HospitalInspections.org

Based on interview and record review, the facility failed to report a death in restraints to the Centers for Medicare and Medicaid Services Regional office within the allotted time requirement resulting in the delayed investigation by the proper authorities for patient death in restraints and the potential for missed opportunities for improvement. Findings include:

On 2/9/2021 at 1045, Quality Specialist Staff C stated Patient #1 had died while still in restraints and it had been reported to the Centers for Medicare and Medicaid Services (CMS) on 11/11/2020 at 1915.

On 2/9/2021 at 1100, review of the "Report of a Hospital Death Associated With the Use of Restraint or Seclusion" form sent to CMS revealed the date and time of death for Patient #1 as 10/28/2020 at 0540. Directly beneath this entry was the date and time the form was submitted which was entered as 11/11/2020 at 1915.

Staff C was queried on 2/9/2021 at 1045 as to why there had been a delay in reporting Patient #1's death while still in restraint to CMS to which she stated there was not a delay. She stated the facility considered "being informed" of the death of the patient at the time the chart was opened for review, and, in this case, Patient #1's medical record was reviewed by the facility on 11/11/2020.

A facility policy was requested of Quality and Regulatory Director Staff F on 2/9/2021 at 1112.

On 2/9/2021 at 1124, Staff F produced an undated document titled, "Death Restraint Reporting to CMS" stating it was a guideline used by the risk department for reporting a death in restraints to CMS. The guidelines state, "1. Each morning review Death Report sent by Health Information Services. 2. Open patient record in Power Chart and review whether the patient died either in restraints or within 24 hours of death...4. If the patient was in any type of restraints, other than bilateral soft wrist restraints, at the time of or within 24 hours of death...an electronic report must be filed with CMS..."