Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62470 (Rev. 07/08)

STATE OF WISCONSIN Chapters 48.60(5)(a), 50.035(5), and 51.64(2), Wis. Stats. Page 1 of 6

CLIENT / PATIENT DEATH DETERMINATION
USE OF FORM Reporting of certain deaths to the Department of Health Services is required by Wisconsin State Statute. This form should be used for this purpose. Failure to report these deaths to the Department may result in a citation of noncompliance by the Department. The information obtained will be used for investigative and statistical purposes and the personally identifiable information will be available only to those persons authorized to access treatment records. If you have any questions regarding this form, call the Reportable Death Review Coordinator at (608) 261-0657.

I. DETERMINATION
Name ­ Deceased Client (Last, First, MI) Ethnicity (Check one.) Date - Birth Gender Date ­ Admission Date ­ Death

M Black - Not Hispanic Asian or Pacific Islander American Indian / Alaska
Name ­ Agency / Provider Address ­ Street Address City

F Yes No

Is this death reportable to coroner / medical examiner?

Hispanic - Mexican, Puerto Rican, Cuban White - Not Hispanic

Certification / License Number County

Provider Type No. (See page 2.) State Zip Code

Name - Client Emergency Contact Person Address ­ Street Address

Relationship City

Telephone Number State Zip Code

Name - Individual Reporting Address ­ Street Address

Title City

Telephone Number State Zip Code

Name - To Whom Reported

Telephone Number

Self Report Other:

Date Reported

INSTRUCTIONS 1. 2. 3. 4. 5. A client death must be reported to the Department within 24 hours after the death or upon learning of the death if there is cause to believe that the death was related to the use of a physical restraint / seclusion, psychotropic medications, or suicide. When in doubt---if the death was due to physical restraints / seclusion, psychotropic medications, or suicide---report the death. Attach a copy of the progress notes or other documentation which provide additional information to determine if there is reasonable cause to believe that the death was due to the use of physical restraints / seclusion, psychotropic medications, or suicide. Check "Yes" or "No" for each item in sections A - C. For assistance, see guidelines on pages 3 and 4. Submit the completed form to the Division of Quality Assurance (DQA) chief or director listed in the attached "Division of Quality Assurance Reportable Death Contact Table" (page 5) in the column headed "Where to Fax the Client / Patient Death Determination Form." No A. Suicide 1. Was there evidence that the client was having suicidal thoughts during the last month? 2. Did the client make any suicide threats or statements during the last month? 3. Did the client make a suicide attempt in the past year? 4. Did the client give away personal possessions within the last month? 5. Was the client found in a position or circumstance which might indicate the death was due to suicide; e.g., hanging, drowning, drug overdose, asphyxiation (being found in a car with the engine running), fall from a bridge or down stairs, a self-inflicted wound, a single car accident with good road conditions, self-immolation (burning)? Psychotropic Medication 1. Was the client on three or more psychotropic medications? 2. Was the client on two or more psychotropics in the same class? 3. Did the physician discontinue a psychotropic medication within the last seven days? 4. Did the client refuse psychotropic medications within the last seven days? 5. Was the client changed to a different psychotropic medication within the last seven days? 6. Did the client's medical / psychiatric condition change in the last seven days, based on observed symptoms and behaviors? (continued on next page)

Yes

B.

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Yes

No B. Psychotropic Medication (continued) 7. Did the client receive any drug(s) to which he / she has a known allergy or adverse drug reaction as documented in his / her record within the last seven days? 8. If the client was on Clozapine, did the known adverse reactions of this medication contribute to the death of the client? 9. Did the client present any signs which would indicate the possibility of neuroleptic malignant syndrome (NMS)? 10. Was a psychotropic medication given with no valid diagnosis for the drug? 11. If the client is a GERIATRIC CLIENT, was he / she on lithium? If "Yes", was lithium used in combination with haloperidol, another antipsychotic, neuromuscular blocker and / or antidepressant? 12. If the client is a GERIATRIC CLIENT, was he / she on a long acting benzodiazepine before therapy with a short acting benzodiazepine? 13. If the client is a GERIATRIC CLIENT, was he / she on Xanax and did he / she experience a sudden withdrawal of this medication within the last seven days? Physical Restraints and Seclusion (See "Note to Hospitals" below.) 1. Did the client die while in restraint or seclusion? 2. Did the restraint / seclusion have a direct relationship to the client's death? 3. Did the client sustain any injury while in restraint or seclusion? 4. Was the client in a prone position when a physical restraint was used?

C.

