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Regulations: Reporting of Client/Patient/Resident Death

Reporting requirements

Under Wisconsin statutes, a program or facility must report the death of a client/patient/resident to the Wisconsin Department of Health Services (DHS) 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 psychotropic medications.
  • A suspected suicide.

Report within 24 hours

DHS must receive notification within 24 hours of the death or learning of the death of a client/patient/resident.

Complete the form

To notify DHS, complete the Client/Patient/Resident Death Determination, F-62470 (PDF).

This form includes guidelines to help you determine if the death is a reportable death, such as:

  • The types of providers required to report a death. (On page 1, go to "Provider Types" listed under Section II).
  • General information and death determination guidelines (on page 4-5, go to Section V).

Submit the form

Submit the completed form by:

Send the form to the attention of:

DHS Division of Quality Assurance

Office of Caregiver Quality

Learn more

For specific reporting requirements, go to:

Report deaths to other agencies

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 that the death was related to the use of restraint/seclusion, psychotropic medications, or was a suicide:

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:

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).

Take action to prevent suicide

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.

Contact us

Questions? Contact the Wisconsin Office of Caregiver Quality:

Last revised March 7, 2023