|Reporting of Client/Patient Death
Attributable to Suicide, Restraint, or Psychotropic Medication
note that blue boxes in PDF files indicate links to
Forms are fillable online, although you will
not be able to save revised forms. You can also print off and photocopy
forms to keep available as needed.
Reporting Requirements for Programs and
Within 24 hours after the death of a client, or learning of a death:
The program or facility that was providing care, treatment or services to
the client is required under Wisconsin statutes to
notify the Department of Health Services if there is cause to believe that the
death was related to:
- the use of a physical restraint or seclusion
- the use of one or more
- the death is a suspected suicide.
to the Department must be via the completed "Client/Patient Death
Determination" form F-62470 (PDF, 239 KB).
The completed F-62470 form
faxed to the appropriate Division of Quality Assurance Director or Chief
listed in the right-hand column of the Reportable Death Contact Table included in the
F-62470 form on page 5.
Background and Procedures:
(PDF, 239 KB), "Client / Patient Death Determination" (adults)
(PDF, 76 KB), "Residential Care Center Resident Death Determination"
These forms and procedures are for reporting to
the Department deaths that may have been related to the use of a physical restraint or
seclusion, a psychotropic medication, or the death is a suspected suicide.
requirement is found under ss. 48.60 (5) (a), 50.035 (5), and 51.64, Wis. Stats.
The list in the Reportable Death Contact Table of programs and facilities required to report these deaths has been expanded to include those required to do so under
40 and DHS 75 (exit DHS) (scroll down to appropriate codes to view).
Also, please note that
the category Comprehensive Community Services for Persons
with Mental Illness under proposed Administrative Code DHS 36 is also included.
Comprehensive Community Services Programs certified under DHS 36 following its
promulgation will be required to report these deaths.
The report should
be faxed to the DQA Director for the respective program or facility reporting a
death. The Reportable Death Contact Table on page 5 of form F-62470 identifies which
DQA director should receive the report.
these revised procedures and form F-62470 to report a death to the appropriate
DQA director. If a fax machine is not available, you may call the
DQA director to obtain his or her
Please review the reportable death procedures and the
"Instructions" and "Client/Patient Death Determination Guidelines" in
the F-62470 form.
These guidelines have been included in that form to assist programs and
facilities determine if there is reasonable cause to believe the client/patient death may
be related to the use of restraint/seclusion, the use of psychotropic medication or is a
If you have any questions, please
contact the DQA Director for your respective program or facility.
PDF: The free Acrobat Reader® software
is needed to view and print portable document format (PDF) files. Learn
January 13, 2014