Article - July 7, 2008 - Nacogdoches Daily Sentinel

Feds release DaVita patient death numbers

By Jessica Savage

Nineteen patient deaths occurred at DaVita Lufkin Dialysis in a five-month period ending in April before its temporary closure, according to a survey released Monday by the U.S. Department of Health and Human Services through an open records request.

A heavily-censored version of the same survey report was released June 30 by the Texas Department of State Health Services with the state citing what it says are exceptions to open records rules. Virtually all the information the 41-page page report contained in the state release was blacked out. The state has requested an opinion from the Texas Attorney General's Office on releasing information on the same survey the federal government has provided.

State and federal health officials conducted an extensive survey of the 700 S. John Redditt Drive Lufkin facility in mid-May following the facility's closure in late April after a spike in patient deaths and health complications. The center reopened July 2 after fixing staffing and operations problems to meet state-required standards.

DaVita spokesman Michael Chee has said the state survey conducted in May found no link between the deficiencies outlined in the report and patient deaths in early April. The state, which acts as a regulatory department making sure health facilities are operating within state guidelines, imposed a level three corrective plan of action at the Lufkin facility — the highest it can give out.

Chee has said facility staff noticed patient health complications in early April, but continued to operate because no source of the problems could be identified after the company conducted its own investigation.

The center temporarily closed its Lufkin doors April 28 and contacted authorities after two patients witnessed a nurse intentionally inject two patients with bleach, according to Lufkin police. Both patients survived and police have since charged former DaVita nurse Kimberly Clark Saenz, 34, with two counts of aggravated assault. Chee has previously said the company suspects the nurse is linked to a cluster of four patient deaths in early April. Police have not filed any additional charges.

The survey released Monday stated DaVita officials failed to monitor care provided to patients and did not immediately detect an increase in adverse events related to health and safety. It also found the facility did not keep complete and accurate patient medical records, including patient deaths which were not properly documented. Causes of death or possible death trends from September 2007 through April 2008 were not documented, the survey stated.

"There was no evidence of any root cause analysis, nor any evaluation of the potential existence of systemic issues," the survey report stated.

The facility had a 7.1 percent higher patient death rate in 2007 than the state average, at 27 percent from the state's 19.9 percent, according to the report. Twenty-five patient deaths occurred between Jan. 1 - Dec. 31, 2007, the report stated.

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