Electronic Form CMS-10455, Report of a Hospital Death Associated with Restraint or Seclusion

Title
Electronic Form CMS-10455, Report of a Hospital Death Associated with Restraint or Seclusion
Memo #
QSO 20-04-Hospital-CAH DPU-REVISED
Posting Date
2019-12-02
Fiscal Year
2020
Summary
The electronic Form CMS-10455, Report of a Hospital Death Associated with the Use of Restraint or Seclusion is replacing the paper version of the Form starting December 2, 2019. Hospitals and/or Critical Access Hospital (CAH) Distinct Part Units (DPUs) will be able to insert the URL below into any browser and click to access the electronic Form CMS-10455. https://restraintdeathreport.gov1.qualtrics.com/jfe/form/SV_5pXmjIw2WAzto8J. A brief Instructional Video on how to complete and submit the electronic Form CMS-10455 is available on the Quality, Safety & Education Portal (QSEP) at https://qsep.cms.gov/pubs/CourseMenu.aspx?cid=0CMSRHDRS_ONL. The Instructional Slides are attached.