PROVIDER TYPE AND NUMBER (Enter applicable number on page 1.) No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Type Facility for the Developmentally Disabled Mendota or Winnebago Mental Health Institute Mental Health Inpatient Program Community Based Residential Facility Nursing Home Mental Health Crisis Service Community Support Program Mental Health Day Treatment Mental Health Outpatient Program Mental Health Day Treatment Services for Children Comprehensive Community Services for Persons With Mental Illness AODA Emergency Outpatient Service No. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Type AODA Medically Managed Inpatient Detoxification Service AODA Medically Monitored Residential Detox Service AODA Ambulatory Detoxification Service AODA Residential Intoxication Monitoring Service AODA Medically Managed Inpatient Treatment Service AODA Medically Monitored Treatment Service AODA Day Treatment Service AODA Outpatient Treatment Service AODA Transitional Residential Treatment Service AODA Narcotic Treatment Service for Opiate Addiction Hospital AODA Inpatient Program AODA Intervention Services

NOTE TO HOSPITALS Medicare regulations at 42CRF Part 482 require that the death of a patient that occurred while a physical or chemical restraint was applied to that patient, while that patient was in seclusion, or where it is reasonable to assume that the patient's death may have resulted from the use of a physical or chemical restraint or seclusion, must be reported to the Health Insurance Specialist of the CMS Regional Office at (312) 353-2888. REASON FOR REPORTING

Name - Therapist Involved in Case

Telephone Number Title Telephone Number Date Signed

SIGNATURE - Person Completing Form

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II. CLIENT / PATIENT DEATH DETERMINATION GUIDELINES
The following guidelines, which are not all-inclusive, are listed to assist the provider in determining if there is reasonable cause to believe the client / patient death may be due to the use of restraint / seclusion, the use of psychotropic medications, or suicide. Note: For the purpose of reporting a death of a patient to HCFA, the Federal definition applicable to that Federal reporting requirement is the following: 1. Physical restraint means any manual method, physical or mechanical device, material, or equipment which is attached or adjacent to the patient's body, which he or she cannot easily remove, which restricts freedom of movement, and / or restricts normal access to one's body. Chemical restraint means a drug or 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 means the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

2.

3.

A.

Suicide Presence of one or more of the following risk factors in the client profile: 1. 2. Clinical syndromes of depression, psychosis, impulsivity, and intoxication. Symptomatic or psychological predictors such as hopelessness, recent losses along with the experience of loss, and panic levels of anxiety. Demographic factors which put a client in a moderate or greater risk category for suicide; e.g., among the seriously mentally ill, male gender, previous suicide attempts, a recent (within the last six months) acute psychotic or affective episode, first decade and---particularly---the first five years of the illness, AODA problems. Recent behaviors that suggest that the client is acting differently; e.g., making final plans, "tidying up" personal affairs, obtaining the means for suicide, seeking out help more often (often with no clear complaint). Lethality: The client's mental intent to die or to kill oneself, including the individual's view of life after death and what relief or reward it offers; specificity and imminence of a suicide plan; availability and lethality of the means for suicide; the opportunity in the suicidal plan for rescue. The absence of positive social supports or the presence of ones that are not helpful or that are harmful; e.g., critical, rejecting.

3.

4.

5.

6. B.

Psychotropic Medications 1. Psychotropic Medication: A psychotropic medication is any drug used to treat, manage, or control psychiatric symptoms or disordered behavior, including but not limited to antipsychotic, antidepressant, mood stabilizing, or antianxiety agents. Medications which may be used either for more general medical purposes or for their effect on psychiatric symptoms would be considered psychotropic medications when they were being used to obtain a psychiatrically related benefit. 2. Presence of one or more of the following psychotropic drug interactions and / or conditions in the client profile: a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. Any anaphylactic reactions Tricyclic antidepressant overdose Lithium overdose Combination of any psychotropic medication(s) and alcohol Bone marrow suppression, especially with clozapine, but also with other neuroleptics and tricyclic antidepressants Hypertensive crisis with monoamine oxidase inhibitors (MAOIs) Cardiac arrhythmias as a result of an antidepressant medication Any drug overdose Any blood level of a drug higher than accepted therapeutic drug level After starting on antipsychotic medication, the client complains of an increased temperature and muscular rigidity Fatal heatstroke, especially if client is on Thorazine History of difficult to control epilepsy Jaundiced skin and sclera Psychotropic medications administered to clients in excess of the recommended geriatric doses which are listed in Appendix P of the Federal Long Term Care Regulations for Nursing Homes Any medication error in proximity to time of client death

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3.

Client experienced the following three operational criteria for a diagnosis of neuroleptic malignant syndrome (NMS). a. b. Hyperthermia: A high temperature in the absence of known etiology Severe extrapyramidal effects characterized by two or more of the following: lead-pipe muscle rigidity, pronounced cogwheeling, sialorrhea, oculogyric crisis, retrocollis, opisthotonos, trismus, dysphagia, choreiform movements, festinating gait, and flexorextensor posturing Autonomic dysfunction characterized by two or more of the following: hypertension, tachycardia, prominent diaphoresis, incontinence

c.

