Care conference held today with resident, daughter Linda Tsutsumi (POA), attending MD, PT, OT, SLP, and social services. Pneumonia (J18.9) noted to be clinically resolving; antibiotic course completed 4/28. Resident O2 sat now 95–96% on 2L NC with trials of room air ongoing. Functional progress noted across therapy disciplines. Diet remains nectar-thick liquids and minced-moist per SLP recommendation. Coccyx wound discussed; family educated on pressure relief and positioning. Discharge goal to home with daughter remains; target date estimated 5/8–5/10 pending continued progress. Resident tearful during conference but verbalized willingness to continue rehabilitation. All team members updated plan of care. Resident and daughter verbalized understanding and agreement with goals.
MDS 3.0 · Section I — Active Diagnoses · target 2026-05-06
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 2026-05-06
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: "[RN] ...10 pending continued progress. Resident tearful during conference but verbalized willingness to continue rehabilitation. All te...", "[MD] ...nt's daughter reports resident has been tearful, expressing hopelessness about recovery, and has had poor appetite since admiss..."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ...ortness of breath with exertion. O2 via nasal cannula continued per physician order. Daughter present at bedside, verbalized understa..."