New Stage 2 sacral pressure injury identified on the weekly sweep, 2.2 × 1.5 × 0.1 cm, not present on admission (facility-acquired) — POA status documented, etiology/stage/measurements recorded, provider notified and a treatment order received, repositioning and support-surface plan intensified, dietitian consulted for nutrition support, the injury coded on Section M, and the care plan revised; measurements to be trended weekly. Skilled assessment required to stage the injury and determine avoidability.
Model abnormal 2
Wound deterioration/infection: the Stage 3 sacral wound now with increased purulent exudate, new periwound erythema extending 3 cm, odor, and a low-grade fever — concerning for local infection/cellulitis. Provider notified, wound culture and possible systemic antibiotics ordered, dressing regimen changed per order, measurements and photos updated, care plan revised; will reassess for systemic signs and support the Section M and Section N updates.
