Page 27 - 2020 ARE eGuide for Clinical at Nonhospital Sites

High risk items in the environment:
Items considered dangerous, such as
intravenous poles and tubing, sharps
container, portable equipment with
tubing or electrical cords, or other
supplies can be removed. Plumbing
features and door handles can be
used for self harm.
Do not place patient in a room with a
door that has a handle, use the
curtain bays. If a patient needs to use
the restroom use a bedside
commode, bed pan, or urinal. A
bathroom is HIGH RISK for suicide.

Screening for suicide: The Nurse completes the Columbia Suicide Severity Rating
Scale (C-SSRS). If the patient screens positive for suicide, complete an assessment of
the patient. The Nurse completes the suicide risk assessment to assess individuals for
suicidal ideation. If the screening is negative be aware that there are some individuals
who do not present with a behavioral health concern as their chief complaint. These
may include: recent diagnosis of a terminal illness, history of mental health diagnosis,
or past trauma experience.

Learn about the One-to-One Sitter Duties
and Responsibilities by clicking on this link.