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Licensing AND Certification Program

Hospital Restraint/Seclusion Death Reporting

Effective date: May 9, 2014

These changes to the current reporting process are an integral part of CMS' efforts to reduce procedural burdens on providers.

​Important Points

  • Facilities required to report: Hospitals, including Critical Access Hospitals with Psych and/or Rehab distinct part units
  • Form CMS-10455 must be used when reporting a death, no other forms are acceptable
  • Hospitals must not send reports of these deaths directly to the RO:
    • Each death that occurs while a patient is in restraint but not seclusion and the only restraints used on the patient were applied exclusively to the patient's wrist(s) and were composed solely of soft, non-rigid, cloth-like materials; and
    • Each death that occurs within 24 hours after the patient has been removed from restraint, when no seclusion has been used and the only restraints used on the patient were applied exclusively to the patient's wrist(s) and were composed solely of soft, non-rigid, cloth-like materials.

What Deaths need to be Recorded:

A death involving ONLY a soft, non-rigid, cloth-like material, wrist restraint and NO seclusion

  • Hospitals, including Critical Access Hospitals with Psych and/or Rehab distinct part units, are required to record the information of the death into an internal log or other system
  • Each entry must be made no later than seven days after the date of death of the patient
  • The record must include the patient’s name, date of birth, attending practitioner, primary diagnosis(es), and medical record number

Hospitals must make this information available to CMS in either written or electronic form immediately upon request.

 What Deaths need to be Reported:

A death involving ALL other types of restraints and ALL forms of seclusion

  • Hospitals, including Critical Access Hospitals with Psych and/or Rehab distinct part units are required to continue regular reporting procedures
  • Providers must contact CMS no later than the close of business on the next business day following knowledge of the patient’s death
  • The hospital staff MUST document in the patient’s medical record the date and time the death was reported to CMS
  • It is recommended that these reports be included in the hospital’s log

Points of contact for CMS Region 9

Rosanna Dominguez / 415-744-3735 / data tracking and reporting
Alex Garza / content and completeness
Linda Brim / content and completeness

NOTE: Failure to comply with the regulation could prompt a survey covering Conditions of Participation for Patient Rights

Procedure for Reporting:

Form CMS-10455 needs to be faxed to the CMS Regional Office.
Regional Office fax number: 443-380-8909

Frequently Asked Questions

Does CMS need to be alerted by phone if the worksheet has already been faxed to the RO?
No. If a facility faxes the report, this will complete the reporting process.
Can a facility create their own worksheet instead of using the CMS worksheet?
No, providers must use the form CMS-10455 that was included in the S&C 14-27-Hospital-CAH/DPU letter that was released on May 9, 2014 ​

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