HospitalInspections.org

Based on interview, review of video recording and record review the facility failed to report a death associated with the use of seclusion by telephone, facsimile, or electronically, as determined by Centers for Medicare & Medicaid Services (CMS), no later than the close of business on the next business day following knowledge of the patient's death for 1 of 1 client. (#1)

The findings include:

On 11/17/22 at approximately 1:30 PM, reviewed video record for client #1. Video recording indicated that at approximately 9:40 AM, client #1 was escorted to seclusion room by staff C. Mental Health Assistant (MHA), and D, Registered Nurse (RN), one staff on each side using underarm support. Client #1 was in seclusion room from 9:40AM on 11/6/22 until 11/7/22 at approximately 6:00AM, when he was found unresponsive and was pronounced deceased by the fire department/Emergency Medical Services at approximately 6:30 AM.

On 11/17/22 at approximately 10:41 AM, an interview was conducted with the Risk Manager, during which a request was made for documentation that the death of client #1 had been submitted to Centers for Medicare & Medicaid Services (CMS), The Risk Manager reported that she had not submitted any documentation by telephone, facsimile or electronically. The Risk Manager reported that the death occurred on Monday, November 7, 2022, in the morning while client #1 was still in seclusion/restraint room. The Risk Manager reported that she was not aware that she had to submit information to CMS within 24 hours.