Incident report — unwitnessed fall. At approximately 0715, resident found seated on floor beside bed by CNA entering room for morning care. Resident reports he attempted to transfer to bedside commode independently without calling for assistance. Resident denies loss of consciousness; oriented x3 at time of assessment. No head strike reported by resident. Vital signs post-fall: T 98.2°F, HR 90, BP 130/80, O2 sat 94% on 2L NC. Neurological check completed — pupils equal and reactive, no focal deficits noted, no visible injury or swelling. Resident assisted back to bed with 2-person assist. Physician notified at 0720; no new orders at this time. Family notified at 0745. Fall risk precautions reinforced verbally with resident, including call-light instruction. Bed alarm re-applied. Will increase monitoring frequency. Documentation forwarded to charge nurse and risk management per facility protocol.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-15
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 2026-04-15
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: "[MSW] ...iew, consistent with nursing reports of low mood. Psychosocial concerns identified: social isolation, adjustment to illness, con...", "[MD] ...etite reportedly poor. Resident reports low mood, poor sleep, and low energy; states he feels hopeless about his recovery and ha..."