by John Foxjohn
When Lackey went on break, everything was fine with Ms. Bryant—she tested well. But when she came back from break, Lackey found Kim Saenz trying to reset the alarm on Ms. Bryant’s dialysis machine, even though she was assigned to a different bay. Ms. Bryant, however, seemed okay and was watching TV. Lackey hadn’t expected Ms. Bryant to start clotting again, but because of the earlier incident, this was the first thing she checked. There was no appearance of clotting in the bloodlines.
Lackey explained that “a number of things can make the alarm go off, including clotting, or pushing medication into a port too fast. When the alarm goes off, the machine shuts down the blood from entering or leaving the patient. The machine has to be reset before the patient can continue to receive treatment.”
After Lackey checked the machine and reset it, she returned Ms. Bryant’s blood to her. Like Ms. Oates, Ms. Bryant was familiar with the tastes and sensations of her medications, and detecting something unusual, she asked, “What are you giving me?” She then turned her head and her heart stopped.
As Ms. Bryant coded, employees rushed to save her, all but one. Martha Mann, a PCT on duty that day, said, “Kim was just standing there watching. She never attempted to help give CPR to save the patient.”
Four years later, Candace Lackey was asked if she knew then what she did now, would she have returned Ms. Bryant’s blood to her. A tearful Lackey responded that she would not have returned the blood.
After Ms. Bryant coded at DaVita, she was also rushed to the hospital in a coma—one that she never awoke from.
Angela Scott, one of Ms. Bryant’s daughters, told The Lufkin News in 2009, “We knew my mother was going to die eventually of kidney failure, but not this way. Not by the hands of someone else.”
* * *
People confronted with disappointment or tragedy often become fixated on the “What if?” questions. What if I had stopped sooner? What if I hadn’t gone there? What if I’d never agreed to do this, or not do that? We can never know, of course, but everyone’s said it at some time in their lives. Would certain things be different if I had or hadn’t acted a certain way?
April 26, 2008, was a day rife with “What if?” questions, and it wasn’t over yet. While horror unfolded within the DaVita clinic, outside it was another perfect spring day in Lufkin. The temperature was in the mid-sixties with little wind and no rain. Many of the East Texas residents would be heading to the lakes for fishing or other activities.
Ms. Opal Few’s usual dialysis appointment was scheduled at the DaVita Lufkin Dialysis Center in the afternoon, but that morning she had received a call from DaVita asking her if she would like to come in early. A couple of patients had canceled their appointments.
Ms. Few was a little silver-haired woman—short and small, but with a feisty and large personality. When she came into a room, people knew she was there. DaVita employees who knew her referred to her as a dream patient—always cheerful and full of life. One employee said she was the kind of patient who made employees happy to take care of her.
When hearing friends, family, and acquaintances speak of ninety-one-year-old Ms. Few, regret spirals through the listeners. She sounded like the type of person whom anyone would have really liked to have known.
Opal Mae Jordan Few was born in Pollok on October 13, 1916, and graduated from high school at Central ISD, a small school in Pollok. She married, and for many years ran a boardinghouse in Lufkin. The family lived downstairs and the boarders lived upstairs.
Linda James, one of Ms. Few’s daughters, stated, “My mother was a family person who loved her family above all else except God. She devoted her entire life to her children, grandchildren, and great-grandchildren.” Above all else, Ms. Few’s children, Linda Few James, Selena Lynch, and Donald Young, remember that their mother believed in doing what was right. Ms. Few instilled these virtues in her children, and lived the moral values she taught them.
One story about Ms. Few epitomized the way she led her life. Ms. Few’s income was based on the number of boarders she had and the money they paid her. One time in particular, her children remember that the house was totally empty of boarders. Their mother had gone to church on Sunday morning with just enough money to either pay the light bill or give a tithe to the church. They said that their mother prayed and asked what the right thing to do was.
Ms. Few left the church with no money. That very afternoon there was a knock on the door, a man looking for a room. By Monday afternoon, the boardinghouse was completely filled.
Linda James, a drug and alcohol abuse counselor, told this story about how her mother instilled values in her: When she was about five or six years old, she went with her mother to the Big Chief convenience store. She wanted a piece of bubble gum, but because she had bad teeth, her mother wouldn’t get her any. So Linda swiped a piece.
On their way home, Linda turned her head so her mother couldn’t see her plop the gum in her mouth, but she didn’t fool her mother, who said, “Linda, look at me.” Her mother figured out she’d stolen the gum, turned around, and made her go back in the store, spit it out into a Kleenex in front of the manager, apologize, pay for the gum, and when they got home, she made Linda iron sheets as punishment. Linda said she still got punished after all that, and she didn’t even get to chew the gum.
For years Ms. Opal Few went up and down, changing sheets, cleaning and cooking meals for her family and boarders. Maybe it was all those trips up and down those stairs, the exercise Ms. Few did to make a living for her family, or just genetics; whatever the reason, Ms. Few reached the age of ninety-one in pretty good shape—a lot better than most of the other dialysis patients. Ms. Few had hip replacement surgery when she was eighty-eight years old, but the surgery was because her hip had simply worn out—not from a fall. She’d worked hard all her life. She eventually moved in with her daughter Linda, who said it was her mother’s arthritis, not illness, that prompted the move.
