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.

Joel Andrews/The Lufkin Daily News (ENLARGE)

RELATED STORIES Full copy of May 2008 state survey Press conference at reopening Protest at DaVita reopening Slideshow from reopening Copy of state's corrective plan Copy of full 2007 state survey Slideshow from reopening Health department survey: 19 died at Lufkin DaVita clinic in five-month period DaVita gets green light to reopen Nurse: Bleach measured in syringes at Lufkin DaVita DaVita: Charges against nurse 'unprecedented' State to require monitors for DaVita before it can reopen Police: DaVita nurse injected 2 with bleach Company's 'town hall meetings' did not solve staffing problems, DaVita patient says DaVita suspects four patient deaths caused by former employee State report: DaVita clinic did not have proper number of trained personnel CompDaVita: Investigation into deaths likely the result of one employee's criminal act Expert: 'Cattle call dialysis' a problem; former DaVita tech says local clinic was 'too impersonal' DaVita: Company saddened by deaths at Lufkin facility EDITORIAL: Agencies respond to plea for updates on investigation into dialysis center EDITORIAL: Company, state need to be more forthcoming with investigation info

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. Thirty-two patient deaths occurred between Jan. 1 - Dec. 31, 2007, according to David Wright, spokesman for the Centers for Medicare and Medicaid Services (CMS) Region VI office. And since the start of the new year through the facility's closure date, 16 patients have died, Wright said, totalling the number of patient deaths at 48 for DaVita Lufkin Dialysis. CMS works in conjunction with the U.S. health department, contracting state health departments to conduct a health surveys. The health surveys are done not only to make sure dialysis centers are in compliance with state licensing standards, but also with federal standards in order for them to be certified to receive CMS reimbursement funds. Reimbursement funds make up a large percentage of dialysis center profits.

The survey further found staff did not properly document an Adverse Occurrence Report Policy, which staff are instructed to fill out for "any unexpected event that is inconsistent with routine operation of a dialysis facility."

A review of a call list in the report showed 34 patients were transported to a local emergency room in April — more than twice the number of listings of any of other month. Only 19 of those patients taken to the ER in April were documented by the facility, the report stated.

During the state and federal health officials' review of 24 patient records, several requests were made to staff to provide documentation of laboratory reports, treatments and physician orders.

"In review of the records it was discovered that the records provided had missing or changed documentation..." the survey stated. "Failure to provide a complete record could potentially cause harm to a patient when the needed information is needed in a timely manner and information provided is incomplete or inaccurate."

The center has a history of being non-compliant with state standards, according to state surveys obtained by the newspaper through open records.

A survey conducted in July 2007 at the Lufkin center stated staff administered treatments to patients against doctors' orders. The surveyor noted she discovered the errors and told the facility administrator. She remained at the facility for the day until patient treatments were corrected, a state spokeswoman said. The surveyor returned a month later and documented that the facility was in compliance with its corrective plan of action.

Surveys conducted in 2003 and 2006 showed reuse technicians were not properly reprocessing used dialyzers according to industry standards and the company's own reuse policy. A follow-up survey to the 2003 report found the center had not corrected infection control problems. Another follow-up survey conducted a month later found the center was in compliance, a spokeswoman said. A follow-up report to the 2006 survey also found the center had complied.

Chee has called those survey reports isolated incidents, saying there is no connection between those reports and the closure or police investigation.

The center's July 2 reopening was met with opposition from four protestors whose family member died at the facility April 1. Wanda Hollingsworth, daughter of the late Thelma Metcalf, along with her sister-in-law, nephew and daughter, held up signs outside the center to gauge public response to the reopening. Several drivers passing by honked in support, as Hollingsworth and family waved signs.

Chee said the facility, which has an estimated 120-patient capacity, treated nine patients its first day back in operation, and is planning to phase in more patients over the next several weeks under state guidance. The state has required the facility have a physician, two nurses and a technical monitor on site to oversee staff and make sure the facility is operating according to state dialysis standards.