DaVita's Lufkin Dialysis Center in 2007 did not have the required number of properly trained personnel present to meet the needs of patients, according to a state health survey conducted nearly a year ago.
An expansion survey conducted by the Texas Department of Health and Human Services on July 18, 2007, indicated the DaVita clinic at 700 S. John Redditt Drive had not adequately staffed its facility and had not given patients the correct prescribed treatments as ordered by a physician. The report was one of several documents released by the state in response to an open records request from The Lufkin Daily News.
A Davita spokesman did not immediately comment on the reports. The spokesman, Michael Chee, has said the company's staffing model has "never deviated from state-mandated staffing requirements."
A recent spike in patient deaths prompted the facility to close its doors April 28. It remained closed Monday pending the outcome of investigations by the Texas Department of State Health Services, Lufkin Police Department and the federal Centers for Disease Control and Prevention.
In the survey conducted in 2007, two clinic employees told a state surveyor they were administering treatments against a physician's order, under the order of a supervisor.
"Both employees said they were instructed to do so by the charge nurse," the report stated.
A charge nurse told the surveyor the facility administrator made the recommendation.
The state surveyor also noted that while she was present, the center ran out of a mix used to treat water before administering dialysis to patients, the report stated. An employee told state health surveyors the only person who knew how to properly mix chemicals to treat water at the facility was also responsible for another facility in Livingston, and was not in Lufkin that day.
The facility administrator was notified of the problem and recommended that patient treatments be altered, the report stated.
"Surveyor informed employee No. 8 around 12:15 p.m. of the concern for patients being placed on the 1K acid instead of the prescribed (amount)," stated the report, which includes patient information withheld by state officials. "The interview with the Charge Nurse revealed that after the surveyors concerns, the facility had some individual jugs of (info withheld) and they began switching patients at about 12:40 p.m. back to the prescribed (amount)."
"A review of the list of patients found 22 (out of 22) patients were being dialyzed with the incorrect dialysate," the report stated.
The surveyor also noted the facility was administering treatment at 32 of its stations — an expansion which had not yet been approved, the report stated.
An exit interview between the state surveyor and a facility administrator stated the staff had been made aware of the problems, the report stated. The report listed a corrective plan of action to be taken, and the plan was accepted by the state Aug. 1, 2007.
State health department spokeswoman Carrie Williams said a surveyor stayed on site July 17 until all corrections were made. The surveyor returned to the facility Aug. 22 and noted that the company's corrective plan had been implemented.
"She went in and all of the items had been corrected," Williams said Monday.
The state considers the deficiencies in the 2007 report as serious, the spokeswoman added.
Roberta Mikles, a patient health care advocate and registered nurse based in California, looked over the surveys Monday at the request of The Lufkin Daily News. She said the type of deficiencies the surveyor found at DaVita's Lufkin facility in 2007 are "very serious infractions."
"I'm just blown away by this. It is just absolutely, positively deplorable," Mikles said.
"When such safety concerns as this are found where patients' lives are placed in jeopardy — especially if their blood potassium level does not warrant a 1K dialysis — it places a patient in jeopardy of having cardiac problems," she said. "Right there you've got a charge nurse that does not have the judgment to know a 1K could kill patients. There should not be any RN in any unit that does not have good judgment when it comes to a situation like this."
Surveys conducted in 2003 and 2006 stated the facility was also non-compliant with state health standards.
"While touring the reuse area of the facility and observing the reuse process, it was determined that the reuse technician did not reprocess used dialyzers according to AAMI standards and the company's own reuse procedure," stated a report conducted April 8, 2003.
The report from that date also stated staff did not have proper training and competency.
A follow-up survey of the facility conducted two months later, on June 2, 2003, noted the center had not corrected infection control problems previously documented.
Williams said the state revisited the facility in July and determined all of the deficiencies had been corrected.
A document made by the surveyor during a revisit to the facility was not included in the open records request for copies of original surveys.
A survey conducted May 23, 2006, stated the facility did not properly document test results for water or a discharge summary of a patient who died. The date of the patient's death was withheld from the survey, but the survey did state that the discharge summary on that patient did not include cause of death or place of death.
Information on several pages of the documents provided to the paper was blacked out because of a pending ruling from the Attorney General's Office on open records rules. Portions of the report, which are said to include medical records, names and quality of care information, are being withheld from the public.
Williams said the state conducts regular surveys of dialysis facilities in compliance with state and federal rules and regulations.
"We look closely at everything from paperwork to patient care. We survey these facilities every three years as well as conduct on-site complaint investigations," she said.
A state health report is expected to be released in the coming weeks regarding a recent investigation into regulatory compliance at the facility.
