Get Form Cms-10455 - Centers For Medicare & Medicaid Services - Cdph Ca

Filling out the Form CMS-10455 is an essential step in reporting a hospital death associated with restraint or seclusion. This guide provides clear and detailed instructions to help you accurately complete the form online.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In the 'A. Hospital Information' section, fill in the hospital name, CCN (certification number), address, city, state, zip code, and the name of the person filing the report along with their phone number.
3. Proceed to the 'B. Patient Information' section. Here, enter the patient's name, date of birth, primary diagnosis(es), medical record number, date of admission, date of death, and cause of death.
4. In the 'C. Restraint Information' section, check only one option that applies regarding the timing of restraint or seclusion relative to the patient's death.
5. Select all types of restraints involved by checking the appropriate boxes such as physical restraint or seclusion.
6. If physical restraints were used, specify the type by selecting from the list provided, including but not limited to side rails, two-point restraints, or four-point restraints.
7. If a drug was used as a restraint, enter the drug name and dosage in the designated fields.
8. After filling out all sections, review your information for accuracy. Once completed, save your changes, and use the options available to download, print, or share the form as needed.

Take action today and complete your documents online with confidence.