Suicide is the third most frequently reported sentinel event. Suicide prevention and protecting
patients from harm or strangulation is a major focus of accreditation surveys.
The Centers for Medicare & Medicaid Services (CMS) has promulgated requirements for
hospitals to prevent ligature risk and self-harm from patients who exhibit suicidal behaviors.
Any hospital that receives Medicare and/or Medicaid payments must implement these changes
for all patients.

CMS tag number 144 in patient rights and tag number 701 in facility services discuss what
units need to be ligature resistant. These tags cover patient assessments, environmental
assessments, education and policy, and procedure requirements.
The Joint Commission (TJC) has multiple requirements to ensure compliance with their
standards regarding ligatures and suicide prevention. These standards will be discussed to
include psychiatric hospitals, behavioral health units, general acute care inpatient units, and
emergency departments.

The webinar will provide resources and tools that can be used to assess patients to determine
if they have suicidal ideations.

At the conclusion of this series, participants should be able to:
 Recite that CMS now has two tag numbers that set forth requirements to prevent
ligature and suicide risks for patients with suicidal ideations.
 Discuss that the Joint Commission has requirements hospitals must follow to prevent
patients from self-harm, including hanging or strangulation.
 Describe that CMS recommends education when policies change and every two years.
 Recall that CMS has recently updated guidelines.

Faculty:
Laura A. Dixon served as the director of risk management and patient safety for the Colorado
Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient
safety and risk management and operations for COPIC from 2014 to 2020. In her role, she
provided patient safety and risk management consultation and training to facilities,
practitioners, and staff in multiple states.

Dixon has more than 20 years of clinical experience in acute care facilities, including critical
care, coronary care, peri-operative services, and pain management. Prior to joining COPIC,
she served as the director, Western region, patient safety and risk management for The
Doctors Company in Napa, California. In this capacity, she provided patient safety and risk
management consultation to the physicians and staff for the western United States

As a registered nurse and attorney, Dixon holds a Bachelor of Science degree from Regis
University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College
of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School
Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and
California.

This speaker has no real or perceived conflicts of interest that relate to this presentation.

Fee is $195