windows should have a plastic window or locked interior safety screens placed over them. Keys should be with staff at all times.

• Furniture should be of a durable heavy-duty design that can’t be broken or dismantled and used as a weapon or tool.

• Electrical cords should be shortened.

• Seclusion room doors should swing outward to minimize injury to staff.

The last recommendation is included to provide an overall level of safety since physical environment in itself cannot ensure a safe facility. The following state requirement applies to all hospitals in Wisconsin regarding adequacy of staffing:

• HFS 124.13 (1) (c) 1: An adequate number of registered nurses shall be on duty at all times to meet the nursing care needs of the patients. There shall be qualified supervisory personnel for each service or unit to ensure patient care management.

The state staffing requirement applying to free-standing psychiatric hospitals in Wisconsin is:

• HFS 124.26 (3) (a): The hospital shall have enough staff with appropriate qualifications to carry out an active program of psychiatric treatment for individuals who are furnished services in the facility.

The federal requirement for all hospitals participating in the Medicare program to maintain a safe environment is:

• 42 CFR 482.13(c)(2): The patient has the right to receive care in a safe setting.

In a free-standing psychiatric hospital, adequate staffing is required per the following federal regulation:

• 42 CFR 482.62: The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

In order to be excluded from the prospective payment systems, a psychiatric unit of a general hospital must meet the following requirement:

• 42 CFR 412.27(1): Meet special staff requirements in that the unit must have adequate numbers of qualified professional and supportive staff to evaluate inpatients, formulate written, individualized, comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

Note:  JCAHO accredited hospitals are deemed to meet Medicare general hospital standards and are not exempted from them. The Two Special Conditions found at 42 CFR 482.61, Special medical records requirements for psychiatric hospitals, and 42 CFR 482.62, Special staff requirements for free-standing psychiatric hospitals, are not deemed.

In summary, proper facility design and adequate staffing are essential elements of effective psychiatric treatment. Hospitals wishing to request consultation may contact their facility assigned bureau engineer.

For additional information please refer to the following resources:

• Surgeon General’s National Strategy at www.mentalhealth.org/suicideprevention (exit DHS);

• National Center for Injury Prevention and Control at www.cdc.gov (exit DHS); and the

• American Foundation for Suicide Prevention at www.afsp.org (exit DHS).

Please share this information with the appropriate staff. If you have questions concerning the regulatory issues, please contact Helen Brewster, ACSW, CICSW, at (608) 243-2089, or David R. Soens, P.E., at (608) 261-5993.

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