As a state health investigation into several dialysis patient deaths at DaVita Lufkin Dialysis continues, industry experts and those who had first-hand experiences at the kidney service company point to patient overload and sub-standard care as problems with the facility.

A former patient care technician for DaVita, who asked that her name not be used, said she resigned after repeatedly voicing her concerns, along with other staff, about not being able to provide personal care for patients who had complications.

"I would tell them, 'With the way everyone is scheduled now, we don't have enough time to do what needs to be done,'" she said.

An industry expert said "cattle call dialysis" is becoming a trend as companies are "simply 'getting them in and getting them out,' as quickly as possible" because of receiving low reimbursement from Medicare.

"Cattle call dialysis leads to all kinds of problems, such as poorly monitored post dialysis hypotension or bleeding. It just leads to generalized, overall, sloppy care," said Joseph Atkins, who has 36 years experience in the dialysis field with 20 of them in end stage renal disease management. Atkins also serves as a consultant for ESRD providers and manufacturers of dialysis supplies.

Toward the end of the tech's three-year employment with DaVita, the company had staff working in three shifts, which it called the "wave," the former tech said. The "wave" consisted of 24 stations, with a nurse and technician at each one, administering dialysis to approximately 10 to 12 patients a day.

During a shift, a technician would have four patients undergoing dialysis at the same time for an average of four hours. At the end of a patient's treatment, the tech would have 15 minutes to ready the machine for the next patient, the former tech said.

If a patient coming off dialysis had complications, such as prolonged bleeding, that patient would be moved to the center of the room to make way for a new patient, she said.

"They would be sitting there until you could go back to them," she said. "It bothered me a lot. When you move a patient out of the spot and into the middle of the room, to me you're just pushing that person aside."

The center she worked at averaged 96 patients a day, she said.

"I couldn't work there any more," the former tech said. "It was too impersonal. You can't be impersonal and work in the medical field, in my opinion."

A spokesman for DaVita said the former employee's comment may or may not be relevant depending on whether she worked at the new facility on South John Redditt Drive or the old location on Chestnut Drive, which closed 18 months ago. Both facilities were located in Lufkin.

"(The new location) is a larger facility with higher capacity and state-of-the-art equipment in place," said spokesman Michael Chee.

He said the company's staffing model has "never deviated from state-mandated staffing requirements."

Texas requires a 4:1 ratio of patients to staff, and for every 12 patients there must be a registered nurse on the floor.

The facility at 700 S. South Redditt Drive has 125 patients and was staffed to treat that number of patients, Chee said. Its capacity is 222 patients.

"We've never had less (staff) than the minimum required by law," he said.

"As DaVita has maintained, it is highly inappropriate for us or anyone not directly involved in this investigation to make any assumptions or draw any conclusions without full consideration of the data, information and investigation that is currently going on," Chee said.

The investigation

DaVita shut down its facility at 700 S. John Redditt Drive on April 28 after contacting officials at the Texas Department of State Health Services and Lufkin Police Department about a recent spike in patient deaths.

More than 200 patient records are under review as officials with the DSHS, LPD, the Center for Disease Control and Prevention and Centers for Medicare and Medicaid Services collect information as far back as 18 months on patients who have died, said Sharon Shaw, administrator for Angelina County and Cities Health District.

Officials are not releasing the number of patient deaths at the center because the time period of the investigation keeps changing, Shaw said Monday.

The facility is expected to be shut down a minimum of 45 days — part of a regulatory agreement with the state — while officials pore through dozens of documents, interview patients and send off lab equipment and water used at the facility to test for contamination, Shaw said.

In a letter to the editor dated Tuesday, DaVita Vice President Jerry McNeill said the company is saddened by the deaths and is continuing to provide care for its 125 patients who have been relocated to other regional facilities, pending the investigation outcome.

"Many of our teammates knew those patients who passed away like friends or family and they have been deeply and emotionally affected," McNeill stated.

"We hope to reopen the Lufkin dialysis care location at the earliest possible opportunity once we are confident that the safety of everyone involved has been addressed," McNeill wrote.

DaVita, Inc., is a nationwide kidney care service company that serves more than 100,000 patients in 43 states at its more than 1,300 outpatient facilities, according to its Web site.

A patient's point of view

Frederic Davis, 47, who had been receiving dialysis treatments at DaVita Lufkin Dialysis Center since February, found out the center had temporarily shut its doors April 29, the day after the facility closed down, when he showed up for treatment. After hearing there was an investigation into recent patient deaths at the facility, Davis said he "wasn't surprised."

