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Restraint, Seclusion, Ligature and Suicide Risks: Complying with the CMS CoPs and TJC Requirements

May 13 @ 8:00 am - 10:00 am MDT


Due to COVID-19, the registration fee is per individual hospital (not system) for this webinar. A single registration provides multiple lines for employees at your hospital, including a link to view the recording for 60 days post-webinar. Please only select a qty. of “1” under Registration and indicate the number of connections requested for your hospital when completing the Attendee information. The person completing the registration will be responsible for sharing the access information with others from your hospital who wish to participate.

Not sure if you’ll be able to make the live session? Everyone who registers will receive a link to the recording to view at their convenience at no additional charge for 60 days post-webinar.

The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (TJC) require hospital staff to be educated on restraint and seclusion, and these topics continue to be a major concern for both CMS and TJC. The leading area of deficiencies in the CMS Conditions of Participation is regarding restraints.

CMS and TJC have also promulgated requirements for hospitals to prevent ligature risk and self-harm from patients who are suicidal.

Resources to aid hospital staff in achieving compliance of the CMS and TJC requirements regarding restraint and seclusion will be provided in this session. Tools to assess a facility’s ability to meet safety requirements and assess patients for risks of self-harm and suicide will also be included in the presentation.

At the conclusion of this session, participants should be able to:

  • Define the CMS requirements for a patient in restraint and/or seclusion, including reporting requirements and an internal log when a patient dies while in restraints.
  • Recall that CMS requires that all physicians and others who order restraints must be educated on the hospital policy.
  • Describe specific items CMS requires to be documented in the medical record for the one-hour face to face evaluation on patients who are violent and or self-destructive. 
  • Recall that CMS has requirements to prevent ligature and suicide risks for patients with suicidal ideations.
  • Identify the Joint Commission requirements for hospitals to follow to prevent patients from self-harm, including hanging or strangulation.

Chief Executive Officer, Chief Operating Officer, Chief Nursing Officer, Compliance Officer, Joint Commission Coordinator, Quality Improvement personnel, Risk Manager, Legal Counsel

Laura A. Dixon, BS, JD, RN, CPHRM, President, Healthcare Risk Education and Consulting, LLC

Laura A. Dixon is the president of Healthcare Risk Education and Consulting. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided consultation and training to facilities, practitioners and staff in multiple states.

Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided consultation to the physicians and staff for the western United States.

As a registered nurse and attorney, Ms. Dixon holds a Bachelor of Science degree from Regis University, a Doctor of Jurisprudence degree from Drake University College of Law, and a Registered Nurse Diploma from Saint Luke’s School of Professional Nursing. She is licensed to practice law in Colorado and California. 

This speaker has no real or perceived conflicts of interest that relate to this presentation. 

May 6; 5:00 p.m. MTN

Access instructions and materials will be emailed to the person completing the registration prior to the program date. If you do not receive the instructions at least 24-hours in advance, please contact IHA.


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May 13
8:00 am - 10:00 am MDT
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Toni Pugmire
(208) 489-1409