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Revision: Environmental Suicide Prevention

PDF Version of DQA 11-019  (PDF, 53 KB)

Date: July 7, 2011 
DQA Memo 11-019
(Replaces DQA Memo 01-032)
To: Hospitals HOSP 08
From: Cremear Mims, Director
Bureau of Health Services

Otis Woods, Administrator
Division of Quality Assurance

Revision: Environmental Suicide Prevention

DSL-BQA-01-032, Environmental Suicide Prevention, dated July 18, 2001, is revised to replace outdated information and provide new environmental safety recommendations. New information is bolded.

All hospitals in Wisconsin must be in compliance with Wisconsin Administrative Code, Chapter DHS 124. Compliance with State law is a requirement for accreditation and Medicare certification.

The purpose of this memo is to clarify regulatory requirements concerning the provision of a safe environment in psychiatric hospitals and psychiatric units of general hospitals. In the course of conducting investigations of inpatient suicides, the Division of Quality Assurance is aware of environmental conditions that enabled patient suicides.

The majority of persons who complete suicide suffer from a treatable mental disorder, a substance abuse disorder, or both. Patients of inpatient psychiatric treatment facilities are considered at high risk for suicide; therefore, the hospital should avoid environmental physical hazards while maintaining therapeutic care. Ongoing assessment of suicidality is a necessary but not complete protection for psychiatric inpatients.

The majority of patients commit suicide via hanging in a bathroom, bedroom or closet. Measures to prevent suicide within patient rooms/ areas include proper assessment of the physical environment design. The following are recommendations only.

  • Ceiling systems of a lay-in ceiling tile design should be avoided. Drop ceiling grids, and any plumbing, piping, ductwork or other potentially hazardous elements concealed above a ceiling can be used as a hanging device. The ceiling should be of monolithic construction.

  • Sprinkler heads should be a flush mounted design.

  • Door-closer devices should be mounted on the public side of a door versus the private patient side of the door. Ideally, the door-closer (if required) should be within view of a nurse or staff workstation. Door hinges should be of the continuous piano style. Door lever handles should point downward when in the latched position. Note that all hardware should have tamper-resistant fasteners.

  • Towel bars are not required for American with Disabilities Act (ADA) accessibility compliance; therefore avoiding towel bar installations in private patient rooms is recommended. If provided, towel bars should be designed to not support the weight of the lowest weighted patient served on the unit.

  • Showerheads should be of the flush mounted design. Push-button shower controls are recommended.

  • Clothing rods or hooks should be designed to not support the weight of the lowest weighted patient served on the unit.

  • Horizontal or partially inclined plumbing/utility pipes should be enclosed.

  • ADA-compliant grab bars are required in 10% of the patient private/semi-private toilet rooms. The remaining 90% are not required to have ADA-compliant grab bars installed unless the patient room is used by a patient with disabilities. Reinforced wall areas for future installation of grab bars should be provided or existing wall capabilities should be verified. Grab bars for fully ambulatory patients should be removed. If grab bars are required for a patient, the bars should be mounted with a continuous rail-to-wall attachment.

  • Shower curtain rods should be designed to not support the weight of the lowest weighted patient served on the unit.

  • Staff members should adequately supervise ADA-compliant patient areas that include grab bars such as clinic, treatment, occupational therapy and physical therapy areas.

  • Seamless floors should be used instead of tile that has sharp corners.

  • Windows should have a plastic covering or locked interior safety screen placed over them. Keys should be with staff at all times.

  • Furniture should be of a solid heavy construction that can't be dismantled and used as a weapon/tool.

  • Electrical cords should be shortened.

  • Electrical receptacles are ground fault protection or safety type.

  • Light fixtures are tamper proof and provided with shatter-proof lenses.

  • Mirrors and other glass objects are shatter-proof.

  • Seclusion room doors should swing outward to minimize injury to staff.

  • Doors to a roof are alarmed, monitored, and limit access.

  • Locks on patient unit doors are easily defeated for emergency access. A retractable jam, push button, or card reader can facilitate prompt staff access.

  • Doors to hazardous areas, chemical, or medications are secured.

The last recommendation is included to provide an overall level of safety since physical environment in itself cannot ensure a safe facility. The following state requirement applies to all hospitals in Wisconsin regarding adequacy of staffing:

DHS 124.13 (1) (c) 1: An adequate number of registered nurses shall be on duty at all times to meet the nursing care needs of the patients. There shall be qualified supervisory personnel for each service or unit to ensure patient care management.

The state staffing requirement applying to free-standing psychiatric hospitals in Wisconsin is:

DHS 124.26 (3) (a): The hospital shall have enough staff with appropriate qualifications to carry out an active program of psychiatric treatment for individuals who are furnished services in the facility.

The federal requirement for all hospitals participating in the Medicare program to maintain a safe environment is:

42 CFR 482.13(c)(2): The patient has the right to receive care in a safe setting.

In a free-standing psychiatric hospital, adequate staffing is required per the following federal regulation:

42 CFR 482.62: The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

In order to be excluded from the prospective payment systems, a psychiatric unit of a general hospital must meet the following requirement:

42 CFR 412.27(1): Meet special staff requirements in that the unit must have adequate numbers of qualified professional and supportive staff to evaluate inpatients, formulate written, individualized, comprehensive treatment plans, provide active treatment measures and engage in discharge planning

In summary, proper facility design and adequate staffing are essential elements of effective psychiatric treatment. Hospitals wishing to request consultation may contact their facility assigned bureau engineer.

For additional information please refer to the following resources:

Surgeon General's National Strategy at; National Center for Injury Prevention and Control at; and, the American Foundation for Suicide Prevention at

Please share this information with the appropriate staff. If you have questions concerning the regulatory issues, please contact Michele Doro, at (414) 227-4106, or David R. Soens, P.E., at (608) 266-9675.


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Last Updated: June 18, 2013