Hospital Restraint/Seclusion Deaths to be Reported Using the Centers for Medicare and Medicaid Services (CMS) Form CMS-10455,
Report of a Hospital Death Associated with Restraint or Seclusion
• Hospital Restraint/Seclusion Deaths to be Reported Using Form CMS-10455: Hospitals must use Form CMS-10455 to report those
deaths associated with restraint and/or seclusion that are required by 42 CFR §482.13(g) to be reported directly to their
Centers for Medicare & Medicaid Services (CMS) Regional Office (RO). This requirement also applies to rehabilitation or psychiatric
distinct part units (DPUs) in Critical Access Hospitals (CAHs).
• RO to Provide Submission Instructions: CMS ROs must provide hospitals with instructions for submitting the form to the RO
by fax and/or e-mail, based on RO preference.