Regulations: Reporting of Client/Patient/Resident Death

Before completing F-62470, prepare the information described below. You will be able to select the sections on the form to view the information requested.

You will be required to provide the following information:

• Deceased Information: First/last name, sex, ethnicity, date of birth, date of death, date of admission
• Provider Information: Agency/clinic/facility name, certification/license number, provider address, provider county, provider type
• Death Determination Information
  • Suicide
    • Do you, the provider, have knowledge that the client/patient/resident was having suicidal thoughts during the last month?
    • Do you, the provider, have knowledge that the client/patient/resident made any suicide threats or statements during the last month?
    • Do you, the provider, have knowledge that the client/patient/resident made a suicide attempt in the past year?
    • Do you, the provider, have knowledge that the client/patient/resident gave away personal possessions within the last month?
    • Do you, the provider, have knowledge that the client/patient/resident was 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
    • Do you, the provider, have knowledge that the client/patient/resident was on three or more psychotropic medications?
    • Do you, the provider, have knowledge that the client/patient/resident was on two or more psychotropic medications in the same class?
    • Do you, the provider, have knowledge that the physician discontinued a psychotropic medication within the last 30 days?
    • Do you, the provider, have knowledge that the client/patient/resident refused psychotropic medications within the last 30 days?
    • Do you, the provider, have knowledge that the client/patient/resident changed to a different psychotropic medication within the last 30 days?
    • Do you, the provider, have knowledge that the client/patient/resident's medical/psychiatric condition changed in the last 30 days, based on observed symptoms and behaviors?
    • Do you, the provider, have knowledge that the client/patient/resident received any drug(s) to which he/she has a known allergy or adverse drug reaction as documented in their record within the last 30 days?
    • Do you, the provider, have knowledge that the client/patient/resident presented any signs which would indicate the possibility of neuroleptic malignant syndrome (NMS)?
    • Do you, the provider, have knowledge that a psychotropic medication was given with no valid diagnosis for the drug?
  • Physical Restraints and Seclusion
    • Did the client/patient/resident die while in restraint or seclusion?
    • Did the restraint/seclusion have a direct relationship to the client/patient/resident's death?
    • Did the client/patient/resident sustain any injury while in restraint or seclusion?
    • Was the client/patient/resident in a prone position when a physical restraint was used?
• Reporting Information
  • Reporter's name, title, email, phone, address
  • Have you previously reported this death to the Department of Health Services? If yes, you will also be asked to provide the name and phone number of the person you reported to as well as the date you reported the death.
  • Is there a person in your agency who was involved in the client/patient/resident case who might have more information about the death (e.g., therapist, manager, social worker)? If yes, you will also be asked to provide the name, title, email, and phone number for the person.
  • Was this death reported to the coroner/medical examiner (ME)? If yes, you will also be asked to provide the name, phone number, and county for the coroner/ME.
  • How did you (e.g., the provider) learn of the death?
  • When did you (e.g., the provider) learn of the death?
  • Cause of death known? If yes, you will be asked to provide a description.
  • Provide a brief summary of the circumstances surrounding the death. You may attach a copy of progress notes or other documentation that provides additional information used to determine whether there is reasonable cause to believe the death was due to the use of physical restraints/seclusion, psychotropic medication, or suicide.
  • You are able to upload up to 10 supporting documents if needed.

The following applies to hospitals, including rehabilitation or psychiatric distinct part units in critical access hospitals.

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

Use electronic form CMS-10455 to report a death. Paper versions of the form are not accepted. For help using the electronic form, refer to the CMS memo QSOG-20-04-Hospital-CAH DPU (PDF).

Questions? Call CMS Chicago Region Office at 312-353-9804.

Note: A death in the following settings must be reported to DHS via the Client/Patient/Resident Death Determination, F-62470 if there is reasonable cause to believe the death was related to the use of restraint/seclusion, psychotropic medications, or was a suicide:

• A hospital with a mental health inpatient unit certified under Wis. Admin. Code §§ DHS 61.71 or DHS 61.79.
• A medically monitored/managed treatment program certified under DHS 75.06, DHS 75.10, or DHS 75.11.

In accordance with 42 CFR § 418.110(p), a hospice must report restraint or seclusion deaths directly to the 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.

A death that is related to a psychotropic medications, physical restraint or seclusion, or is a suicide must be reported to the Wisconsin Department of Children and Families (DCF). Complete the following forms:

• DCF-F-CFS-2183-E, Resident Care Center Statutorily Reportable Death (Word)
• DCF-F-CFS2146-E, Serious Incident Report (Word)

Find these forms at Child Welfare Licensed Facility Forms and Publications.

For more information, refer to DCF's Child Welfare Licensing Series Memo 2017 - 04L, Reporting Serious Incidents (Re-issued) (PDF).

In 2020, 861 Wisconsin residents died by suicide. More information on Wisconsin data, as well as the state's suicide prevention plan, are found on our Suicide Prevention webpage.

Zero Suicide is a system-wide, organization commitment to safer suicide care in health and behavioral health systems. The Zero Suicide Toolkit is a detailed guide to Zero Suicide implementation and strategy. You also can attend a Zero Suicide training.

Resources and organizations

• Prevent Suicide Wisconsin
• Question, Persuade, Refer - QPR Institute
• Suicide Prevention - DHS
• Suicide Prevention Resource Center (SPRC)
  • Engaging People with Lived Experience
• Zero Suicide Institute
  • Preventing Suicide in Emergency Departments
  • Suicide Care Training Options

Evidence-based tools

• CALM: Counseling on Access to Lethal Means - SPRC online training
• Columbia Suicide Severity Rating Scale - The Lighthouse Project
• Safety Plan Template - Stanley-Brown - SPRC

Evidence-based treatments

• Assessing and Managing Suicide Risk - SPRC
• Collaborative Assessment and Management of Suicidality (CAMS) Proven Suicide Treatment Training - CAMS-care
• Experiential Trainings on the Chronological Assessment of Suicide Events (CASE Approach) for Clinicians - Training Institute for Suicide Assessment & Clinical Interviewing
• Dialectical Behavior Therapy (DBT) Training and Resources - Behavioral Tech
• Recognizing & Responding to Suicide Risk: Essential Skills for Clinicians - American Association of Suicidology

Safer care transitions

• Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care - Zero Suicide Institute
• Continuity of Care for Suicide Prevention: The Role of Emergency Departments - SPRC
• Promote Social Connectedness and Support - SPRC
• Toolkit: Transition - Zero Suicide Institute

• 988 Suicide & Crisis Lifeline - 988
• County Crisis Lines - Prevent Suicide Wisconsin's county directory
• Crisis Text Line - Text HOME to 741741
• Emergency - Call 911
• Farmers Wellness Helpline - 888-901-2558, a program of the Wisconsin Department of Agriculture
• The Trevor Project 24-hour LGBTQ crisis line - 866-488-7386
• Veterans Crisis Line - Dial 988, then press 1