HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to report a hospital death associated with the use of restraints to CMS no later than the close of business on the next business day following knowledge of a patient's death, for 1 of 1 patients whose death occurred within 24 hours after restraint removal.

Findings are as follows:

Review of the patient's Emergency Room Progress Notes dated 1/26/2024 revealed the following:

-4:50 PM: The patient was placed in four point restraints "attempting to jump off bed, and spit, scratch, and pitch staff."
-5:36 PM: The patient was found unresponsive and "had a cardiac arrest while in restraints in the ED [Emergency Department]"
-5:38 PM: "Compressions began"
-7:05 PM: "ROSC" (Return of Spontaneous Circulation)

Review of the patient's electronic medical record revealed a physician's note dated 1/27/2024 at 1:48 PM indicating that the patient expired, listing date and time of death as 1/27/2024 at 1:42 PM.

Additional record review revealed a Medical Provider Note dated 2/16/2024 which stated that on 2/16/2024 at 3:00 PM, form CMS-10455 was submitted which reported a death within 24 hours of the removal of a restraint.

During a surveyor interview with the Systems Manager on 2/29/2024 at 10:00 AM, she acknowledged that she reported the death late because she did not learn that the patient had been in restraints within 24 hours of their death until 2/26/2024.