Hospital Report to HCFA -- Patient Death in
Seclusion or Restraint
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of BQA 00-035 (PDF, 7 KB)
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Date: April 26, 2000 DSL-BQA 00-035
To: Hospitals HOSP 16
From: Otis Woods, Section Chief, Health Services Section
via: Susan Schroeder, Director, Bureau of Quality Assurance
The hospital Condition of Participation: Patients’ Rights
(exit DHFS) that
became effective for all hospitals participating in the Medicare program on August 2,
1999, contained, at 42 CFR 483.13(f)(7), the following requirement applicable to patients
restrained or secluded for behavioral management:
HCFA has directed the Bureau of Quality Assurance (BQA) to notify Wisconsin
hospitals that they must report to the HCFA Regional Office any death that occurs
while a patient is restrained or in seclusion for management of behavior, or where it is
reasonable to assume that a patient’s death is a result of restraint or seclusion
used to manage behavior. There are no death reporting requirements for restraints used in
acute medical and surgical care. Behavior management is not limited to patients with
psychiatric or developmental disabilities diagnoses; the HCFA definitions are based on the
purpose of the restraint, not on the diagnosis of the patient.
The HCFA definition of restraint and of seclusion found at 42 CFR 482.13(f)(1) is:
-
The patient has the right to be free from seclusion and restraints, of
any form, imposed as a means of coercion, discipline, convenience, or retaliation by
staff. The term ``restraint'' includes either a physical restraint or a drug that is being
used as a restraint. A physical restraint is any manual method or physical or mechanical
device, material, or equipment attached or adjacent to the patient's body that he or she
cannot easily remove that restricts freedom of movement or normal access to one's body. A
drug used as a restraint is a medication used to control behavior or to restrict the
patient's freedom of movement and is not a standard treatment for the patient's medical or
psychiatric condition. Seclusion is the involuntary confinement of a person in a room or
an area where the person is physically prevented from leaving.
The HCFA mandated report is in addition to the report required by state statutes,
s. 50.04(2t) and s. 51.64. State statutes require hospitals to report to the Bureau of
Quality Assurance (BQA) within 24 hours when there is reasonable cause to believe a
patient death may have been due to physical restraints/seclusion, psychotropic
medications, or suicide in a psychiatric hospital or in a psychiatric unit of a hospital.
HCFA has directed BQA to conduct an investigation of deaths that occur while a patient
is restrained or in seclusion, or where it is reasonable to assume that a patient's death
is a result of restraint or seclusion, within 5 business days. The information that HCFA
will be collecting from hospitals includes:
Contact Information: Facility contact and facility contact’s phone number.
Provider Information: Hospital name, Medicare provider number, address and zip
code.
Patient Information: Name, date of birth, Medicare/Medicaid number, admitting
diagnoses, date of admission, date/time of death, cause of death, length of time in
restraints/seclusion, circumstances surrounding the death, whether or not a root cause
analysis has been conducted, results of any facility investigation.
Restraint/Seclusion Information: Type (physical
restraint/seclusion/ drug used as
restraint); restraint method; reason(s) for seclusion/restraint use; less restrictive
methods of behavior management considered; restraint/seclusion order date/time; quote of
actual restraint/seclusion order; monitoring method(s), frequency, last date/time
monitored; last date/time of assessment; other instances of restraint/seclusion deaths
since 8/2/99; if prior deaths, were steps taken with previous deaths to prevent
reoccurrence?
Hospitals should be prepared to supply the above details either by telephone to the
HCFA contact person, Dorsey LeCompte, at the time of the initial report, or to the
BQA surveyor onsite.
Dorsey LeCompte’s telephone number is (312) 353-5183, and her
e-mail address is: DLecompte@cms.hhs.gov
Questions regarding this memo may be directed to BQA:
-
Juan Flores, Supervisor, Health Care Regulatory Southern Unit, (replaced by Cremear Mims, (414) 227-4556)
-
Jane Walters, Supervisor, Health Care Regulatory Northern Unit, (replaced by Jan Heimbruch, (608) 243-2086)
-
Helen Brewster, Lead Worker, Health Services Section, (608) 243-2089
-
Otis Woods, Section Chief, Health Services Section,
(replaced by Cremear Mims)
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