The resident's anticoagulation medication Eliquis was stopped in July 2025 before a procedure to place a suprapubic catheter. Nobody restarted it until October 1, when the nurse practitioner finally noticed the oversight and ordered an immediate loading dose.
During those missing months, the resident's medical records told a contradictory story. Progress notes from September 17, September 24, and September 30 all listed "Eliquis 5 mg oral every 12 hours" on the active medication list. Each note included a statement claiming the nurse practitioner had "reviewed the resident's medications in the facility chart" and directing staff to "refer to the facility's Medication Administration Record for a complete and up to date list of active medications."
But the resident wasn't receiving any Eliquis.
The discrepancy came to light only when the nurse practitioner wrote in an October 1 progress note that "chronic anticoagulation stopped in July 2025 prior to procedure" and "anticoagulation was not restarted." She ordered the medication restarted that same day at 2:46 PM, prescribing a loading dose of 10 mg twice daily for seven days, then the standard 5 mg twice daily with no stop date.
When inspectors interviewed the nurse practitioner on October 22, she acknowledged that medications listed in progress notes "may not always be accurate or reflect medication changes." She called the failure to restart Eliquis "an oversight."
The attending physician told inspectors the same day that Eliquis "should have been restarted after the suprapubic catheter insertion procedure." The doctor said the medication lists on progress notes were supposed to reflect active medications carried over from previous notes, and that she reviewed the facility's Medication Administration Record for accuracy.
She could not explain how the Eliquis was missed.
The facility's administrator and director of nursing revealed a systemic problem when inspectors questioned them the following day. Both acknowledged they knew the medication lists on progress notes "were not always accurate" but said they were "unaware of the specific process of how the medication list got on the progress note."
The administrator admitted "the medications should have been reviewed and the failure to restart the Eliquis should have been caught."
Eliquis prevents blood clots and reduces stroke risk in patients with conditions like atrial fibrillation. Stopping the medication without medical justification can lead to serious complications including stroke, pulmonary embolism, and deep vein thrombosis.
The inspection found the facility failed to ensure medications were administered as prescribed and that medical records accurately reflected the resident's current treatment plan. Multiple staff members acknowledged the medication tracking system was flawed but had not implemented safeguards to prevent such oversights.
The three-month gap between stopping and restarting the blood thinner represents exactly the kind of medication error that federal regulations are designed to prevent. Progress notes served as false documentation, repeatedly asserting the resident was receiving medication that had actually been discontinued months earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for White Oak Manor - Charlotte from 2025-10-27 including all violations, facility responses, and corrective action plans.