CMS-10455 Health Death Report Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved

OMB No. 0938-1210

REPORT OF A HOSPITAL DEATH ASSOCIATED WITH RESTRAINT OR SECLUSION

A. Hospital Information:
Hospital Name

CCN

Address
City

State

Person Filing the Report

Zip Code
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
02 Two Point, Soft Wrist
03 Two Point, Hard Wrist
04 Four Point, Soft Restraints
05 Four Point, Hard Restraints
06 Forced Medication Holds
07 Therapeutic Holds
If Drug Used as Restraint:
Drug Name

Form CMS-10455 (XX/XX )

08 Take-downs
09 Other Physical Holds (specify):
10 Enclosed Beds
11 Vest Restraints
12 Elbow Immobilizers
13 Law Enforcement Restraints

Dosage

1