Inadequate Orientation and Training of Agency Staff
Summary
The facility failed to ensure that competent and trained staff were providing resident care, as evidenced by the reliance on contracted Agency Staff (AS) who were not adequately oriented or trained. The nursing schedule revealed that 5 out of 7 nurses were AS, and one LPN admitted to not knowing how to check wander guards and not completing an orientation checklist. The facility had recently established an orientation checklist and a binder with resources, but there was no evidence of AS completing this checklist. Additionally, it was observed that residents were upset due to late medication administration when only AS were working, and AS frequently asked non-nursing staff for assistance in locating supplies.
Penalty
Resources
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A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
The facility failed to ensure that the nurse overseeing the Restorative Nursing Program had documented competencies, qualifications, or a defined job description, despite policy assigning responsibility for restorative oversight to specific clinical staff. One resident with severe dementia developed left-hand clenching and pain; the Restorative Nurse documented assessments and the possible use of a palm protector, but there was no further documentation of restorative services, no record that restorative services were in place, and no follow-up provider communication beyond an earlier notification noted by the DON. Another resident with advanced debility, chronic pain, and hand tremors had a care plan for frequent restorative services, but documentation showed repeated refusals due to pain, painful palm protector application, and lack of a consistent pain-management plan before interventions. The Restorative Nurse reported evaluating the resident and notifying the provider to discontinue restorative services, yet no supporting provider notification documentation was available, while she also stated she independently assesses and determines residents’ appropriateness for restorative services without documented restorative-specific competencies.
The facility allowed uncertified Unit Aides (UAs) to perform CNA-level direct care despite job descriptions and the DON’s statements limiting UAs to non–hands-on helper tasks. Multiple alert and oriented residents reported that a UA assisted them with bed baths, incontinence care, transfers (including use of a mechanical lift), showering, and dressing. A CNA confirmed that, when short-staffed, UAs were used as additional CNAs and performed ADL care and transfers, and that another UA on nights escorted residents requiring one-person assist to the restroom. The DON stated that CNAs must be certified or enrolled in an LPN program and that UAs have no formal training requirement and should not provide resident care, while facility job descriptions showed UAs are intended only for cleaning, transport, and simple assistance at meals, and CNAs are responsible for ADLs and direct resident care.
A resident with aphasia and chronic kidney disease was admitted with documented redness on the right thigh and a physician order for weekly skin assessments. The admission evaluation instructed staff to complete a thorough head-to-toe skin assessment, but the next-day skilled documentation by an LVN indicated the resident had no skin conditions. Later that day, a hospital documented redness and bruising to the hip, back, and leg, and the DON reported to a hospital physician that bruising had been present on admission but had enlarged. Facility CNAs and an LVN gave inconsistent accounts of seeing or not seeing bruising, with one LVN stating she used only bathroom light and that night nurses did not typically perform full skin assessments. The DON and ADON acknowledged that admitting nurses were responsible for initial skin assessments, that staff generally did not measure skin conditions, and that a recent EMR change contributed to incomplete documentation. These actions and omissions resulted in incomplete and inaccurate skin assessment and documentation, contrary to the facility’s Skin Management policy and the physician’s orders.
A resident with a history of circulatory surgery, an aortocoronary bypass graft, and on anticoagulant therapy experienced an acute onset of profuse rectal bleeding and shortness of breath during a night shift. An ACMA was functioning as charge on one hall while an LPN covered the other hall; the ACMA reported the resident’s bleeding and distress, and the LPN came once to the room but did not provide ongoing assessment or monitoring, later stating they were behind on work and relying on the ACMA to monitor. EMS later found the room with evidence of a significant hemorrhagic event and the resident unconscious on the toilet. Progress notes lacked documentation of significant change in condition, assessments, or interventions for the bleeding and respiratory distress, and the facility failed to notify the medical provider of a critical Hgb of 6.3 or of the acute bleeding. The facility also could not produce annual competency records for the LPN or ACMA, and the resident’s family was not notified of the change in condition or death until later.
