Reporting of Client/Patient/Resident Death

• Client/Patient/Resident Death Determination, F-62470 (PDF)

Submit the completed form by fax or email to:

Department of Health Services
Division of Quality Assurance/Office of Caregiver Quality
Fax: 608-264-6340
Email: DHSCaregiverIntake@dhs.wisconsin.gov

• DQA Numbered Memo 16-008 (PDF) – Centralized Reporting of Client/Patient/Resident Death Determination

The reporting requirements are found under:

• Community-Based Residential Facility – Wis. Stat. § 50.035(5)(b)
• Adult Family Home – Wis. Admin. Code § DHS 88.03 (5)(e)1
• Nursing Home – Wis. Stat. § 50.04(2t)(b)
• Treatment Facility (mental health or substance abuse program/service) – Wis. Stat. § 51.64(2)(a)

• Hospital Restraint/Seclusion Deaths: 42 CFR & 482.13(g)

In accordance with requirements at 42 CFR § 482.13(g), Death Reporting Requirements, all patient deaths associated with restraint or seclusion (except 2-point soft wrist restraints that must be recorded in an internal hospital log or other system) in a hospital are required to be reported to the Centers for Medicare & Medicaid Services (CMS) Regional Office (RO). 

CMS Memo QSOG-20-04-Hospital-CAH DPU, “Electronic Form CMS-10455, Report of a Hospital Death Associated with Restraint or Seclusion,” provides information on the process that hospitals (including rehabilitation or psychiatric distinct part units in critical access hospitals) must use to report a patient death associated with restraint or seclusion, using an electronic report form. The electronic version of Form CMS-10455 is replacing the paper version starting December 2, 2019. Beginning January 1, 2020, the CMS RO resource mailboxes will no longer accept paper versions of Form CMS-10455.

Questions regarding reporting of hospital restraint or seclusion deaths may be directed to the CMS Chicago Region Office at 312-353-9804.

Note: A hospital may have a mental health inpatient unit certified under Wis. Admin. Code §§ DHS 61.71 or DHS 61.79 or a medically monitored/managed treatment program certified under DHS 75.06 DHS 75.10 or DHS 75.11. A death in these settings must be reported to DHS via the Client/Patient/Resident Death Determination, F-62470 if there is reasonable cause to believe that the death was related to the use of restraint/seclusion, psychotropic medications, or was a suicide.

• Hospice Restraint/Seclusion Deaths: 42 CFR §418.110(p)

A hospice must report restraint/seclusion deaths directly to the Centers for Medicare & Medicaid Services (CMS), Office of the Regional Administrator (Chicago Regional Office) at 312-886-6432.

The hospice must report:

• Each unexpected death that occurs while a patient is in restraint or seclusion.
• Each unexpected death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
• Each death known to the hospice that occurs within one week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death.

• Residential Care Centers for Children and Youth

Refer to Wisconsin Department of Children and Families (DCF), Child Welfare Licensing Series Memo 2017 – 04L, Reporting Serious Incidents (Re-issued). A death that is related to a psychotropic medications, physical restraint/seclusion or is a suicide must be reported using form DCF-F-CFS-2183-E, Resident Care Center Statutorily Reportable Death. The death should also be reported as a serious incident using form DCF-F-CFS2146-E, Serious Incident Report. Forms can be found at the Child Welfare Licensed Facility Forms and Publications website.