Accreditation & Regulatory Journal
September 2023


Providing a Safe Environment for Suicidal Patients

Provided By: CIHQ
By: Connie Compton
According to the CDC, there were nearly 46,000 deaths from suicide in the United States in 2020. The nation’s mental health crisis is weighing profoundly on emergency departments and non-psychiatric hospitals.
CMS §482.13(c)(2) states all patients have a right to receive care in a safe setting. Well, that seems like a straightforward statement, but what does that really mean for hospitals when it comes to suicidal patients? This article discusses caring for patient’s at risk of self-harm in non-behavioral health units (medical inpatient units, ED, ICU, etc.).
Environmental Risk Assessment
To comply with CMS, all hospitals must identify and mitigate environmental risks. The environmental risk assessment must be appropriate to the specific care environment and patient population. This includes medical units that may sometimes care for patients at risk for harm to self or others. Although CMS does not require hospitals use a specific tool, the chosen tool must assess the patient’s environment for ligature risks, harmful unattended items, and staffing levels to support patient observation and monitoring. The findings of the assessment must be documented and mitigation strategies implemented. Suggested tools include the Veteran’s Administration Environmental Risk Assessment Tool and the FGI Behavioral Health Design Guide.
Determining the Patient’s Risk of Suicide
Behavioral health patients need to be screened to identify the risk of being a danger to self (i.e., suicide or self-harm) in accordance with nationally recognized standards and guidelines. The assessment should be performed at the time the patient presents for care. The assessment should consist of a two-phased approach:
  1. Screen the patient to determine if suicide or self-harm ideation is present. If the screen is negative, then no assessment is required. (Any patient which has attempted suicide in the past should undergo an assessment.)
  2. If the screening result is positive, then an assessment should be performed. The assessment should identify the patient’s level of suicide risk or lethality of the ideation.
Assessing the Level of Suicide Risk
Based on the results of the assessment, the patient risk of self-harm is determined. As a general rule, a patient assessed to have any of the following should always be considered high risk for being a danger to self:
  • Current attempt to commit suicide or is actively engaging in self-harm behaviors
  • Suicide ideation with a concrete plan
  • Presence of hallucinations which “command” the patient to commit suicide or to harm him or herself.
Safety Measures
For patients determined to be at risk for self-harm, interim patient safety measures need to be implemented to mitigate ligature and safety risks that were identified during the environmental risk assessment. Safety measures may include, but are not limited to the following:
  • 1:1 monitoring with continuous visual observation
  • Removal of sharp objects
  • Removal of equipment that can be used as a weapon or to inflict harm
  • Securing personal belongings
  • Removal of any other item(s) that may contribute to harmful behavior
Training of Staff
CMS requires hospitals train staff to identify patients at risk of harm to self or others, the identification of environmental patient safety risk factors, and mitigation strategies. CMS allows the hospital flexibility to tailor the training based on the type of service and patient population served.
The training should be conducted upon initial orientation and at least every two years. CMS requires the training be conducted for direct employees, volunteers, contractors, per diem staff, and contracted staff that provide clinical care.
Survey Tip
The documented environmental risk assessment is the foundation of an effective suicide prevention program. Remember, medical units which may occasionally provide care to suicidal patients need to be included in the environmental risk assessment. Be prepared to easily retrieve and provide this document during your next survey.
Center for Disease Control and Prevention. (2022). Preventing Suicide. Retrieved from
Center for Medicare and Medicaid Services. (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Retrieved from