The facility failed to ensure nursing staff maintained required competencies and responded appropriately during an emergency. Review of personnel files showed that nearly half of the CNAs lacked current CPR certification, despite job descriptions requiring CPR training and maintenance, and the DSD confirmed that CPR renewals and mock codes were not being maintained or documented. CNA competency evaluations had not been completed annually since 2024, and licensed nurse skill evaluations for an RN and several LVNs were incomplete, missing dates and signatures. One RN’s IV therapy competency was evaluated by an LVN, even though the DON stated IV therapy was outside the LVN scope, while the DON’s job description assigned her responsibility for annual competency training. In a resident emergency involving low oxygen saturation, an RN did not assess the resident, did not obtain full VS, left the bedside to call 911, and did not return or document assessments, while an LVN left the resident alone multiple times instead of using a walkie talkie, administered only 2 L/min O2 without reassessment, did not obtain BP, and failed to document pre- and post-oxygen VS, contrary to facility CPR and oxygen administration policies.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Lack of Qualified Oversight and Documentation in Restorative Nursing Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff directing and overseeing the Restorative Nursing Program possessed appropriate competencies, as required by facility policy. The Restorative Nursing Program policy identified the Restorative Nurse, Restorative Aide, therapy staff, and the DON as responsible for program oversight, including assessment and re-evaluation when functional decline is noted. However, the facility could not provide a job description, qualifications, training, or education documentation related to restorative services for the Restorative Nurse whose personnel record was reviewed. For one resident with severe Alzheimer’s dementia, staff documented new issues with left-hand clenching. Nursing progress notes showed that the Restorative Nurse assessed the resident’s hands, noting that the resident could open the left hand only with touch and that fingernails were making marks on the skin, with the resident verbalizing pain (“ow”) when opening the hand. The Restorative Nurse documented she would consider a palm protector, but there was no further documentation regarding this intervention, no evidence the resident was on restorative services, and the DON later stated restorative services were discontinued without supporting documentation from the Restorative Nurse. The DON also stated that although the provider had been notified of the resident’s hand pain earlier in the year, there was no further documented communication with the physician. For another resident with advanced physical debility, chronic pain, and chronic bilateral hand tremors, the care plan called for restorative services five times weekly, with the Restorative Nurse to review the program monthly and as needed. The restorative program included active range-of-motion exercises and use of a squeeze ball and finger-to-thumb pinches, but restorative documentation showed the resident frequently refused due to pain. Nursing notes indicated the Restorative Nurse would evaluate the need for increased pain medication, that the resident refused a palm protector due to painful manipulation, and that the resident did not tolerate passive range of motion with difficulty applying the palm protector. Staff interviews confirmed the resident was often in pain during palm protector application and did not have a set pain-management plan prior to restorative interventions. The Restorative Nurse stated she notified the provider and completed an evaluation that led to discontinuation of restorative services, but no documentation of provider notification was produced, and the Restorative Nurse described herself as the one who assesses and informs the provider about appropriateness for restorative services, despite the absence of documented competencies or role description.
Uncertified Unit Aides Performing CNA-Level Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that only staff with appropriate competencies and certification provided resident care, despite having 62 residents in the building. A CNA reported that Unit Aides (UAs) were supposed to perform only non–hands-on tasks such as taking vital signs, answering call lights, making beds, and passing snacks and ice water. However, multiple residents who were alert and oriented to person, place, and time stated that a specific UA had assisted them with direct care tasks. One resident reported that the UA helped with bed baths by washing areas the resident could not reach. Another resident, who required a two-person assist for incontinence care, stated that the UA worked as another CNA when surveyors were not present and had assisted CNAs with incontinence care. Additional residents reported that the UA had helped with transfers to a wheelchair, provided support during transfers, assisted with incontinence care and rolling in bed for cleaning, and helped with showering and dressing, including putting on underwear, socks, pants, and shoes. A CNA confirmed that, prior to the survey, they had been working with the UA as another CNA on a hall where they were short-staffed due to CNA call-ins, and that the UA assisted with CNA duties such as transferring residents with a mechanical lift, performing other transfers, and dressing residents while the CNA supported them. The CNA also reported that another UA on night shift had performed CNA duties, including escorting residents who required one-person assist to the restroom. The UA in question told the surveyor that she was not involved in patient care. The DON stated that CNA duties include ADL assistance such as hygiene, bathing, transfers, and incontinence care, and that working as a CNA requires formal certification or enrollment in an LPN program, while the UA role requires no formal training or education. The DON stated that UAs performing CNA duties is not acceptable because they are not properly trained or certified and could cause injury or other adverse effects, and that UAs should only perform tasks such as making beds, stocking supplies, passing ice water and snacks, brushing hair, and painting nails. Facility job descriptions for UAs and CNAs corroborated that UAs are intended to perform helper and non-direct-care tasks, while CNAs are responsible for resident care and ADLs, confirming that UAs were used outside their defined scope of duties.
