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TAMPA GENERAL HOSPITAL
PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT
Tag No.: A0213
Based on medical records and interview it was determined the facility failed to report a death that occurred within 24 hours after removal or the restraints in one (#1) of one reportable event.
Findings included:
Review of Patient #1 medical record reveals Patient #1 was in violent restraints on 09/02/2022 at 9:14 AM. On 09/02/2022 at 12:11 PM, the patient arrived from the Emergency department to the floor with 4 points (both hands and both legs) violent restraints. The nurse placed call to Physician and the violent restraints discontinued. Further review of the medical record reveals the patient expired on 09/02/2022 at 6:10 PM.
The facility was unable to provide evidence that the facility reported the incident to CMS (Center for Medicare & Medicare Services).
On 09/26/2022 at 9:30 AM an interview was conducted with the Manager of Patient Safety. They stated they have reported the event to the Agency for Health Care Administration and Joint Commission, but did not report to CMS which was an oversight.
The facility reported the event as of 09/27/2022 at 8:30 AM to CMS, 25 days after the death of Patient #1.