DDA Mortality Review Provider Report
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)DDA Mortality ReviewProvider ReportNAME OF PERSON COMPLETING FORM (PRINT) FORMTEXT ?????POSITION / TITLE FORMTEXT ?????DATE COMPLETED FORMTEXT ?????TELEPHONE NUMBER FORMTEXT ?????Complete upon the death of a person who was receiving services from a contracted or licensed provider or was being transported to/from services provided by contracted or licensed providers. This report must be sent to the DDA Case Resource Manager (CRM) within 7 calendar days of the person’s death. Note: Information provided in this report is the best information available at the time and in no way represents a complete history or a professional medical opinion. The person completing the form is not attempting to render a professional opinion and is operating based on the known facts immediately following the death. I. General InformationDECEASED’S LEGAL NAME (FIRST NAME)MIDDLE NAMELAST NAME FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDRESS FORMTEXT ?????AGENCY / RESIDENTIAL PROVIDER NAME FORMTEXT ?????GENDER FORMCHECKBOX Male FORMCHECKBOX Other FORMCHECKBOX FemaleETHNICITY FORMCHECKBOX African American FORMCHECKBOX Asian/Pacific Islander FORMCHECKBOX Caucasian FORMCHECKBOX Hispanic FORMCHECKBOX Native American FORMCHECKBOX Other: FORMTEXT ?????DATE OF DEATH (MM/DD/YYYY) FORMTEXT ?????TIME OF DEATH FORMTEXT ??: FORMTEXT ?? FORMCHECKBOX AM FORMCHECKBOX PM FORMCHECKBOX EstimateDATE OF BIRTH (MM/DD/YYYY) FORMTEXT ?????AGE FORMTEXT ???PLACE OF DEATH (CHECK ALL THAT APPLY) FORMCHECKBOX Deceased’s residence FORMCHECKBOX Nursing Facility FORMCHECKBOX Hospital FORMCHECKBOX Hospice Facility FORMCHECKBOX Unknown FORMCHECKBOX Other (specify): FORMTEXT ?????Was provider aware of client’s location / current condition at time of death? FORMCHECKBOX Yes FORMCHECKBOX No (explain): FORMTEXT ?????SOURCE OF INFORMATION (CHECK CORRECT BOX) FORMCHECKBOX Death Certificate FORMCHECKBOX Medical Provider FORMCHECKBOX Family or Caregiver FORMCHECKBOX Other (specify): FORMTEXT ?????APPARENT PRIMARY CAUSE OF DEATH FORMTEXT ?????APPARENT SECONDARY CAUSE OF DEATH FORMTEXT ?????OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE APPARENT CAUSE LISTED ABOVE (SUCH AS SIGNIFICANT ILLNESS OR DISEASE) FORMTEXT ?????WAS 911 CALLED? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownTIME OF CALL FORMTEXT ??: FORMTEXT ?? FORMCHECKBOX AM FORMCHECKBOX PM NAME AND POSITION OF CALLER FORMTEXT ?????DEATH CERTIFICATE OR WORKSHEET OBTAINED FORMCHECKBOX Yes FORMCHECKBOX No TYPE OF RESIDENCE WHERE DECEASED LIVED FORMCHECKBOX Supported Living (24/7 on-site) FORMCHECKBOX ARC / Assisted Living FORMCHECKBOX Homeless FORMCHECKBOX Supported Living (24/7 available) FORMCHECKBOX Community ICF/IID FORMCHECKBOX Own home FORMCHECKBOX DDA Group Home FORMCHECKBOX SOLA FORMCHECKBOX Parent’s home FORMCHECKBOX Foster Home / Licensed Staffed Residential FORMCHECKBOX State Hospital FORMCHECKBOX Adult Family Home FORMCHECKBOX Nursing Facility FORMCHECKBOX Other (specify): FORMTEXT ?????II. Medical InformationCONDITIONS EXISTING PRIOR TO THE PERSON’S DEATH (CHECK ALL THAT APPLY) FORMCHECKBOX Allergies (type): FORMTEXT ????? FORMCHECKBOX Alzheimer’s or Dementia FORMCHECKBOX Anemia / Blood Disorder FORMCHECKBOX Cancer (type): FORMTEXT ????? FORMCHECKBOX Coronary Disease: FORMCHECKBOX Arrhythmia FORMCHECKBOX Congestive Heart Failure FORMCHECKBOX Heart Attack (Myocardial Infarction FORMCHECKBOX Other FORMCHECKBOX Diabetes: FORMCHECKBOX Insulin Dependent FORMCHECKBOX Non-insulin Dependent FORMCHECKBOX Fracture(s) (type and body part): FORMTEXT ????? FORMCHECKBOX Gastric disease (e.g. ulcer, reflux) FORMCHECKBOX Hypertension FORMCHECKBOX Hypotension FORMCHECKBOX Hypothyroidism FORMCHECKBOX Limited mobility / Paralysis FORMCHECKBOX Notifiable Condition / Communicable Disease (specify): FORMTEXT ????? FORMCHECKBOX Pressure Injury(s) (specify): FORMCHECKBOX Renal / kidney disease FORMCHECKBOX Respiratory disease: FORMCHECKBOX Asthma FORMCHECKBOX Chronic Obstructive Pulmonary Disease (COPD) FORMCHECKBOX Pneumonia FORMCHECKBOX Recurrent aspiration FORMCHECKBOX Ventilator FORMCHECKBOX BiPap / C-Pap FORMCHECKBOX Tracheostomy FORMCHECKBOX Seizures FORMCHECKBOX Sepsis FORMCHECKBOX