Resident #1 should have received 12 mg of warfarin on November 11, 12, and 13, according to Unit Manager #1's explanation to federal inspectors. The resident had been difficult to get to a therapeutic blood level and required frequent dosage adjustments.
The manager discovered her error while reviewing lab results on November 14. She had intended to increase the resident's warfarin from an unspecified lower dose to 12 mg based on a physician-approved protocol, but found no record of the order when she checked the system.
Warfarin prevents blood clots but requires precise dosing based on regular blood tests measuring PT/INR levels. The therapeutic range is 2.0 to 3.0.
The facility's nurse practitioner explained that lab results were sent to the facility, and unit managers used the physician-approved warfarin protocol to adjust doses. She told inspectors the missed doses did not harm Resident #1, and when she checked on him after being notified, "he was fine."
But the error compounded when staff failed to obtain the required blood sample on November 13. Unit Manager #1 had to order an immediate PT/INR lab draw for November 14.
The resident's test result came back at 2.8 — within the therapeutic range despite missing three days of medication. He resumed the 12 mg dose at 8:00 PM on November 14.
The nurse practitioner said she expected staff to follow the warfarin protocol for all residents receiving the medication. Unit Manager #1 told inspectors she believed she had written the physician order to increase the dose but discovered she had not.
Director of Nursing staff discovered the problem during routine review. She explained that Unit Manager #1 was reviewing PT/INR results from November 13 when she noticed the lab work for Resident #1 was not obtained.
The facility immediately ordered the lab draw and notified the nurse practitioner about the missed medication. The director said Unit Manager #1 reported she thought she had entered the new warfarin order, but it was not in the system.
Federal inspectors found the facility failed to ensure medications were administered according to physician orders. The violation received a minimal harm rating, affecting few residents.
The facility administrator told inspectors she expected policies and procedures to be followed to prevent medication errors. The director of nursing said she expected changed warfarin orders to be entered into the system according to the warfarin protocol.
The inspection occurred November 14 in response to a complaint. No other details about the complaint were provided in the federal report.
Warfarin dosing errors can have serious consequences. Too little medication increases stroke and clot risks, while too much can cause dangerous bleeding. The medication requires careful monitoring and precise administration.
Unit Manager #1's assumption that she had entered the order highlights a gap between intention and execution in the facility's medication management system. The resident went three days without proper anticoagulation therapy because of the manager's unverified belief.
The facility's protocols appeared to function correctly once the error was discovered. Staff immediately ordered the missing lab work, notified the prescribing clinician, and resumed proper dosing.
But the near-miss raises questions about verification procedures for critical medication changes. The unit manager's certainty that she had entered an order she had not suggests inadequate confirmation systems for high-risk medications like warfarin.
The resident's therapeutic blood level despite missing doses may have prevented immediate harm, but the three-day gap in anticoagulation could have had serious consequences for someone requiring precise blood thinning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Greens At Cabarrus from 2025-11-14 including all violations, facility responses, and corrective action plans.