Life Safety Compliance Solutions

Ligature Risk Assessment

It’s not enough to simply recognize ligature risks in health care facilities. Creating a safe environment for all requires performing an assessment, establishing a plan, and then following through.

Recent reports of patient suicide among the top three sentinel events-at a rate of 85 deaths per year-have encouraged regulators to turn a keen eye toward potential hanging or choking points. However, during a survey, facilities must demonstrate more than just awareness. Strategies must be in place; staff must be trained; and every effort must be made to adjust, replace, and repair areas of risk as needed.

Also of note: EC.02.06.01, one of the most stringent standards set by The Joint Commission, applies to any setting that specifically is designated to treat psychiatric and behavioral health patients. This focus includes inpatient psychiatric units in psychiatric hospitals and general or acute hospitals, as well as any “safe room” used to treat such patients in emergency or other departments. Within these areas, ALL ligature and other self-harm risks must be identified, mitigated, and/or eliminated.

Areas that must be assessed for risk include:

  • Common areas
  • Patient rooms
  • Bathrooms
  • Emergency rooms
  • Any room designated a safe room

Specific items to be assessed might include, among others:

  • Access card readers
  • Baseboards
  • Ceilings
  • Chairs/furniture
  • Coat hangers
  • Curtain cubicle tracks/curtain rods
  • Fire extinguishers
  • Grab bars
  • Medical gas outlets
  • Plumbing/plumbing fixtures (toilets, toilet paper dispenser, toilet seat, etc)
  • Security camera
  • Signage
  • Standard sprinkler heads
  • Tables
  • Televisions
  • Wall-mounted items
  • Window hardware/treatments
  • Alcohol-based hand sanitizers
  • Beds
  • Chimes/strobes
  • Cords
  • Cover plates
  • Door closures/hardware/tops
  • Fire hose cabinets
  • Medical equipment
  • Nurse call pull cord/pillow speaker
  • Receptacles
  • Robe/towel hooks
  • Shower curtain/doors / head/ rod
  • Smoke detectors
  • Suspended ceilings
  • Tamper-proof screws
  • Trash bags
  • Window glass
  • Wireless access points

The good news is that health care facilities don’t have to go it alone. Life Safety Compliance Solutions, the only national turnkey provider of all things life safety, can perform ligature risk assessments as well as assist in remediation of deficiencies. In the first half of 2017, ligature risks and the presence of risks with inadequate mitigation plans were among the most frequently cited life safety standards. This doesn’t have to be your story. We can help reduce those risks and citations-and as a result, ultimately save lives.



Ligature Risk Assessment




Jeff I just wanted to touch base with you about your staff, Vicki and Tommy were very helpful and informed. It’s nice to work with knowledgeable people and not someone who is just quoting a code book and telling you that you have to do it this way and only this way.

Thank you again and I look forward to working with your staff in the future. My COO and I will be passing our experience on to other facilities so maybe they will reach out to you.

Larry Volpato FMM3
Department of Human Services/Torrance State Hospital




We recently had ligature risk assessments at 2 of our Campuses and both assessments were exactly what we needed to move forward with compliance.

The documentation sent after the assessment was perfect for what we needed as an Action Plan and also to help with securing funding.

We are thankful for the partnership with Life Safety Compliance Solutions.

Thank you!

Gary Uselton
Director of Facilities Management/TriStar Skyline Medical Center