Mortality Review Internal Investigation
Case Manager:
First Name
Last Name
Date:
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Month
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Day
Year
Date Picker Icon
Individual:
Date of Death
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Month
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Day
Year
Date
Timeframe of review: The review covers the thirty (30) day period immediately before the death of the Individual; and if applicable, the hospitalization or placement in a hospice setting or nursing facility in which the Individual's death occurred.
A clear statement indicating why the investigation/review is being conducted.
A clear narrative of the thirty (30) day period immediately before the death of the Individual; and if applicable, the hospitalization or placement in a hospice setting or nursing facility in which the Individual's death occurred and the death in a time-line format including what, where, and when the death happened or is alleged to have happened.
Identification by name and title of all involved parties or alleged involved parties including: the Individual who died; all staff assigned to the Individual who died at the time of the incident; all alleged perpetrators, when indicated; and all actual or potential witnesses to the death.
Signed and dated statements from all involved parties, including all provider staff assigned and present at the time of death, including all actual and potential witnesses to the death. If no provider staff were present at the time of death, a statement should be included indicating this
Copies of all records, policies, and other documents reviewed that provide evidence supporting the findings of the investigation or review (if not already submitted).
A narrative review of the Individual's records, documentation, and staff ratios/supervision level, relevant to the services being provided to the Individual at the time of death.
A narrative review of Provider policies and procedures relevant to the 30-day timeframe and the Individual's death.
A narrative summary of the findings and observations of all record, document and policy review associated with death.
A narrative review of Provider policies and procedures relevant to the 30-day timeframe and the Individual's death.
A statement of specific findings and conclusions from the review.
An identification of and explanation for any discrepancies/conflicts between the evidence gathered and how the discrepancy is resolved and/or explained. If there were no discrepancies/conflicts, a statement should be included indicating this.
A statement indicating if rights have been violated, if services and/or care were not provided or were not appropriately provided, if agency policies and/or procedures were not followed, and/or if any federal or state regulations were not followed.
A clear statement of substantiation or non-substantiation of any allegation that includes a description/summary of the evidence that resulted in the finding. If there were no allegations, a statement should be included indicating this.
A definitive description of all corrective actions developed and implemented and/or to be implemented because of the investigation or review, including completion dates for each corrective action. Documentation of implementation of any corrective actions developed because of the review. If the corrective action included training, training documentation should include all required training components. If there were no corrective actions, a statement should be included indicating this.
Other pertinent information:
Submit
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