Analysis of Deaths in Developmental Disabilities Administration Residential Supports
Explore the review process and findings of deaths among individuals receiving residential supports from the Developmental Disabilities Administration in Washington State in 2013. This detailed analysis covers mortality reviews, place of death, residence at the time of death, and the percentage of reviews by residence type.
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Mortality Reviews Analysis of deaths of individuals receiving residential supports from the Developmental Disabilities Administration of Washington State 2013 Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 1
Mortality Reviews Developmental Disabilities Administration (DDA) Regional Process: All deaths of DDA clients are reported to the Regions. The Regional Quality Assurance Manager requests additional information from all residential agencies, adult family homes, children s licensed facilities and nursing agencies serving children receiving Medically Intensive Children s Program services. The Region/RHC then further reviews each death of a client receiving residential services for circumstances/cause of death; whether policies and procedures were followed; whether proper clinical and medical practices were observed, etc. Unexplained or unusual deaths are carefully considered and reviewed. Families and legal representatives (guardians) are encouraged to seek an autopsy in these cases. Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 2
Mortality Reviews DDA Central Office Process: All results must be subsequently forwarded to the DDA Office of Quality Programs and Stakeholder Involvement for Central Office Mortality Review Team (MRT) action. The MRT includes administrative, medical, investigatory and other professional personnel who: Review 100% of mortality review reports from the Regions and RHCs; Review data from the Incident Reporting system, the CARE database and other sources to identify any trends or patterns that need addressing; and Make reports and recommendations to DDA management concerning needed training, policy or procedural changes. Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 3
Mortality Reviews Place of death Hospital 42 SL/Group Home 39 Adult Family Home 10 RHC 7 Nursing Facility 7 Unknown 2 Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 4
Mortality Reviews Residence at time of death SL/Group Home 66 Adult Family Home 22 RHC 10 Parent/Own home 3 Nursing Facility 3 Foster Home/Staffed Residential 2 Community ICF/MR 1 Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 5
Mortality Reviews Percent of DDA client mortality reviews by residence type 7.6% 8.0% 7.1% 6.0% 4.0% 3.6% 4.0% 2.0% 0.0% Supported Living Adult Family Home RHC Licensed Staff Res 2013 2013 2013 2013 Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 6
Mortality Reviews Age at time of death 90 + 1 81 to 90 5 71 to 80 17 61 to 70 24 51 to 60 21 41 to 50 23 31 to 40 5 21 to 30 7 11 to 20 1 Birth to 10 3 Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 7
Mortality Reviews Primary cause of death Heart Disease 27 Pulmonary/Respiratory 26 Pneumonia 17 Unknown 14 Cancer 9 Kidney/Renal Failure 6 Nervous system 5 Other 2 Sepsis 1 Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 8
Mortality Reviews Primary cause of death, percent and number of reviews Cancer, 9, 8% Kidney/Renal Failure, 6, 6% Unknown, 14, 13% Sepsis, 1, 1% Heart Disease, 27, 25% Pulmonary/ Respiratory, 26, 24% Other, 2, 2% Pneumonia, 17, 16% Nervous system, 5, 5% Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 9
Mortality Reviews Aspiration Pneumonia involved Yes 26, 25% No Unknown 7, 7% 72, 68% Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 10
Mortality Reviews Aspiration pneumonia deaths involved deaths by year 40 26 26 25 2010 2011 2012 2013 Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 11
Mortality Reviews Most deaths occurred in a hospital and second was Supported Living/Group home home. 64% of the deaths reviewed were individuals between the ages of 41 and 70. 26 deaths had aspiration pneumonia involvement which is the same number as last year. This number has decreased dramatically from 2011 s 40. The top three primary causes of death reviewed were, heart disease at 25%, pulmonary/respiratory at 24% and pneumonia at 16%. Washington State DSHS/DDA Data Source: Mortality Review Database Lenora Sneva 4-14 Total 2013 reviews = 107 12