Failure to Perform and Document Accurate Skin Assessments for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff had and used appropriate competencies to complete accurate and thorough skin assessments for a newly admitted resident, as required by physician orders and facility policy. The resident was an older adult male admitted with diagnoses including aphasia following cerebral infarction and anemia in chronic kidney disease. On admission, the Clinical Evaluation documented redness on the front and rear right thigh and directed staff to complete a thorough head-to-toe skin assessment and identify all abnormalities. A physician order dated the day of admission required weekly skin assessments starting the following day. Progress notes confirmed the resident’s admission and that he was to be transferred to a local hospital the next morning for feeding tube replacement. On the morning after admission, the Daily Skilled Documentation completed by LVN C indicated “no” to the question asking whether the resident had any skin conditions, despite the prior documentation of redness to the right thigh and the physician’s order for skin assessments. Later that same day, documentation from the local hospital recorded skin integrity findings of redness and bruising to the right hip, back, and leg. A subsequent progress note from the facility documented that the DON spoke with a hospital physician who reported bruising on the resident’s leg that was getting progressively worse; the DON stated to the physician that the bruising had been present on admission but was not as large. However, there was no complete or accurate skin assessment in the facility record reflecting the presence, description, or progression of this bruising. Interviews with facility staff showed inconsistent recognition and documentation of the resident’s skin condition and revealed gaps in assessment practices. LVN C, who cared for the resident on the morning shift and transferred him to the hospital, recalled excoriation on the bottom and groin and a healed great toe amputation but denied seeing any large bruising. CNA C, who changed the resident’s brief overnight, reported not seeing any bruising and noted the resident did not express pain when turned. LVN B, who had the resident on the night shift, stated she observed a previous injury on the leg that she thought was a bruise or discoloration but could not recall which side; she also stated she only used light from the bathroom to avoid waking the resident and that night nurses did not typically perform full skin assessments. The ADON and DON confirmed that admitting nurses were responsible for initial skin assessments, that staff generally did not measure bruises or other skin conditions, and that documentation practices were affected by a recent change in the electronic medical record system. The facility’s Skin Management policy required identification, assessment, and ongoing monitoring of individuals at risk for skin compromise, but the resident’s records and staff interviews demonstrated that these assessments were not completed completely and correctly for this resident. Observation at the local hospital two days after admission showed a large red and purplish bruise starting above the right hip and extending down the right thigh, measuring 15 inches in length. Hospital nursing staff confirmed the presence of bruising but did not have measurements from the time of transfer. Facility leadership acknowledged that skin conditions, including bruises that were getting larger, should be documented and that inaccurate or incomplete skin assessment documentation could allow conditions to worsen. Despite this, the resident’s facility documentation did not accurately reflect the bruising described by the hospital physician and observed later, nor did it align with the facility’s own policy requiring thorough skin assessments and ongoing monitoring. This combination of incomplete assessment, inconsistent staff observations, and inadequate documentation constituted the failure to ensure sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable well-being of the resident. The report explicitly states that the facility failed to ensure that skin assessments were completed completely and correctly for this resident. The DON and ADON described that nurses generally did not measure skin conditions and relied on descriptive documentation, and that the transition to a new computer charting system contributed to confusion about how to document existing versus new skin issues. The Administrator further noted that features needed for documentation were still being added to the electronic medical record and that staff needed education on the new system. These statements, combined with the lack of accurate skin assessment entries and the discrepancy between facility records and hospital findings, demonstrate that the nursing staff did not consistently apply the competencies and skills necessary to assess, evaluate, plan, and implement care related to the resident’s skin condition as required by the facility’s Skin Management policy and the physician’s orders.
Failure to Assess, Monitor, and Notify Provider for Resident With Profuse Bleeding and Critical Lab Value
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and competent nursing staff to assess, monitor, and intervene for a resident with a known high-risk medical history who experienced an acute onset of profuse bleeding. The resident had a history of surgical aftercare following surgery on the circulatory system, including the presence of an aortocoronary bypass graft, and was receiving anticoagulant therapy (Eliquis) for atrial fibrillation. The resident’s care plan and physician orders directed staff to monitor for specific signs of bleeding and adverse reactions to anticoagulant therapy, such as blood in the stool or urine, changes in mental status, shortness of breath, and other symptoms. The facility also had an Acute Condition Changes – Clinical Protocol policy requiring baseline assessments, monitoring, and timely physician notification for acute changes in condition. On the night of the incident, assignment sheets showed that an ACMA was the charge nurse on one hall (South hall) for the 7:00 p.m. – 7:00 a.m. shift, while an LPN was the charge nurse on the other hall (North hall). EMS records documented that they were dispatched in the early morning hours after facility staff reported that the resident had blood in the stool starting about three hours earlier and was recovering from abdominal aortic aneurysm surgery. When EMS arrived, they observed the resident’s room with signs of a significant hemorrhagic event, including towels saturated with blood and blood on the floor, and found the resident unconscious