This came out Sept. of 2006, I did a search on Fornits and I don't think this report has been posted before. It includes adult patients as well, but it shows the extent to which facilities go to sweep restraint and seclusion deaths under the rug. 44 out of 104 deaths not properly reported is more than "human error", it's deliberate deception. State agencies are just as guilty by neglecting to investigate deaths within the required time period. No wonder NATSAP wants State oversight, the inept State agencies have been a boon to them.
PDF version:
http://oig.hhs.gov/oei/reports/oei-09-04-00350.pdf.
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
HOSPITAL REPORTING
OF DEATHS RELATED TO
RESTRAINT AND SECLUSIONDaniel R. Levinson
Inspector General
September 2006
OEI-09-04-00350
(Extract, pg. 17, "Findings")
Hospitals failed to report to CMS 44 of 104 documented deaths related to restraint and seclusion between August 2, 1999, and December 31, 2004Using CMS, State survey agency, P&A, and FDA documentation, we identified 104 behavior management deaths related to
restraint and seclusion that occurred between August 2, 1999, and December 31, 2004. Hospitals did not report 44 of these deaths directly to CMS as required. Hospitals must report to CMS any death that occurs while a patient is restrained or in seclusion for behavior management, or when it is reasonable to assume that a patient’s death is the result of restraint or seclusion.17 As illustrated in Table 1, we identified unreported behavior-management deaths related to restraint and seclusion based on our analysis of information from State survey agencies, P&As, and FDA, as well as in documentation maintained by CMS.
State survey agency-, P&A-, and FDA-documented deaths not reported by hospitals to CMS regional officesState survey agency-, P&A-, and FDA-documented deaths not reported by hospitals to CMS regional offices
36CMS-documented deaths not reported directly by hospitals to CMS
regional offices, but received second hand from other agencies
8Total documented deaths not reported directly to CMS
44CMS-documented deaths reported directly by hospitals to regional offices
60Total deaths documented by CMS and other agencies 104[/list]Source: Office of Inspector General analysis of CMS, State survey agency, P&A, and FDA death reports, 2005(Extract, pg 18)
CMS and State survey agencies do not consistently take action in response to reported deaths in a timely manner, limiting their ability to address potentially harmful conditionsMost deaths that hospitals reported directly to CMS were reported late. Of the 60 behavior management restraint and seclusion-related death reports provided directly to CMS by hospitals, fewer than one-third were reported to CMS before the close of business on the day after the patient’s death, as required. The median number of days between a patient’s death and hospitals’ notification to CMS was The rest of the report is well worth reading. Getting accurate numbers on program deaths and abuse is impossible considering the unwillingness of facilities to make reports combined with the regional offices and State survey agencies negligence in performing timely investigations.