Davis said some employees who worked at the center provided care while others conducted themselves as if they were "just trying to get a paycheck."

"It was rolling the dice with who you got," he said.

During days when Davis was scheduled for treatment and couldn't make it, he said staff would call him repeatedly, asking if he was going to come in for his appointment.

"They never showed concern for my health or other patients, but they were concerned about getting me in that seat," he said.

The center charges an average of $1,000 per visit, which is paid in full by his Medicaid, Davis said.

Atkins said Medicare pays an average of $130 a visit to a company.

"Most patients are on Medicare or Medicaid (which pays about the same as Medicare). As for patients with commercial insurance, they and their insurance company are carrying the weight of the entire dialysis industry. A unit with 5 to 10 percent of patients with insurance pays better than, or just as much as, all the Medicare and Medicaid patients put together."

DaVita's first quarter profits rose by 14 percent this year, which is attributed to an increase in daily dialysis treatments, The Associated Press reported.

The company said total treatment rose during the quarter to just over 3.9 million, or 50,837 per day, from about 3.7 million, or 47,807 daily.

In an interview Wednesday, Davis said his health and treatment has improved since he was relocated to Henderson Kidney and Dialysis Center in Lufkin.

"It's been completely different," he said. "I can tell a difference. I was constantly be in pain at DaVita, but haven't had any of those problems at Henderson."

"My condition definitely got worse and instead of better at DaVita," he added.

Chee said he could not comment on Davis' health care, treatment or complications because of privacy regulations.

"It's impossible for us to comment on any specific patient's care, treatment or complications for privacy regulations and because it would be inappropriate. Every patient is different and requires a different level of attention," he said.

"The bottom line is if there are significant, serious complications, there are specific protocols in place it calls for patient to be transferred to immediately to the hospital or other appropriate health care facilities."

How dialysis works and possible complications

Dialysis is a filtering process of the kidneys used after kidney functions either fail or drop below 15 percent of their normal functioning level. The process removes waste from the body by filtering blood through a dialyzer, an artificial kidney, and then back into the body. The process can take any where from three to five hours, depending on a patient's need. Most patients who require dialysis have reached that need from an ongoing illness, such as diabetes or kidney disease, and will need it for the rest of their lives, unless they have a kidney transplant.

"There are many complications that can occur, such as hypovolemic induced hypotention, excessive clotting or excessive post dialysis bleeding," industry expert Atkins said. "Air emoblism can occur during hemodialysis, particularly if the person has a caregiver who is not careful during initiation or discontinuing hemodialysis. Sometimes people are talking and joking around when using a dialysis catheter, instead of paying attention to what they are doing."

Atkins said a death in any facility should be considered a cause for concern.

"Please keep in mind that dialysis doesn't save everyone," he said. "If you are extremely elderly, have cancer, a very bad cardiovascular system, brittle diabetes — those patients are not going to do well."

The former tech said she never had any patients die during dialysis while she worked for the company, and felt "devastated" after reading about the recent patient deaths at the center.

"I'm devastated by it. Most of the names I see in the obits are patients I had, so I knew these people," she said. "I've seen anywhere from 10 to 15 names (in newspaper obituaries) from February to the present. That's just names that I recognize of patients who were there (when I worked there)."

"I just hope that they figure out what it was and correct the problem so that these patients can get back to some kind of normal life and not be shuffled all over Angelina County," the former tech said. "I also hope that they take into consideration that there has to be some level of personalized care for these patients."

Dialysis state oversight

In Texas, the state health service department has the authority to inspect and enforce punishment on facilities it finds non-compliant by assessing a fine.

Roberta Mikles, a health care patient advocate and retired nurse in San Diego who co-founded the Association of Dialysis Advocates, said there needs to be more oversight by state departments to hold dialysis care companies accountable.

"It is my opinion that without an effective oversight system, or a system that has effective sanctions, in addition to adequate facility supervision, there will be problems in facilities regarding patient safety," she said.

"Texas is a forerunner when it comes to oversight as they have been able to fulfill the Center for Medicare and Medicaid Services' request of every three years inspection of facilities with the exception of a few facilities, is my understanding. They are a forerunner also as they can sanction facilities, for that which CMS does not provide, which is most important."

Texas Department of State Health Services is required by federal law to conduct a surveyed inspection of dialysis centers every three years in order for those facilities to receive CMS reimbursement. An open records request submitted Friday to the state for copies of surveys conducted at DaVita Lufkin Dialysis Center was pending Wednesday.