on the toilet with blood on their socks, legs, and in the toilet. Progress notes for that date did not show documentation of a significant change in condition, nor did they show assessments, monitoring, or interventions for the resident’s shortness of breath, screaming, blood in the toilet, or refusal to be transported to the hospital. Interviews revealed that the LPN was the only licensed nurse in the building on the weekend and did not obtain a full report on the South hall because the ACMA was functioning as the charge for that hall. The LPN stated that the ACMA reported the resident was screaming, hurting, having a bowel movement, and there was blood, and that the resident had a history of abdominal aortic aneurysm surgery, raising concern about bleeding. The LPN instructed the ACMA to send the resident to the hospital, but the resident refused, and the LPN did not perform ongoing assessments or monitoring, citing being behind on work and relying on the ACMA to monitor and report. The ACMA reported that the resident was on the toilet and bleeding around 1:15 a.m., with vital signs within normal limits, and refused to go to the ER; the ACMA contacted the LPN, who came once at about 1:32 a.m. to check on the resident while the resident was back in bed, with blood left in the toilet for the LPN to see. The ACMA stated that later, as the resident continued to pass blood, became pale and shivering, and remained in pain while refusing pain medication and hospital transfer, they eventually called 911 when the resident’s condition worsened. The facility was unable to produce annual skills competencies for either the LPN or the ACMA, and a family member reported they were not notified of the resident’s change in condition or of the resident’s death until later, despite the resident’s room being on the South hall where the events occurred. The report also notes that the facility failed to notify the medical provider of a critical hemoglobin lab value of 6.3 (normal reference range 13.7–17.5) and failed to notify the medical provider of the acute onset of profuse bleeding. There is no documentation that the physician was contacted regarding the critical lab result or the resident’s active bleeding, despite facility policy requiring timely physician notification for acute changes in condition and the resident’s known risk factors and anticoagulant therapy. Additionally, the facility’s own policy required that direct care staff, including nursing assistants, be trained to recognize and report significant changes, and that phone calls to physicians be made by adequately prepared nurses with organized, pertinent information; however, the documented events and interviews show that the ACMA was functioning as charge on one hall and that the LPN did not consistently assess or directly manage the resident’s rapidly changing condition. These combined failures to assess, monitor, intervene, and notify the medical provider for a resident with profuse bleeding and a critical hemoglobin value constituted the cited deficiency.
Failure to Maintain Nursing Staff Competency, CPR Certification, and Appropriate Emergency Response
Penalty
Summary
The facility failed to ensure nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards. Review of CNA personnel files showed that 16 of 34 CNAs did not have current CPR certification, despite the facility’s CNA job description requiring CPR training after employment and maintenance of CPR certification. The Director of Staff Development (DSD) stated the facility did not require CNAs to maintain current CPR certification, acknowledged CNAs were hired with valid CPR that was allowed to expire, and confirmed there were no mock code drills documented in staff files. The DON stated she did not know if CNAs were required to be CPR certified but agreed they should be, and stated that the risk of CNAs not being CPR certified could lead to residents’ death. Record review further showed that CNA competency evaluations were not completed annually. CNA files indicated the last competency skills evaluations were done in 2024, and the DSD confirmed she had not completed annual competency evaluations since then, stating that annual skills competency was the method to determine if a CNA was competent to work. The DON stated the DSD was responsible for yearly CNA competency evaluations and that without these evaluations, CNAs might perform patient care not according to facility policies and procedures. For licensed nurses, review of Licensed Nurse Skill Evaluations revealed incomplete documentation for one RN and four LVNs, with missing evaluator initials, employee initials, and dates. The DON confirmed that these evaluations must be fully completed with initials and dates to be valid and stated she was not aware they were incomplete. Additional review of a Licensed Nurse Skill Evaluation for one RN showed that this RN was evaluated for IV therapy by an LVN, even though the DON stated LVNs were not allowed to work with IVs because it was outside their scope of practice. The DON reported she had an LVN assist her with yearly Licensed Nurse Skill Evaluations because she needed help, despite her job description stating she was responsible for ensuring all nursing personnel received annual competency training. In a separate resident emergency event, an RN and an LVN did not follow facility policy and expected emergency procedures. The RN, after being notified by an LVN that a resident had low oxygen saturation, did not assess the resident, did not obtain full vital signs, left the bedside to call 911, did not return to the resident’s room, and did not document vital signs or assessments before or after oxygen administration. The LVN reported the resident “did not look good,” obtained an oxygen saturation of 89%, left the resident alone twice (including to get the crash cart) instead of using the provided walkie talkie to call for help, administered oxygen at 2 L/min without increasing it, did not recall rechecking oxygen saturation, did not check blood pressure because she was busy, and did not document vital signs or assessments before or after oxygen therapy. The DON stated that during an emergency the RN’s role was to assess the resident and delegate tasks, that vital signs must be taken to determine stability, that residents should not be left alone because CPR might be needed, and that staff were expected to use walkie talkies in emergencies. Facility policies on CPR and oxygen administration required staff to be trained in CPR/BLS, participate in mock codes, assess residents before and during oxygen therapy, obtain and document vital signs and lung sounds, and document all assessment data and oxygen therapy details.
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