State monitors staying at Lufkin DaVita

Do they ever learn???

State monitors staying at DaVita
State survey raises concerns with facility's water distribution system; DaVita officials say deficiencies have been corrected

By JESSICA SAVAGE
The Lufkin Daily News
Wednesday, April 15, 2009

Findings in a state inspection last month at the troubled Lufkin DaVita Dialysis clinic means state monitors are staying in place longer than expected.

Inspectors were supposed to have left in mid-March, but will be staying through Friday, according to a spokeswoman with the Texas Department of State Health Services.

A state surveyor who visited the facility March 17 found a component of the facility's water distribution system — a vital part of dialysis — had not been properly tested since the facility reopened nine months ago, according to a survey report released by the state. It also stated the facility had an "immediate jeopardy" situation, which could have put patients at risk. DaVita corrected that problem immediately, said Carrie C. Williams, DSHS assistant press officer.

Details of the immediate jeopardy deficiency were not made public by the state, which released a heavily censored version of the report Monday per an open records request by The Lufkin Daily News. Four of the seven pages are either partially or completely blank where the surveyor made notes about deficiencies found at the facility. The state has requested the Texas Office of the Attorney General make a ruling on the public release of that information.

A DaVita spokesman said the immediate jeopardy situation had to do with the measurement amount the facility used to test water quality.

"It was never a question about the water quality," said Richard A. Grenell, senior vice president-communications for DaVita. "It was how big the sample size was that was tested."

Grenell said the state required them to test a sample of water using a smaller size (5 milliliters) than the manufacturer of the water quality system required (10 milliliters).

"Within an hour and a half we had that resolved," he said.

The DaVita spokesman also said two standard deficiencies found at the facility have since been corrected. They are related to a water system upgrade the facility has made since it reopened July 2, Grenell said.

"This is a new process we are using to make that facility even more safe," Grenell said.

The facility has installed a high quality water purification system called deionization — a water treatment process that uses reverse osmosis to purify water.

Purified water is an important part of dialysis treatments, which involves a patient whose kidneys are failing being hooked to a dialysis machine for an average of three hours, three times a week. The machine uses a three-component cleaning system to filter a patient's blood: purified water, a salt and vinegar solution and sodium bicarbonate — a key material used in kidney dialysis.

The survey found the facility failed to ensure monthly testing on one of two bicarbonate mixing tanks, the report stated. If the tanks are not tested and disinfected on a weekly basis, bicarbonate can readily grow bacteria. That bacteria could produce a toxic by-product that in high enough numbers could cause the destruction of a patient's red blood cells, resulting in severe illness and possibly death.

Grenell said the facility had been disinfecting the tanks as required. He added that staff was testing tank No. 1 for water quality, but not tank No. 2. He said both tanks receive water from the same source of purified water, so testing one would take care of both. However, the state requires testing of both, which Grenell said DaVita is now doing.

The state is also requiring DaVita to test its water quality after it changes the system's filters every two weeks.

"The state, rightly so, is being hyper-sensitive about the process," Grenell said. "Our water quality has never been in question. However that scare (in 2008) has caused everything along the process to be questioned. We have submitted ourselves to testing from any state agency that wants to come in and test."

On April 28, 2008, the facility closed its doors for nearly two months as state and federal health investigators tried to determine what had caused a spike in patient deaths and health complications. Two weeks ago an Angelina County grand jury indicted a former nurse on charges she intentionally injected patients with bleach, killing five and injuring five others.

A survey done in June 2008 found 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 that were not properly documented. Nineteen patients died in a five-month period.

The survey found the facility had a 7.1 percent higher patient death rate than the state's average, according to the report.

Since the state imposed a corrective plan of action requiring four state monitors be in place, the facility has fully cooperated, Williams said.

After reviewing a censored copy of the March survey, a dialysis industry expert said deficiencies at this clinic should be a cause for concern considering its past problems.

"Frankly, nothing would surprise me about this facility. But, I am surprised that any deficiencies exist, at all, after the debacle the patients, facility and staff has suffered over the last couple of years. If these guys aren't vigilant by now, they never will be," said Joseph Atkins, who has 37 years experience in the dialysis field, 20 of them in end stage renal disease management. Atkins also serves as a consultant for ESRD providers and manufacturers of dialysis supplies.
~~~~~~~~~~~~~~~~~~

Find this article at:
http://www.lufkindailynews.com/hp/content/news/stories/2009/04/15/DaVita_survey.html