The Lufkin Daily News has the complete May 2008 survey of the Lufkin DaVita dialysis unit that the Texas Department of State Health Services conducted from April 28th to May 13th. It's some tough reading, my heart goes out to the people who had to rely on this unit for dialysis. From the first page the survey raises concerns with how the events were described by DaVita. The April 28th survey by the state was precipitated by complaints.
This contradicts the way the events leading to closure that day have been described by DaVita. There is a lot to digest here but one concern leaps out:
A review of the Meeting Minutes and the required Death Notification Forms (CMS 2746) and hospital information received during the onsite survey facility visit found that there were a total of 19 deaths from December 1 - April 28, 2008 and 25 deaths from January 1-2007 through December 31 2007.
According to the 2007 Dialysis Facility Report provided to the facility in September 2007, the facility had a 27% mortality rate which was greater than the State Average of 19.9%. There was no evidence that the 2007 Dialysis Facility Report had been reviewed and analyzed by facility management including the Medical Director to improve patient outcomes or that any plan had been developed, adopted, and implemented to correct poor outcomes.
The Dialysis Facility Report that was published in September of 2007 was reporting data for 2006; this indicates that there has been problems at this facility for several years. The Dialysis Facility Reports do exclude the deaths of patients who are just starting dialysis (from page 3-4 of Guide to DFR (PDF link)):
It [the Dialysis Facility Report] also excludes from analysis patients who died during the first 90 days of ESRD, since such patients have incomplete data.
It is critical that patients who died in the first 90 days of treatment are included in the reckoning of what happened at the DaVita Lufkin dialysis unit. We don't have a complete idea yet of how bad things were in Lufkin.
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