Comments
By professional
Jul 24, 2008 11:23 AM | Link to this
Would staff feel resentment towards patients who did not meet goals which affected their (staff) bonuses?
By The Wave
Jul 24, 2008 10:50 AM | Link to this
Problems concerning the wave have been brought up at staff meetings only to be ignored by those in charge. They say just give it time and once you get used to it you will like it. BULL!!! Just their way of pacifying the workers.
They promise you big bonuses, but put the goals for the bonuses out of reach because they base them on things that are not in your control. How are you supposed to control what a patient eats or how much they drink between treatments? You can't! You can counsel them about what they are supposed to do and warn them of adverse affects if they don't do what they are supposed to do. But you can't go home with them and hold their hand to make sure they do it. They are running patients through these clinics like cattle, making a fortune off of the government and insurance companys and could care less about the patients or the people who do all of the work for them. I understand that this is a "for profit" company, but what would be the harm in putting some of that profit back into the business and doing things right instead of cutting corners until you finally cut the corner too sharp and start costing people their lives?!
By To ex tech Indiana
Jul 24, 2008 9:38 AM | Link to this
You are absolutly right. You are not allowed time to focus on patient care and individual patient needs with "the wave". I honestly believe that the reason that master plan was implemented was to ensure that there was absolutly no down-time for the direct care staff, ensuring that the company got every second they were paying for from staff. While there is nothing wrong with getting your moneys worth from employees, there is a problem when you push the employees to the point where they are unable to do their job in a safe manor, especially in the healthcare field where you have other peoples lives in your hands. The object of "the wave" was to maximize the number of patients that went through the clinics every day, not to maximize patient care.
By ex tech indiana
Jul 23, 2008 10:25 PM | Link to this
The wave had to be one of the worst ideas for Davita to come up with. It simply does not work! They base this on not having any problems with patient care. So, if you run into a tiny issue with treatment your whole schedule is screwed up. It's not just Davita with "impersonal" problems. I worked in 2 different companies, both had these issues. If you took extra time out for someone's personal care you were accused of either flirting or favoring or just plain taking up to much time! Let's go people hurry up! I mean it's just a schedule not people's lives right???? WRONG!
By still watching
Jul 22, 2008 9:51 AM | Link to this
I don't think the interest in this story is fading, I think part of the problem is that people aren't taking the time to read the survey and don't understand the severity of the deficienceis found. Then there are some that want to believe that it was just the nurse and an isolated incident. They are attempting to charge her with "a cluster of 4 deaths". What about the other 15 patients that died in a four month period? Who are they going to blame those on? I have read several DaVita surveys from several different states and this is definatly not an isolated incident. The same deficiencies found in Lufkin have been found in many other DaVita units across the country. Funny how DaVita prides itself on its trainin process, yet these surveys clearly show LACK of adequate training. Including one facility that had a nurse in charge who did not have the qualifications to be in charge of anything; reuse technicians that didn't have adequate training, but were training other reuse technicians. This story is far from over, but it goes way beyond the Lufkin facility. My prayers are with those that have no choice but to return to this facility. Keep your eyes open after the monitors leave.
By To Jim
Jul 22, 2008 1:39 AM | Link to this
You raise some interesting and valid points. The point you made about the computer records also bothers me and here's why. The patient treatment data is entered by the assigned staff members electronically through a keyboard into a pre-existing template and certain data may also be sourced dirctly from the dialysis machine. The template will have pre-entered data such as the patient name, ID, orders for dry weight, dialysate prescription etc. The record is signed electronically at the end of the treatment by the staff member and the charge nurse. All goes into the patient's electronic record. You are correct in stating that this data is backed up - usually each night. This data is also transmitted to a central corporate server for 2 purposes - one, to have a central secondary or back-up record and two, so the data can be accessed and used to file insurance and medicare claims. This system is so important that even modest sized dialysis companies employ a cadre of IT and Network staff to build, modify, monitor and maintain this system. Given the importance of the electronic information it is absurd, ridiculous, unfathomable to believe the assertion that no one realized that by changing the patient's status from reuse to non-reuse that all the previously entered reuse data would be lost. Further it is equaly more absurd that a company the size of DaVita would utilize a system that could do this. The missing information is most likely residing somehwere in a back up file -I guess the important question is whether anyone actually asked for it.
By Jim Serino
Jul 22, 2008 12:30 AM | Link to this
Although I am recent to this information. Yes I know of issues since I lost someone to improper care by a load of doctors. I also found out that Dialysis doesn't really clean the blood as you would think since my relative had many causes for his death. The leading factor is his death was blood poisoning. I had found things out through real research several years ago that Dialysis is as harmful as it is helpful. The process of dialysis is to clean the blood of certain things mainly water. but in that process it removes many things that are helpful to the body.