When Ms. Few was eighty-seven years old, she went into the hospital very ill with a virus. She was admitted on a Monday, and on Wednesday, Linda said she got a call from a nurse. The nurse was whispering, and told her that she needed to get up there right away because her mom was dying. Linda learned that for three days the hospital had been giving her mother Lasix—a drug that treated fluid retention in patients. Linda recalls that the nurse said that the drug was shutting down her kidneys.
Linda James rushed to the hospital. Later, in explaining what had happened, the doctor told her that it was really hard when someone is older to know what is wrong with them. Ms. Few’s life was saved, but the damage was done. When Ms. Few went into the hospital, she had 40 percent kidney function. When she came out, she had 10 percent.
Most people would have filed a lawsuit immediately, especially when the doctor admitted that he’d made a mistake, but Ms. Few said she knew it was an accident. They were trying to do what was best for her and the thought of a lawsuit never occurred to her. When it was brought up, she wouldn’t hear of it.
The doctor’s mistake was one of the chief causes she had to start dialysis to begin with. Ms. Few had wanted to stop dialysis and stay at home—she had things to do and didn’t want to be tied to a chair for so long—but of course, her doctors and family told her she couldn’t.
Right up until April 26, 2008, Ms. Few led a very independent life. She still did all her own cooking and cleaning, and took care of Linda’s ten– and twelve-year-old kids after they got out of school while Linda worked. The ten-year-old was autistic and had to be monitored closely because of his special needs. Every day when the children got home, Ms. Few had pizza and a cold Dr Pepper waiting on them. She even babysat her two-year-old great-grandchild whose mother was attending the Academy of Hair Design, a beauty school.
On that “What if?” Saturday morning, Ms. Few answered the phone when DaVita called. She was glad to be able to get in for her treatment early and get it over with.
After Ms. Few was called back to begin her treatment, Heartsfield hooked her to the machine. The older woman had no problems, her vitals were good, and she was progressing well with her treatment. The nurse made her rounds of the patients, and then checked on Ms. Few again and found her doing well. Before leaving to go on her break, Heartsfield asked her teammate to look after her patients until she returned.
Approximately thirty minutes later, the length of breaks at DaVita, Donnya Heartsfield returned to her patients. She found Ms. Few unresponsive and with no pulse. She yelled for help, and the staff attempted to save Ms. Few, but to no avail. She became the fifth patient in twenty-six days to die on the dialysis machine.
After Ms. Few was transported away from DaVita, Dr. Nazeer asked RN Sharon Smith what meds Ms. Few had been given. When Smith checked the computer, she didn’t see where the meds were documented. Smith asked Saenz if she’d given Ms. Few her meds, and when Saenz said yes, Smith told her to document it. Saenz then went to the computer and put in a time she’d given the meds.
Just one week later, the syringe that Saenz had used to administer Ms. Few’s meds would become a key piece of evidence in leading investigators to the true cause of so many unanswered what-ifs.
CHAPTER 6
IN PLAIN SIGHT
When Kimberly Clark Saenz awoke around 4 A.M. on April 28, 2008, it was to a cool, windy Monday morning. Chances are that, like most of the other days she’d worked as a nurse for DaVita Lufkin, she didn’t want to go in, but felt she didn’t have a choice. They needed the money and she’d already missed a lot of days that month.
She probably had no inkling that by the end of the day she would become the subject of an investigation, or that news stories carrying her name would soon bounce all across the United States.
After dressing in regulation nursing scrubs and putting her hair in its usual ponytail, she would’ve made her way down the steps of her double-wide trailer (which sat next door to Saenz’s parents, Bennie and Kent Fowler). A large sign in front of a huge pine tree at the edge of the road announced the family’s affiliation with the Clawson Assembly of God Church.
Deep in the woods of East Texas, the early-morning darkness would be complete—no lights anywhere as Saenz eased her way through a heavy dew that blanketed the driveway. The moisture, combined with the layer of fine red dirt that accumulated on the windshield, meant that her wipers smeared across the glass before eventually clearing enough for her to see.
With her lights on bright, she would be able to see some of the wildlife that flourished in the dense forest that lined the edges of the rough, pothole-laden blacktop. The twisting road mostly held dense trees and underbrush, but was occasionally interrupted with pockets of human habitation—from run-down trailers, to wood and brick houses, and even a scattering of mansions sitting off the road on hilltops.
Because of the darkness and the rough condition of the road, it took Saenz almost fifteen minutes to travel the four miles from her home to Highway 69, the main thoroughfare through Pollok, an unincorporated community in the northwest corner of Angelina County.
After turning right on the highway, she could speed up, passing Central High School on the left and a couple of churches on the right—one of them her own. Her quick trek took her past a Polk Pick-It-Up, a convenience store and meat market. At that hour everything was closed except the convenience store.
