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Q & A: Recommendation for reporting restraints-related deaths

Emergency Management Alert, March 19, 2007

Sue Dill-Calloway, RN, MSN, JD, is the director of hospital risk management for OHIC Insurance Company in Columbus, OH.  Ms. Calloway originally spoke to the editors of the HCPro newsletter, Briefings on the Joint Commission, about the CMS Conditions of Participation (CoP) restraint and seclusion standards.

Q: Regarding the new CMS restraint and seclusion standards, do you have to report deaths to CMS even if the patient's death is not due to the restraint?

A: CMS published changes to the restraint and seclusion standard on December 8, 2006 in the Federal  Register. (Federal Register Vol. 71, No. 236, p.71377-71428.

The hospital must report each death to CMS that occurs while a patient is in restraints or seclusion and within 24 hours after the patient has been removed from restraint and seclusion, regardless of whether the death was due to a restraint. For example, a terminal patient is expected to die. If the patient had restraints on or was restrained within 24 hours of death, you would need to report that.

There is also the "one week rule," where the hospital has to report any death that occurs within one week after restraint or seclusion where it is reasonable to assume that the restraint or seclusion contributed to the death either directly or indirectly. Basically, you only report because of this rule when the death is due to the restraint or seclusion.

In addition, the death must be reported by phone to CMS no later than the close of business following knowledge of the death. Staff must document in the patient's medical record the date and time they reported the death to CMS.

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