Incident report completed for Robert Tyndall. At approximately 1930, resident found on floor beside bed by CNA during routine rounding. Resident alert and oriented x3 at time of discovery, denies loss of consciousness. States he attempted to ambulate to bathroom independently without calling for assistance, reports feeling dizzy upon standing. No visible injuries noted on immediate assessment; neurological check completed — pupils equal and reactive, no facial drooping, grip strength equal bilaterally, speech clear. Vitals post-fall: BP 118/74 (orthostatic component suspected, admission BP 148/92), HR 90, O2 sat 94%. MD notified at 1940, no new orders received at this time. Family (wife Eleanor Tyndall) notified at 1955. Resident reminded of call light use and fall prevention protocol. Bed alarm reactivated. Non-skid footwear applied. Will reassess in 1 hour and monitor closely per facility fall protocol.
MDS 3.0 · Section I — Active Diagnoses · target 2026-03-19
I0900Peripheral Vascular Disease···☐ NOT CODED
I2000Pneumonia···☐ NOT CODED
I2500Wound Infection···☐ NOT CODED
I3500Pressure Ulcer Stage 3···☐ NOT CODED
I4500Diabetes Mellitus···☐ NOT CODED
MDS · Section O — Special Treatments · target 2026-03-19
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···☐ NOT CODED
O0100F2Ventilator/Respirator Post-admit···☐ NOT CODED
Gap detection · grounded
claude-opus-4-7 · 847ms · 2.1k tok
DEPRESSIONmedium
Notes describe depressive symptoms. Score a PHQ-9 (D0150) or staff assessment (D0500) at next MDS to capture for nursing classification.
Field: pdpmDepression
Evidence: "[MSW] ...ay verbally. Resident denies history of depression when asked directly, though nursing staff have noted flat affect since admissio..."