The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|SINAI HOSPITAL OF BALTIMORE||2401 WEST BELVEDERE AVENUE BALTIMORE, MD 21215||June 25, 2013|
|VIOLATION: MEDICAL RECORD SERVICES||Tag No: A0450|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of one out of fourteen open medical records, it was determined that the medical record content (signature) illegibility and correction of errors was performed improperly.
Patient #7 is a [AGE] year old female admitted on [DATE] for an abdominal mass with subsequent surgical intervention. On review of Patient #1 ' s medical record, specifically, the " Transfusion Service Record " , it was determined that in 7 of 7 of the transfusion verification forms the signatures of the person initiating the transfusion as well as the co-verifier ' s signatures are illegible.
In addition, on further review of the " Transfusion Service Records " it was determined that in 6 of the 7 forms, the original clock number (used to identify the person documenting) had been obliterated by scratching out the documentation The acceptable standard of practice requires the writer to cross through the error with one line, write the word error, initial the error, and then make the necessary corrections.