The Ligature Risk Assessment Policy serves as a critical risk management tool in healthcare facilities across the United States. This document has become increasingly important due to heightened focus on patient safety and regulatory compliance, particularly in mental health settings. The policy addresses Joint Commission requirements, state-specific regulations, and industry best practices for identifying and mitigating potential ligature risks. It includes detailed assessment procedures, documentation requirements, and specific responsibilities for various stakeholders involved in maintaining a safe healthcare environment.
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1. Purpose and Scope: Defines the objectives and applicability of the policy
2. Definitions: Key terms used throughout the policy including technical terms, regulatory references, and role definitions
3. Roles and Responsibilities: Defines who is responsible for assessments, implementation, and oversight
4. Assessment Procedures: Detailed steps for conducting ligature risk assessments
5. Documentation Requirements: Required documentation and record-keeping procedures
1. Training Requirements: Staff training procedures and certification requirements (include if facility handles direct patient care)
2. Emergency Procedures: Response procedures for immediate risks (include for clinical settings)
3. Vendor Management: Requirements for external contractors (include if using third-party services)
1. Assessment Checklist: Standardized form for conducting ligature risk assessments
2. Risk Rating Matrix: Tool for evaluating and prioritizing identified risks
3. Mitigation Measures: List of approved methods for addressing identified risks
4. Inspection Schedule: Timeline for regular assessments and reviews
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