Joint Commission and Ligature Points

[Davey Do]

Last week, Wrongway Regional Medical Center (WRMC) had a Joint Commission survey. The surveyors found ligature points, being chairs, in the community room. A ligature point is defined as "A feature in an environment which could be used to support a noose or other strangulation device (especially, for the purpose of attempting to commit suicide)".

Joint Commission has ruled that patient care areas are to be “Without points where a cord, rope, bedsheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.”

The area of concern Joint Commission found was that the geriatric and child psych units community rooms were without doors. Therefore, it is believed that patients could unnoticeably enter the community room with noose made from a cord, rope, bed sheet or other fabric/material and attempt to commit self harm or suicide. Therefore, doors with locking devices need to be installed on the community rooms.

Fine. Sure. Okay. I guess, theoretically speaking, a suicidal patient could enter the community room unnoticed with a noose made out of a cord, rope, or bed sheet or other fabric/material, stand on a chair, throw it up over some ligature point and attempt to commit self harm or suicide. So doors need to be installed.

But what to do in the meantime?

WRMC administration has deemed that, until doors with locking devices can be installed, a specific staff member will act as a door, sitting in front of the community room doorway 24/7. This staff member will assure no suicidal patient will enter the community room with a noose made out of a cord, rope, bed sheet, or other fabric/material and attempt to commit self harm or suicide!

That staff member acting as a door will be allowed to do nothing else: No patient care, no 15 minute safety rounds, no charting, and of course no electronic devices of any sort, or reading material of any kind! The staff member is to just sit there and act like a door!

I kid you not!

The staff member assigned as a door will be relieved every 2 hours.

[UrbanHealthRN, BSN, RN]

This might just be my dark humor coming out, but does the JC realize that if a person really wants to kill themselves, they'll find a way to do it no matter what? Literally just being alive is a risk to a suicidal person- they could find some way to cut their wrists with a jagged fingernail, or who even knows what else. I just feel like the list of changes to make to a unit will never, ever end, and the question is, at what point do we draw the line? (Answer according to the JC: we don't draw lines, because they're dangerous).

[TriciaJ, RN]

2 hours ago, Daisy4RN said:

No, you cannot carry saline flushes in your scrub pocket because it is unsafe. So back to the end of the Pyxis line for you.

Nurse: What is your goal for today?

Pt: I want to win the lotto (pt was serious)

Why are saline flushes stored in the damn pyxis? What a nuisance. No reason they can't be in their original box (with the lid torn off) in the med room.

If the patient's goal is to win the lotto, that should go on the board. Who are we to interfere with a patient's independent goal-setting? The more ridiculous, the better. The fastest way to eventually get rid of one stupid thing.

[Kooky Korky, BSN, RN]

On 5/13/2019 at 10:07 PM, Davey Do said:

Last week, Wrongway Regional Medical Center (WRMC) had a Joint Commission survey. The surveyors found ligature points, being chairs, in the community room. A ligature point is defined as "A feature in an environment which could be used to support a noose or other strangulation device (especially, for the purpose of attempting to commit suicide)".

Joint Commission has ruled that patient care areas are to be “Without points where a cord, rope, bedsheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.”

The area of concern Joint Commission found was that the geriatric and child psych units community rooms were without doors. Therefore, it is believed that patients could unnoticeably enter the community room with noose made from a cord, rope, bed sheet or other fabric/material and attempt to commit self harm or suicide. Therefore, doors with locking devices need to be installed on the community rooms.

Fine. Sure. Okay. I guess, theoretically speaking, a suicidal patient could enter the community room unnoticed with a noose made out of a cord, rope, or bed sheet or other fabric/material, stand on a chair, throw it up over some ligature point and attempt to commit self harm or suicide. So doors need to be installed.

But what to do in the meantime?

WRMC administration has deemed that, until doors with locking devices can be installed, a specific staff member will act as a door, sitting in front of the community room doorway 24/7. This staff member will assure no suicidal patient will enter the community room with a noose made out of a cord, rope, bed sheet, or other fabric/material and attempt to commit self harm or suicide!

That staff member acting as a door will be allowed to do nothing else: No patient care, no 15 minute safety rounds, no charting, and of course no electronic devices of any sort, or reading material of any kind! The staff member is to just sit there and act like a door!

I kid you not!

The staff member assigned as a door will be relieved every 2 hours.

Sorry, DD, but I agree that this "door" should be doing absolutely nothing else. Definitely no rounds, definitely no leaving the post for any reason without a relief staff member being the door.

It will be super hard to keep staff awake on Nights. The Charge Nurse will be blamed if anything goes wrong.

