CMS Revises Conditions of Participation Related to the Hospital Patient Rights – Restraint-Related Death Reporting

Hospital Patient Rights – Restraint-Related Death Reporting – §482.13:

Effective July 16, 2012, CMS is replacing the requirement that hospitals must report deaths that occur while a patient is only in soft, 2-point wrist restraints with a requirement that hospitals must maintain a log (or other system) of all such deaths. This log must be made available to CMS immediately upon request. The log is internal to the hospital and that the name of the practitioner responsible for the care of the patient may be used in the log in lieu of the name of the attending physician if the patient was under the care of a non-physician practitioner and not a physician.

Compliance Considerations:

  • You will want to revise policies and procedures related to restraint-related death reporting to reflect the CoP change.  Note that this reporting change is only for deaths of patients in soft, 2-point wrist restraints and not all restraint related deaths.  Be sure your policy clearly indicates the reporting that is required for each restraint type. 
  • Identify who is responsible for the development and maintenance of the log to record deaths of patients in soft, 2-point wrist restraints.  Ensure the log captures all elements required by CMS:  patient’s name, date of birth, date of death, name of attending physician or other licensed independent practitioner who is responsible for the care of the patient, medical record number, and primary diagnosis (es). 
  • Note:  Deaths that meet the requirements for inclusion on the internal log must be recorded on that log within 7 days of the patient death. 
  • Educate staff on the new reporting requirements including medical documentation requirements. 
  • Be certain your staff knows that they must document in the patient’s medical record the date and time of death and if the death was reported to CMS or recorded in the internal log.
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