Form 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 THE USE OF RESTRAINT OR SECLUSION

CMS-10455 (Revised)

**If a Two Point Soft Wrist Restraint was used alone without use of seclusion, drug used as restraint, or other physical restraint,
DO NOT SEND REPORT OF DEATH TO THE RO. Documentation of this death must be entered in the hospital/CAH internal
log or tracking system as well as in the patient’s medical record, per 42 CFR § 482.13(g).
If any other combination of restraint and/or seclusion was used, COMPLETE SECTIONS A-D

A. Hospital Information:

Address
City

State

Name of Person Filing the Report

Zip Code
Filer’s Phone Number

Title of Person Filing the Report

B. Patient Information:
Primary Diagnosis(es) / Psychiatric Diagnosis(es) if applicable:
Date of Admission

Date of Death

Time of Death

Condition Leading to Death

C. Restraint Information Part I (check only one) - Patient Death Occurred:
While in Restraint, Seclusion, or Both
Within 24 Hours of Removal of Restraint, Seclusion, or Both
Within 1 Week, Where Restraint, Seclusion or Both is REASONABLE TO ASSUME 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):
Two Point, Hard Wrist
Two Point, Soft Wrist
Four Point, Soft
Four Point, Hard
Side Rail (x4)
Soft Ankle (x1) (x2)
Forced Medication Hold
Therapeutic Hold
Take-down
Enclosed Bed

Vest Restraint
Elbow Immobilizer
Bilateral Secured Mitten
Bilateral Unsecured Mitten
Roll Belt
Lap Belt
Drug Used as Restraint/Violent Behavior
Spit hood
Other Restraint Type:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1210 (Expires XX/XX/XXXX). The time required to complete
this information collection is estimated to average 0.33 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you
have questions or concerns regarding where to submit your documents, please contact Caroline D. Gallaher at [email protected]

D. Restraint Information Part II:
1. Reason(s) for Restraint/Seclusion use:

2. Circumstances Surrounding Death:

3. Restraint/Seclusion Order Details:
a. Date & Time Restraint/Seclusion Applied:
b. Date & Time Patient Last Monitored:
c. Total Length of Time in Restraint/Seclusion:
d. Drug: Name/Route/Dose/Time:

Yes

4. Was restraint/seclusion used to manage violent or self-destructive behavior? If NO, stop here.
a. If YES, was 1 hour face-to-face evaluation documented?

Yes

No

No

b. Date/Time of Last Face-to-face Evaluation:
c. Was the order renewed at appropriate intervals based on patient’s age?

Yes

No

5. If simultaneous restraint and seclusion ordered, describe continuous monitoring method(s):

For Regional Office to Complete:
E. RO Action(s):
1. Was a survey authorized?

Yes

No

If YES, date SA received authorization for investigation:
If NO, provide brief rationale:
2. In the past two years, has a survey related to a restraint/seclusion death at this hospital resulted in finding
condition-level or IJ patients’ rights deficiencies?

Yes

No

3. If applicable, what deficiencies were cited related to Restraint/Seclusion or patient rights:

4. If an Immediate Jeopardy (IJ) was cited, was the Accrediting Organization notified (if deemed)?
5. Does Protection & Advocacy (P&A) have a current Data Use Agreement (DUA): (Do not notify the P&A unless a
survey was authorized)

Yes

No

6. If answer to E1 and E5 is YES, date RO notified P&A

CMS-10455 (Revised 2017)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1210 (Expires XX/XX/XXXX). The time required to complete
this information collection is estimated to average 0.33 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you
have questions or concerns regarding where to submit your documents, please contact Caroline D. Gallaher at [email protected]