Paper versions of the form are not accepted. Use electronic form CMS-10455 to report a death. ![]() Exception: Use of 2-point soft wrist restraints that must be recorded in an internal hospital log or other system. In accordance with 42 CFR § 482.13(g), all patient deaths associated with restraint or seclusion in a hospital are required to be reported to the CMS (Centers for Medicare & Medicaid Services) Regional Office. The following applies to hospitals, including rehabilitation or psychiatric distinct part units in critical access hospitals. General information and death determination guidelines (on page 4-5, go to Section V).(On page 1, go to "Provider Types" listed under Section II). The types of providers required to report a death.This form includes guidelines to help you determine if the death is a reportable death, such as: ![]() To notify DHS, complete the Client/Patient/Resident Death Determination, F-62470 (PDF).
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