In retrospective diagnosis, if one of these three items (3a - 3c) has not been specifically documented, a probable diagnosis is still permitted if the remaining two criteria are clearly met and the client displays one of the following characteristic signs: clouded consciousness as evidenced by delirium, mutism, stupor or coma; leukocytosis (more that 15,000 white blood cells / mm); serum creatine kinase level greater than 1,000 IU / ml. (Source: The Manual of Clinical Psychopharmacology - 2nd Edition) C. Physical Restraints and Seclusion 1. Presence of one or more of the following indicators: a. b. c. d. e. 2. Client found suspended by / from restraint Client found sliding from bed / wheelchair / chair Client's neck / head found under / between side rails Client found in tipped wheelchair with a restraint intact Autopsy report indicates asphyxiation or possible asphyxiation

Position of actual restraint. a. b. c. Restraint under client's ribs exerting pressure Restraint across chest and conforming to body in a tight appearing fashion Restraint across throat area

3. 4. 5.

Physical hold by staff utilized in proximity to time of death of client. Resident found expired in seclusion / locked room. Presence of one or more of the following physical signs: a. b. c. Discolored areas on skin Red markings on skin Swollen tongue

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Division of Quality Assurance (DQA) Reportable Death Contact Table
No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Provider Type Facility for the Developmentally Disabled Mendota or Winnebago MHI Mental Health Inpatient Program Community Based Residential Facility Nursing Home Mental Health Crisis Service Community Support Program Mental Health Day Treatment Mental Health Outpatient Program Mental Health Day Treatment Services for Children Comprehensive Community Services AODA Emergency Outpatient Service AODA Medically Managed Inpatient Detox Service AODA Medically Monitored Residential Detox Service AODA Ambulatory Detoxification Service AODA Residential Intoxication Monitoring Srvc AODA Medically Managed Inpatient Treatment Service AODA Medically Monitored Treatment Service AODA Day Treatment Srvc AODA Outpatient Treatment Service AODA Transitional Residential Treatment Srvc AODA Narcotic Treatment Service for Opiate Addiction Hospital AODA Inpatient Program AODA Intervention Services Admin. Rule HFS 134 HFS 124 HFS 124 HFS 83 HFS 132 HFS 34 HFS 63 HFS 61.75 HFS 61.91 HFS 40 HFS 36 HFS 75.05 HFS 75.06 HFS 75.07 HFS 75.08 HFS 75.09 HFS 75.10 HFS 75.11 HFS 75.12 HFS 75.13 HFS 75.14 HFS 75.15 HFS 124 HFS 75.16 Type of License or Certification License Approval Approval License License Certification Certification Certification Certification Certification Certification Certification Certification Certification Certification Certification Certification Certification Certification Certification Certification Certification Approval Certification Where to Fax the Client/Patient Death Determination Form DQA Regional Field Operations Director for the Region where your facility is located. See attached page with a list and map. Director, Health Services Section, Fax (608) 264-9847. For questions about reporting a death, call (608) 264-9887. Director, Health Services Section, Fax (608) 264-9847. For questions about reporting a death, call (608) 264-9887. DQA Regional Field Operations Director for the Region where your facility is located. See attached page with a list and map. DQA Regional Field Operations Director for the Region where your facility is located. See attached page with a list and map. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657. Director, Health Services Section, Fax (608) 264-9847. For questions about reporting a death, call (608) 264-9887. Chief, Behavioral Hlth Certification Section, Fax (608) 261-0655. For questions about reporting a death, call (608) 261-0657.

For additional information (including copies of annual Act 336 Reports) contact: Richard Ruecking, Reportable Death Review Coordinator DQA / Bureau of Health Services / Behavioral Health Certification Section Phone: (608) 261-0657 Fax: (608) 261-0655

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Regional Field Operations Director, Northeastern Regional Office, Green Bay, Fax: 920-448-5254. For questions about reporting a death, call 920-448-5249. Regional Field Operations Director, Northern Regional Office, Rhinelander, Fax: 715-365-2815. For questions about reporting a death, call 715-365-2802. Regional Field Operations Director, Southeastern Regional Office, Milwaukee, Fax: 414-227-4139. For questions about reporting a death, call 414-227-4908. Regional Field Operations Director, Southern Regional Office, Madison, Fax: 608-266-9422. For questions about reporting a death, call 608-266-9875. Regional Field Operations Director, Western Regional Office, Eau Claire, Fax: 715-836-2535. For questions about reporting a death, call 715-836-4753.