Minutes after turning on the highway, she came to the loop around Lufkin. She turned right, traveled through two traffic lights, and arrived at the DaVita Lufkin Dialysis Center. A fellow DaVita employee said she saw Saenz sitting in her car with her eyes closed and her head back for several minutes. She said she was about to go back and check on Saenz, when her coworker’s car door finally opened.
The atmosphere Saenz encountered at DaVita on April 28 was extremely tense, as it had been for some time. All throughout April 2008, the clinic had existed in what is called a comorbid state. There were simply too many unexplained patient deaths at DaVita Lufkin and too many patients suffering serious health complications.
From April 1 to April 28, the facility had had to transport thirty-four patients by ambulance to hospital emergency rooms. This number was three times the amount of patients taken to the hospital in March. Even more disturbing to DaVita officials were the nineteen patients who’d died in a five-month span from December 2007 to April 2008.
This was the atmosphere of the clinic that Kimberly Clark Saenz walked into on the twenty-eighth of April 2008. Anxiety was already high, and things began to go wrong immediately. One of the patient care technicians had to call in sick, so Amy Clinton, the head investigator who had taken over the operations of the clinic, called an off-duty RN by the name of Dale Stockwell to come to work.
Clinton never thought calling Stockwell in would cause any problems. But looking back, it may have only highlighted a problem that already existed.
* * *
Amy Clinton was a professional, smart, and vivacious woman in her early thirties, with a classic beauty. Not the beauty queen type of looks, but the kind that proclaims breeding and class—the type that makes men look twice, and then a wistful third time.
Clinton earned her bachelor of science degree at Stephen F. Austin State University in Nacogdoches, Texas (pronounced Nak-uh-DOE-chez), and became a registered nurse. She worked in a busy hospital emergency room for a year before starting to work as a dialysis nurse in 1997.
Owing to her intelligence, hard work, and ability to lead and interact with her coworkers and subordinates, she soon climbed the corporate ladder. People who worked with and under Clinton were quick to point out that she knew how to listen—even to the people under her—and was receptive to implementing advice if it made sense and fit what was best for the patients.
People who talked about Amy Clinton described her as kind and caring. Nursing wasn’t an occupation to her, but a calling. She honestly cared about the patients, their suffering, and their problems. Several commented that it wasn’t only her aptitude and professionalism, but her compassion that was much of the reason behind her quick ascent in the company.
When Clinton arrived at the DaVita Lufkin Dialysis Clinic, she didn’t know that location’s employees, their specific problems or issues, but she knew how DaVita was structured and how each clinic was supposed to be run. DaVita basically had three tiers of employees who dealt with patients. The lowest tier was the patient care technicians (PCTs). These employees weren’t nurses, but people hired and trained to care for patients as they underwent the dialysis process.
The second tier of employees were the licensed vocational nurses (LVNs) like Kimberly Clark Saenz. Unlike the techs, the LVNs were nurses who went to two years of college to earn their licenses. For the most part, LVNs and PCTs performed the exact same job; despite the extra education, the only practical difference between the two at DaVita was that the LVNs could give shots but the techs couldn’t.
The top tier of employees were the RNs—registered nurses. Like Clinton, RNs had attended four years of college and had progressed beyond LVNs. These nurses held supervisory roles, responsible for all the other employees caring for patients. In most circumstances, DaVita Lufkin had three RNs on duty per shift. One acted as the med nurse, responsible for drawing up and administering the meds to the patients, and the other two as charge nurses, one for each of the two bays of patients in the facility.
Except in emergencies or when there was a shortage of people to work on a given
day, the RN usually didn’t have direct involvement with patient care. This job fell to the techs and the LVNs. Because she was new to the facility and didn’t know the staff, Clinton was unaware that this was a huge point of contention with Kimberly Saenz. Saenz constantly voiced her displeasure to other DaVita employees about caring for patients. She thought patient care was beneath her as a nurse. The only job she cared about doing was that of med nurse.
Because of illness, vacation, time off, and other such issues, there wasn’t always an RN available to do the med job, and even when there was, the staff sometimes got behind and the LVNs had to act as med nurses and pull their own meds.
On the morning of April 28, when Amy Clinton had to find a replacement for the PCT who’d called in, she didn’t think anything about it when Dale Stockwell agreed to come in. However, Stockwell was an RN, so Clinton had to change the schedule around. Stockwell became the med nurse for that day, and the LVN scheduled to do that job was relegated back to patient care. With most that wouldn’t have been a problem, but on that day, Kimberly Saenz was scheduled to be the med nurse.
When Clinton informed Saenz that she’d been switched, Saenz got teary-eyed and upset, which surprised Clinton. She didn’t understand what the problem was. After all, nurses were supposed to take care of patients. That’s why most went into the field, and that’s why most stayed with it. After talking to her for a few minutes, Clinton thought Saenz would be okay.
It wasn’t until later, when another employee came to Clinton and told her that she needed to talk to Saenz, that Clinton realized that the LVN hadn’t gotten over it. Clinton found Saenz not at her station but out back on the loading dock smoking a cigarette and still very upset about the assignment change.