Nursing assessment completed for Shirley Tompkins, Day 11 of skilled stay. Respiratory status continues to improve; O2 weaned to 1L NC overnight with saturations maintained at 96–97%. Cough now rare and nonproductive. Lung sounds clear in upper lobes, faint diminishment remains at left lower lobe. During routine skin assessment this morning, a Stage 2 pressure injury identified on the coccyx, approximately 2.0 cm x 1.5 cm, shallow open area with pink wound bed, no exudate, no odor, surrounding skin mildly erythematous. Resident reports area 'tender.' Resident spending increased time in bed secondary to fatigue and post-fall anxiety. Physician/NP notified of skin finding. Repositioning schedule reinforced with CNA staff, pressure-relieving mattress overlay requested. Resident appetite improved slightly; consuming approximately 60–70% of meals. Family updated during evening phone call.
MDS 3.0 · Section I — Active Diagnoses · target 2026-05-11
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 2026-05-11
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: "[NP] ...orted GI side effects. Resident reports low mood, expressing discouragement about slow recovery progress and reluctance to parti..."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[NP] ... oxygenation needs and consider weaning supplemental O2 if saturation maintained. Nutrition consult placed. Therapy to continue current..."