The purpose of this letter is to notify you that the CMS reporting requirements located in the Code of Federal Regulation (CFR), Title 42, Section 482.13(g) for deaths associated with the use of restraints or seclusion have been updated. Pursuant to this section, hospitals must report deaths associated with the use of seclusion or restraint.
1) The hospital must report the following to CMS:
(i) Each death that occurs while a patient is in restraint or seclusion.
(ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
(iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of the restraint or placement in seclusion contributed directly or indirectly to a patient's death. "Reasonable to assume" in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing, or asphyxiation.
2) Each death must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient's death.
3) Hospital staff must document in the patient's medical record the date and time the death was reported to CMS.
The interpretive guidelines that detail what is considered a restraint or seclusion, the provisions for a hospital's use of restraints or seclusion, and the reporting requirements can be found in 42 CFR 482.13(e)-(g).
The information in this All Facilities Letter is a brief summary of 42 CFR 482.13(g). Facilities are responsible for following all applicable laws and for being aware of all legislative changes. CDPH's failure to expressly notify facilities of legislative changes does not relieve them of this responsibility. Facilities should refer to the full text of 42 CFR 482.13 to ensure compliance.
For additional questions, please contact Cassie Dunham, Manager of Non-Long Term Care Facilities, Policy Unit, at Cassie.Dunham@cdph.ca.gov or by phone at (916) 552-8778.
Original Signed by Kathleen Billingsley, R.N.
Kathleen Billingsley, R.N.
Center for Health Care Quality