One must understand that the elder generation was one not to question authority. So they go in silence . They are also frighten that if they complain they won't get even the littlest of care. Yes there are cruel people when they have a bad day. They don't mean to take it out on the patient. But they have so much paperwork to fill out that it is ridiculous.
When I read that there were patient records missing that really disturbed me since I had been in computers and that has to be a paper trail with this besides a backup procedure that has to go on in the night time hours since Dialysis centers close down. Now if Davita is negligent in this then I say sue them big time. This may hurt several good people there but then this is the price we all pay for is that good people always suffer at the hands of the few.
I see this place opening up soon because the other centers will not be able to handle the load for too long and because the rate at which people are coming into their later years into Dialysis this will not last for too long.
Yes there should be a major monitoring factor here. But I have known that in Texas they have certain rules and books on bad doctors, even though that information is paid for with your state's tax dollars. You the public are not to see this information not even in a court. That is why the information was redacted. It comes under Restraint of TRADE and the reason for the redaction. The state can and has been sued for that by those bad doctors and the same is true for companies of this sort. It is to protect the state not the public.
I know that this is bad but politicians made those rules and they aren't about to change them. This is the case in many states. The only way here is to go to Federal Court were they can get the clean document. But this case may never make it that far.
This unit may lose their license but Davita will open up another facility with the equipment from this unit in another county. This is a fact of life.
My heart goes out to those that lost loved ones to the incompetence of certain people.
Sincerely
Jim Serino
jim(dot)serino(AT)mindspring(dot)com
By Carley
Jul 21, 2008 10:48 PM | Link to this
To EVHAI
I agree with everything you said. I can assure you that the "same old thing" will be in place at Lufkin DaVita in the next few months, just as soon as the "police" are not watching their every move.
By Every Village Has An Idiot
Jul 21, 2008 6:52 PM | Link to this
Well it seems that interest in this story is beginning to fade. Is it becuase that the general view is that it was an isolated case and now all the facts seem to be known? Well hardly on both counts. Yes this story is about circumstances at one dialysis unit in Lufkin Texas but keep in mind while it easy and right to cast blame on one local adminstrater and medical director and criticize other "professionals" within the unit, these individual's bosses carry as much if not more blame for allowing the situation to fester as long as it did. These "bosses" are not just responsible for this one unit but many others in Texas and a bit higher up the ladder, 100's of units in multiple states and this corporation operates over 1,000 units nationwide. The situation in Lufkin is not just demonstrative of sloppy care but of a sloppy managerial mindset that permeates through the dialysis business. DaVita would be better served if it spent its' vast resources on developing good solid management and oversight process rather than its attempts to create a "fun culture" with cutesy region names, corporate executives dressing up like muskateers and prize give-aways. Don't get me wrong I think it great to be able to have a little fun in the workplace but fun must come after the job is done and Lufkin while just one example shows that job isn't getting done. Hopefully DaVita's learned the lesson of Lufkin and is instituting changes across the board to ensure there is no repeat at another one of its units, that remains to be seen. As far as the facts being known, today there is still no explanation as to those unusually highy number of patinet deaths - sure there's the alleged bleach incident but nothing to date connects the alleged occurence on that one day with all the other days when more than the usual number of patients were transported out of the unit by ambulance and more than the usual number of patients died. That alleged incident had nothing to do with improper documenatation, incomplete or "inadvertantly" lost or deleted records or the repeated failure of the nursing staff to properly assess patinets while undergoing treatment. That incident had nothing to do with the claims of an internal investigation which it seems did not actually take place. The fact is the alleged bleach incident had no, or at least very little connection to the bulk of the deficiencies found at the Lufkin unit. And attention should not be fixated on just that one alleged act. Certainly if it is true that the nurse injected bleach into the blood lines of two patients causing injury, it is a heinous and unforgavable act. And she should pay the consequences. If it is true! But what we do know is that a corporation which collected millions in insurance and medicare payments operated this unit for years in a way, that in repeated state surveys showed numerous deficiencies, which posed at the very least some level of jeopardy to patient safety. That this same company months if not a year ago had identified a long term problem with patients dying, did nothing to correct it and then audaciously made public statements contrary to the facts found. This failure of management and oversight, this failure of process, this failure of care and concern is by far more heinous then the alleged acts of a single individual on a single day and this should not be forgotten.
By wondering
Jul 19, 2008 5:46 PM | Link to this
have you read the survey here?
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