Crosswalk

Revisions to Form CMS-10455 Hospital Death Associated with Restraint or
Seclusion Crosswalk
Issue #

Page
#

Section

Action to be
performed

Changes to
Reporting

Reason for the
Change

1.

1

Heading

Revise as follows:

To ensure that
hospitals/CAHs are
submitting required
reports. The Regional
Offices were overburdened with reports
from hospitals/CAHs
submitting reports that
are not required. This
heading is added to
provide clarity to the
hospitals/CAHs about
the types of
restraint/seclusion that
are required to be
submitted.

2.

1

A

Revise as follows:

Added: *If a Two
Point Soft Wrist
Restraint was
used alone
without use of
seclusion, drug
used as a
restraint , or
physical
restraint, DO
NOT SEND
REPORT OF
DEATH TO RO.
Documentation
of this death
must be entered
in the
hospital/CAH
internal log or
tracking system
as well as in the
patient’s medical
record, per 42
CFR 482.13(g). If
any other
combination of
restraint and/or
seclusion was
used,
COMPLETE
SECTIONS A-D.
Add: Filer’s Title

3.

1

B

Revise as follows:

Add: Psychiatric
Diagnosis(es) if
applicable

4.

1

B

Revise as follows:

Remove:
medical record
number

5.

1

B

Revise as follows:

Add: Time of
Death

To identify person
responsible for
required information
To track data related
to incidence of
restraint and seclusion
usage with a medical
versus a psychiatric
diagnosis
This additional
information would not
be necessary to assess
for threat to health
and safety or for
oversight.
To assess with the
triaging of
information in order

6.

1

B

Revise as follows:

Remove: Cause of
Death

7.

1

B

Revise as follows:

Add: Condition
leading to death

8.

1

B

Revise as follows:

Add: Mortality
Review : Yes or
No check boxes

9.

1

B

Revise as follows:

Add: Report
Submission
Documented in
Medical Record
Yes or No check
boxes

10.

1

C

Revise as follows:

Added: “IS
REASONABLE
TO ASSUME”

11.

1

C

Revise as follows:

Added Under
Restraint type:
multiple
commonly
reported restraint
examples with
check boxes for
selection

to determine if a
survey should be
authorized (assess
staffing patterns
relative to day and
night shifts trends)
The majority of
reports stated “cardiac
or respiratory arrest”.
This information was
not useful in
determining how the
restraint may have
been related to the
patient’s death.
To encourage
providers submitting
reports to describe the
suspected medical
condition contributing
to the death of the
patient
Part of hospital review
data for unexpected
/unanticipated deaths;
performance
improvement reviews
42 CFR §482.13(g)
The hospital must
document in the
patient’s medical
record the date and
time the death report
entry was made into
the log or tracking
system.
To aid providers in
submitting required
reports. Providers
were submitting
unnecessary reports in
which the use of
restraint/seclusion was
not reasonable to
assume contributed to
the patient’s
death.(Reduce
burden)
To assist providers in
reporting restraint
types on form using
check boxes rather
than writing/typing
the name of the
restraint type used
(reduce burden)

12.

2

D

Revise as follows:

Added: Section D
Restraint
information Part
II added to
document

13.

2

D

Revise as follows:

Added: 1. Reason(s)

14.

2

D

Revise as follows:

15.

2

D

Revise as follows:

Added: 3.
Restraint/Seclusion
Order Details

16.

2

D

Revise as follows:

Added: 4. Was
restraint/seclusion
used to manage
violent or selfdestructive
behavior

17.

2

D

Revise as follows:

18.

2

E

Revise as follows:

Added: 5. If
simultaneous
restraint and
seclusion used to
manage violent or
self-destructive
behavior check Yes
or No (check
boxes)
Added: Section E
for the Regional
Office ONLY to
complete

for
Restraint/Seclusion
Use

Added: 2.
Circumstances
Surrounding Death:

Added to assist
Regional Office staff
in assessing
information related to
the health, safety and
wellbeing of patients
who require
restraint/seclusion
intervention.
Filer of report to
describe events
leading up to
restraint/seclusion use
to determine if least
restrictive measures
were attempted; to
determine behavior
that led to
restraint/seclusion use
To assess what events
led up to the patient’s
death. Requires
Hospital or CAH to
self-investigate for
potential process
improvement to
ensure the safety of
patients and staff.
To assess restraint
order regulatory
requirements (Date &
Time of the order as
well as monitoring
requirements) to
ensure compliance.
To assess specific
requirements related
to violent or selfdestructive behavioral
interventions to
ensure compliance
and safety of patients
and staff.
To assess specific
requirements related
to violent or selfdestructive
behaviorial
interventions to
ensure compliance
and safety of patients
and staff.
To document finding
related to triaging of
the MS 10455 form.
Currently, ROs only

enter data into ACTS
when a survey is
authorized. Because
of this process there
was no way to capture
data related to CMS
10455 data when no
surveys were
authorized. This
section will allow
Central Office
oversight data to be
collected more
efficiently and will
provide
documentation of the
RO process for
reviewing these forms
to ensure all relevant
hospital survey
historical data is
reviewed prior to
survey determinations
being made.