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Based on record review and interview the facility failed to report a patient death that occurred while the patient was in restraints to the Centers for Medicare and Medicaid Services (CMS) by close of business on the next business day following knowledge of the patient's death.

Findings:

Record review of Patient #1's medical record documented Patient #1 was in both soft wrist restraints, and a vest restraint at the time of his death.

Review of the medical record revealed there was no documentation of the death having been reported to CMS.

During an interview on 1/18/22 at approximately 11:30 AM, the Corporate Director of Risk Management stated the facility had not reported any deaths of patients in or following use of restraints or seclusion to CMS in the past year. She stated the death of Patient #1 was reportable and should have been reported. She stated, "it was missed because the report only showed soft wrist restraints." She stated she is aware that the death of a patient in restraints other than soft wrist restraints needs to be reported to CMS the next day.

During an interview on 1/19/21 at 10:35 AM, the Risk Manager stated patients that die while in soft wrist restraints are not reportable to CMS. The documentation for Patient #1 showed soft wrist restraints. This is why his death was not reported. He was also in a vest.

Review of policy and procedure titled, "Restraints, Safe Restraints Process" with an effective date of 02/15/2020 and a revision date of 04/14/2021 read, " I. Standard/Purpose: UF Health Central Florida recognizes and respects patient's dignity, rights, and wellbeing and supports a patient's right to be free from restraint. Restraints will only be used when clinically justified to protect the immediate physical safety of the patient, staff, or others. IV. Reporting Requirements: Risk Management reports to Center for Medicare Services any patient death occurring: 1. During restraint. 2. Within 24-hours after removal from restraint. 3. Within 1-week after restraint where it is reasonable to assume that use of restraint or seclusion directly or indirectly contributed to the death.