Incident report filed: Mr. Delacroix found seated on floor beside bed at approximately 1605. Resident states he 'tried to get up to use the bathroom' and his legs 'gave out.' No loss of consciousness reported by resident. Neuro check completed: alert and oriented x3, pupils equal and reactive, no slurred speech, no new focal deficits. Skin assessment: no abrasions, lacerations, or bruising identified. Vital signs post-incident: BP 118/72, HR 92, RR 20, SpO2 95% on 2L NC. Physician notified; no new orders at this time beyond continued monitoring. Family (daughter Maria) notified by phone at 1625. Bed alarm reactivated, bed in lowest position confirmed, call light within reach, nonslip footwear applied. PT notified of incident for reassessment. Documentation forwarded to charge nurse and DON per facility protocol.
MDS 3.0 · Section I — Active Diagnoses · target 2026-05-12
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 2026-05-12
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···✓
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] ...lobe infiltrate. Resident also endorses low mood, decreased interest in activities, and poor appetite since his hospitalization...."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ...post-incident: BP 118/72, HR 92, RR 20, SpO2 95% on 2L NC. Physician notified; no new orders at this time beyond continued m...", "[OT] ...ce and dyspnea with sustained activity; SpO2 monitored throughout, lowest 92% on 2L NC during dressing task. Resident instru..."