Form Cms-10455 - Report Of A Hospital Death Associated With Restraint Or Seclusion

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-1210
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
If Drug Used as Restraint:
Drug Name
Dosage
Form CMS-10455 (11/13)
1

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