Form CMS-10455 Health Death Report Form

Report of a Hospital Death Associated with Restraint or Seclusion

A. Hospital Information:

Hospital Name: __________________________________CCN: _______________________

Address: __________________________City: _____________ State: _____ Zip Code: _______

Person Filing the Report: ________________________ Filer’s Phone Number: _____________

B. Patient Information:

Name: ____________________________________ Date of Birth: ______________________

Primary Diagnosis(es): _________________________________________________________

____________________________________________________________________________

Medical Record Number________________________________________________________

Date of Admission: _________________ Date of Death: ______________________________

Cause of Death: _______________________________________________________________

C. Restraint Information (check only one):

_____While in Restraint, Seclusion, or Both

_____Within 24 Hours of Removal of Restraint, Seclusion, or Both

_____Within 1 Week, Where Restraint, Seclusion or Both Contributed to the Patient’s Death

Type (check all that apply): Physical Restraint ________ Seclusion __________ Drug Used as a Restraint_________

If Physical Restraint(s), Type (check all that apply):

_____01 Side Rails _____08 Take-downs

_____02 Two Point, Soft Wrist _____09 Other Physical Holds (Specify)

_____03 Two Point, Hard Wrist _____10 Enclosed Beds

_____04 Four Point, Soft Restraints _____11 Vest Restraints

_____05 Four Point, Hard Restraints _____12 Elbow Immobilizers

_____06 Forced Medication Holds _____13 Law Enforcement Restraints

_____07 Therapeutic Holds _____14 Other Physical Holds

If Drug Used as Restraint: Drug Name_____________________ Dosage________________