Surgical Procedure: FORMTEXT ?????Reason: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Surgical Procedure: FORMTEXT ?????Reason: FORMTEXT ????? FORMCHECKBOX Surgical Procedure: FORMTEXT ?????Reason: FORMTEXT ????? FORMCHECKBOX Swallowing disorder: FORMCHECKBOX Feeding tube FORMCHECKBOX Dysphagia with diet restriction FORMCHECKBOX Syndrome (specify): FORMTEXT ????? FORMCHECKBOX Thrombosis or Embolism Type: FORMTEXT ????? FORMCHECKBOX Other (if related to death): FORMTEXT ?????When was the deceased last treated by any health care provider? Summary / diagnosis / date of treatment: FORMTEXT ?????Hospitalizations (most recent):Date: FORMTEXT ????? Reason: FORMTEXT ?????Date: FORMTEXT ????? Reason: FORMTEXT ?????Date: FORMTEXT ????? Reason: FORMTEXT ?????Was the deceased in hospice care? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownWas CPR performed? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf yes, by who: FORMTEXT ?????Was there a DNR in place? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownWas there a POLST in place? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIII. Medications and Treatments1. Was deceased on prescribed medications? FORMCHECKBOX Yes FORMCHECKBOX No2. Was nurse delegation in place? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, was the nurse delegator contacted regarding the death? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, date of contact: FORMTEXT ?????3. Was Private Duty Nursing in place? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, was the private duty nurse contacted regarding the death? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, date of contact: FORMTEXT ?????IV. Mental HealthDid any mental health issues contribute to the death (such as suicide or inability / noncompliance with care)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownV. Description of DeathDESCRIBE THE CIRCUMSTANCES OF DEATH, including illness or course of symptoms that led up to their death. Include interventions such as CPR or transfer to hospital. ATTACH ADDITIONAL PAGES AS NEEDED. FORMTEXT ?????VI. Attachments – All boxes must be checked.ATTACHEDN/APENDINGBowel program or protocol FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Care / progress notes from the previous seven days (prior to death or hospitalization) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Client refusal of Healthcare Services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Death certificate / worksheet FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Diabetic Care Protocol FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX IISP, Nursing Plan of Care, Treatment Plan, or Negotiated Care Plan FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medication / Treatment Administration Record (MAR / TAR – signed) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Results of any internal investigations related to death or care leading up to death FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Seizure protocol FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Skin Care Protocol FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Specialized diet (if history of swallowing problems) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physicians Orders for Life-Sustaining Treatment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other; specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PROVIDER NAME (PRINT) FORMTEXT ?????JOB TITLE FORMTEXT ?????DATE FORMTEXT ?????For DDA Case Resource Manager Only (Complete within five business days following the date of receipt and send to the regional Nursing Care Consultant, and copy regional Quality Assurance Manager and CRM Supervisor)I have reviewed this report and there is: FORMCHECKBOX Additional Information (specify below) FORMCHECKBOX No additional information FORMTEXT ?????In your opinion, was the death (check all that apply): Refer to DDA Policy 7.05 Attachment C for definitions of these terms. FORMCHECKBOX Unexpected FORMCHECKBOX Expected / Anticipated FORMCHECKBOX Suspicious FORMCHECKBOX Accidental FORMCHECKBOX Unknown CRM NAME (PRINT) FORMTEXT ?????DATE REVIEWED FORMTEXT ????? ................
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