Hospital Restraint/Seclusion Death Report Worksheet

Instructions for completing CMS 10455-Report of a Hospital Death
Associated with the use of Restraint or Seclusion
The hospital/CAH is to complete sections A-D.
Section A. Hospital Information
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Document the complete name of hospital/CAH, CCN#, and full address. Use the legal
name of the hospital/CAH that is used on the facility’s enrollment form (Form CMS855A)
Document the name of the person filing the report and include their title and contact
information/phone number

Section B. Patient Information
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List the patient’s name and date of birth (DOB)
List the medical diagnosis(es) and include psychiatric diagnosis(es) if applicable
List the date of the patient’s admission or presentation for care
List the date and time of death
Condition leading to death- This should be the physician’s best medical opinion to
include any contributing factors leading to the death. A condition may be listed as
“probable” even if it has not been definitively diagnosed. (cardiac or respiratory arrest is
not a sufficient answer to this question)
Mortality Review to be completed- indicate Yes or No
Report Submission- The date and time that the CMS 10455 report was submitted to CMS
must be documented in the patient’s medical record. Indicate if this has been documented

Section C. Restraint Information Part I
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The hospital/CAH is to select one of the following to indicate when the patient’s death
occurred:
o While in restraint, seclusion, or both
o Within 24 hours of the removal of restraint, seclusion, or both
o Within 1 week (7 days), where the use of restraint, seclusion, or both is
reasonable to assume contributed to the patient’s death. If the use of restraint or
seclusion was not a factor in the patient’s death (i.e.: no falls, aspiration, became
injured by self or others, entanglement, etc.) and the patients’ death occurred 2-7
days after the removal of the restraint, the hospital/CAH would not be required to
report the death. However, if the use of the restraint or seclusion was a factor (i.e.:
while being placed in restraint or seclusion or while in restraint, or seclusion, the
patient fell, became entangled, became injured by self or others, aspirated, etc.)
and the death occurred 2-7 days after the use of restraint, seclusion, or both, the
hospital/CAH would be required to report the death.

Section D. Restraint Information Part II

1. The hospital/CAH must document the circumstances leading up to the use of
restraint, seclusion, or both (patient behavior, alternative interventions attempted,
etc.)
2. The hospital/CAH must document the circumstances or events leading up to the death
of the patient
3. Document the restraint or seclusion order details
a. Date & Time restraint or seclusion was applied
b. Date & Time the patient was last monitored and/or assessed.
c. Total length of time restraint and/or seclusion were applied
d. For drug(s) used as a restraint:
i. List the drug name, drug dose, and time drug was administered (for
ALL doses). When a combination of drugs was used that resulted in
drug used as restraint, enter this information for each drug.
4. Document if the restraint or seclusion was used as an intervention for violent
behavior. If NO-- report documentation is completed for #4 and #5 of this section.
a. Indicate if the face-to –face evaluation was completed and documented
b. Indicate the date and time the face-to-face evaluation was completed
c. Indicate if the order was renewed at required intervals (age dependent), if
applicable
5. If simultaneous restraint and seclusion were ordered, describe the continuous
monitoring method(s) that were used to monitor the patient. (i.e.: 1:1 continuous staff
monitoring, use of 1:1 staff as well as video monitoring, etc.).

Hospital/CAH documentation stops here.
Section E- Regional Office to Complete this Section
1. Indicate if a survey was authorized.
a. If a survey was authorized based on reported information document the date that
the State Agency (SA) was notified
b. If a survey was not authorized, provide a rationale for this decision. (i.e.: not
indicated based on review of reported events)
2. Indicate if the hospital/CAH has had a survey based on a previous report of a patient
death associated with restraint or seclusion, and if so, was there a condition-level or IJ
finding.
3. If yes to #2, list the deficiencies cited on those 2657s.

4. The Accreditation Organization must be notified of IJ findings. Please indicate if this was
done.
5. The State Protection and Advocacy Agency (P&A) is to be notified only when a survey is
authorized AND the P&A has a current Data Use Agreement (DUA). Indicate if the P&A
was notified. Please send questions regarding whether or not a P&A has a current DUA
to [email protected].
6. If a survey was authorized and the P&A was notified, document the date of the P&A
notification.