A&M's report has not been formally released, but has been posted online. The report is currently under review by the CMS Freedom of Information Group office in Baltimore. No timeline for its release by CMS is available. Parkland officials cited legal concerns in declining to make the document available.
According to the document, serious deficiencies continue at Parkland in 20 broad categories, including nursing services, utilization review, infection control, discharge planning, lab, surgical and emergency services, and professional practice evaluation.
The analysis by A&M cites numerous specific incidences "that lead to an overall concern about the safety of the care environment at Parkland" such as:
- An emergency department patient who was triaged and provided a medical screening exam but waited for 14 hours before a staff member noticed that the patient's care hadn't been completed.
- House cleaning staff moved a patient to a hallway to clean the patient's room then took a lunch break without completing the cleaning or returning the patient to the room.
- Some 250 medication errors over three months with 58% involving the wrong dose, wrong drug, wrong patient or wrong frequency.
- Discharging psychiatric ER patients with only bus vouchers and instructions to call 911 in the event of recurring suicidal thoughts
- Patients leaving the hospitals without having ports or other lines properly removed.
- A patient whose surgery had to be terminated after anesthesia had been administered because of staff failed to obtain signed consent for the procedure.
- Residents taking cell phone pictures of surgical procedures in violation of patient privacy rules
- Missing supplies from crash carts that involved an eight minute delay in a code team's efforts to resuscitate a patient.
- Lack of resident oversight by an attending physician that resulted in procedures being incorrectly performed. The report notes one incident when a resident made six failed attempts to place a peripheral arterial line.