This is no different, though, than sitting 1:1 with a patient or being the ward/pod/hallway monitor on Nights. Absolutely no reading, no earphones, no headphones, no telephones, no TV, no distraction of any kind. I feel almost as strongly about no music, period, except maybe from an old transistor radio or overhead Muzak.

If you are expected to give up one of your staff members to fill this post instead of being given an extra staff member, that is wrong. It's a whole new role and should earn you a whole extra staff member.

I think the door should be relieved every 30 minutes. Certainly on Night shift.

[JKL33]

1 hour ago, TriciaJ said:

Why are saline flushes stored in the damn pyxis? What a nuisance. No reason they can't be in their original box (with the lid torn off) in the med room.

? Please stop! You're going to hit upon the billing and inventorying and auto-ordering and auditing benefits of some of our "safety" mechanisms if you're not careful!

Well, and beyond that, it is extremely unsafe to use those flushes to dilute medications, so best to keep tabs on who might be doing criminal behaviors with them. ?☠️

[Daisy4RN]

2 hours ago, TriciaJ said:

Why are saline flushes stored in the damn pyxis? What a nuisance. No reason they can't be in their original box (with the lid torn off) in the med room.

If the patient's goal is to win the lotto, that should go on the board. Who are we to interfere with a patient's independent goal-setting? The more ridiculous, the better. The fastest way to eventually get rid of one stupid thing.

When they first stopped keeping them in the box we were told the flushes were a medication, next they said it was for billing, and next to prevent diversion. Nobody had time to constantly wait in line every time so nurses would take a handful with morning meds.

I did write patients ridiculous goals on the white boards but of course got talked to about that so I did at least try to get to a realistic goal. But for that one, yep, winning the lotto went on the board, who has time to mess around with that.

[Kooky Korky, BSN, RN]

3 hours ago, UrbanHealthRN said:

This might just be my dark humor coming out, but does the JC realize that if a person really wants to kill themselves, they'll find a way to do it no matter what? Literally just being alive is a risk to a suicidal person- they could find some way to cut their wrists with a jagged fingernail, or who even knows what else. I just feel like the list of changes to make to a unit will never, ever end, and the question is, at what point do we draw the line? (Answer according to the JC: we don't draw lines, because they're dangerous).

So because someone really wants to kill himself, we should not try to prevent suicide?

[rnhopeful82, ASN, RN]

When the person is the door, are people allowed to go into the room? If there were no doors previously, I would assume so. So are they just a gatekeeper/watcher of the chairs? It reminds me of the movie Labyrinth where the adorable Sir Didymus was in charge of the bridge. He said no one shall pass this way without my permission! She said well, may we have your permission? And he said ....yes? and they crossed.

[UrbanHealthRN, BSN, RN]

34 minutes ago, Kooky Korky said:

So because someone really wants to kill himself, we should not try to prevent suicide?

We definitely should. And facilities do take steps to prevent suicide. My question is, at what point do we either 1) say enough is enough, and stop coming up with ridiculous policies that may or may not change anything; 2) recognize that something might be dangerous, but come up with a more realistic solution for it than making a person act as a door for 8 hours?

[KonichiwaRN]

1 hour ago, UrbanHealthRN said:

We definitely should. And facilities do take steps to prevent suicide. My question is, at what point do we either 1) say enough is enough, and stop coming up with ridiculous policies that may or may not change anything; 2) recognize that something might be dangerous, but come up with a more realistic solution for it than making a person act as a door for 8 hours?

We can't.

Remember. We are in the profession where we can't dare be "our selves."

Example:

This Columbia Suicide Rating Scale really doesn't make sense. But we have to use it. It's based on "research." Oh dear, I need to wash my mouth with soap & water now.

My honest opinion regarding that is..they're in it to make money (the people who are in place to implement or develop those policies), while using "safety" as a reason.

[Davey Do]

1 hour ago, UrbanHealthRN said:

say enough is enough, and stop coming up with ridiculous policies that may or may not change anything

I do believe this was one of the nails I drove into my own coffin as a home health agency nursing supervisor back in '94.

I challenged JC surveyors when they wanted certain guidelines. I don't recall the specifics, but basically I informed the surveyors that the guidelines were already taken care of in another P&P. We debated the points and the administrator, who was the agency's owner, acquiesced and informed the surveyors the requested guidelines would be generated.

The moral of the story is, if you want JC's certification, you must jump through their superfluous hoops.

[Megan1977, MSN, EdD, RN]

This is a spoof- right?? ??. Nobody is dumb enough to come up with that ridiculous solution.

[kbrn2002, ADN, RN]

I've heard of some dumb doozies the safety police ding dongs have come up with but this is beyond bonkers. So if I get this right the floor can be short staffed already, probably per usual but somebody still has to do nothing but be a door? Wow, how do they come up this stuff??