Incident report: At approximately 1215, resident found seated on floor in room beside bed. Call light within reach but not activated. Resident alert and oriented upon staff arrival, denies loss of consciousness. States he was attempting to reach his water pitcher on the nightstand and 'lost his balance.' No visible injury noted at time of incident; skin intact, no head strike reported or observed. Vitals post-fall: BP 140/84, HR 92, RR 20, O2 sat 92% on 2L NC. Charge RN notified immediately; physician notified at 1220. Neurological checks initiated per protocol. Daughter notified by charge RN at 1235. Bed alarm re-applied and call light repositioned within easy reach. Bedside table repositioned. Incident attributed in part to dyspnea-related fatigue and reaching behavior. Fall risk precautions reinforced with resident. Will continue to monitor.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-14
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 2026-04-14
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···☐ NOT CODED
O0100F2Ventilator/Respirator Post-admit···✓
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Evidence: "[MD] ...ter reports he has seemed withdrawn and tearful since discharge, with decreased interest in activities he previously enjoyed. A..."