CMS SOM App. M, Tag L861

Hospices must report deaths associated with the use of seclusion or restraint.

(1) The hospice must report the following information to CMS:

(i) Each unexpected death that occurs while a patient is in restraint or

seclusion.

(ii) Each unexpected death that occurs within 24 hours after the patient has

been removed from restraint or seclusion.

(iii) Each death known to the hospice that occurs within 1 week after restraint or

seclusion where it is reasonable to assume that use of 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 referenced in this paragraph 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) Staff must document in the patient's clinical record the date and time the death

was reported to CMS.

Interpretive Guidelines §418.110(p)

If a patient has an unexpected death that occurs while in restraint or seclusion, or an

unexpected death occurs within 24 hours after restraint or seclusion has been

discontinued, the death must be reported to CMS Location. Additionally, if a death

occurs within one week after the use of restraint or seclusion and it is reasonable to

assume the death was associated with restraint and/or seclusion, the death should be

reported to CMS Location.

Restraint means:

(1) Any manual method, physical or mechanical device, material, or equipment that

immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or

head freely, not including devices, such as orthopedically prescribed devices, surgical

dressings or bandages, protective helmets, or other methods that involve the physical

holding of a patient for the purpose of conducting routine physical examinations or tests,

or to protect the patient from falling out of bed, or to permit the patient to participate in

activities without the risk of physical harm (this does not include a physical escort); or

(2) A drug or medication when it is used as a restriction to manage the patient’s behavior

or restrict the patient’s freedom of movement and is not a standard treatment or dosage

for the patient’s condition.

Seclusion means the involuntary confinement of a patient alone in a room or an area

from which the patient is physically prevented from leaving. Patients who request private

rooms would not be considered in seclusion.