Report of a Hospital Dealth Associated with Restraint or Seclusion (CMS-10455)

The CMS 10455 Report of a Hospital Death in Restraint or Seclusion form is utilized for the purpose of determining cases that warrant on-site investigation to determine the hospital’s compliance with the Medicare Condition of Participation (CoP) for patient’s rights. Based on information gathered from CMS Regional Offices (ROs), the current collection tool associated with this package did not provide the needed information to thoroughly evaluate whether the case warrants an on-site investigation. The ROs provided feedback for data needed on the CMS 10455 form to evaluate whether the case warrants an on-site investigation. The collection tool was revised based on the ROs need for additional information to assess for compliance with CoPs as well as the health and safety of patients requiring the use of restraint and/or seclusion.

The latest form for Report of a Hospital Dealth Associated with Restraint or Seclusion (CMS-10455) expires 2022-07-31 and can be found here.

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Federal Enterprise Architecture: Health - Health Care Services

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