Hospital Restraint/Seclusion Deaths - CMS requires all hospitals to report deaths associated with restraint and/or seclusion on the electronic CMS-10455 form. The only reporting requirement exceptions are deaths associated with 2-point soft wrist restraints. See QSOG-20-04-Hospital-CAH-DPU.
Hospitals must report the following information to CMS no later than the close of business on the next business day following the acknowledgment of the restraint and/or seclusion associated patient death:
- Death that occurs while a patient is in restraint or seclusion.
- Death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
- Death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient's death.
2-Point Soft Wrist Restraint Exception - When the patient was not in seclusion and when the only restraints used on the patient were those applied exclusively to the patient's wrist(s), the death could be considered a 2-point soft wrist restraint situation. To be a soft wrist restraint, the restraint on the patient's wrist must be composed solely of soft, non-rigid, cloth-like materials. In these cases, the hospital staff must record the death in an internal log or other system. The hospital must record no later than seven (7) days after the date of death, submit the following information:
- Death that occurs while a patient is in such restraints.
- Death that occurs within 24 hours after a patient has been removed from such restraints.
- Death entry must document the patient's name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient, medical record number and primary diagnoses.
Questions regarding reporting of hospital restraint or seclusion deaths may be directed to the CMS Chicago Regional Office at ChicagoNLTCPOC@cms.hhs.gov.