Cabarrus Health and Rehabilitation Center's Director of Nursing told federal inspectors that three separate staff members were supposed to verify medication orders for Resident #6 when he arrived from the hospital in October. None of them caught the error.
The facility had transcribed the resident's Finasteride prescription incorrectly from his hospital discharge summary. Finasteride treats enlarged prostate and male pattern baldness.
"The cross-checks probably were not completed," the Director of Nursing admitted to inspectors during an October 29 interview.
The nursing home's medication verification process required three levels of review. First, the hall nurse was supposed to check admission orders. Then the Unit Manager on the resident's hall would verify them. Finally, another Unit Manager would conduct a third review for accuracy.
All three failed.
The Director of Nursing explained that the transcription error occurred due to "human error." She told inspectors that the facility's pharmacy typically sends alerts when medication discrepancies are detected, but no alert was received for Resident #6.
The facility also maintained an admission Audit Checklist designed to catch exactly this type of mistake. The checklist required staff to verify that admission orders entered into the medical record matched the hospital discharge summary. It also required documentation if the in-house physician changed any orders.
The Unit Manager was supposed to complete the audit checklist, then pass it to the Assistant Director of Nursing for review. The Director of Nursing should have received the completed audit as a final check.
When inspectors asked to see Resident #6's admission Audit Checklist, the Director of Nursing could not provide it.
The Medical Director reviewed both the hospital discharge medication list and the facility's medication orders dated October 8 during his interview with inspectors on October 29. He said he was unaware that the Finasteride had been transcribed incorrectly.
"This would not have caused harm to Resident #6," the Medical Director told inspectors.
He confirmed that he expected nursing staff and the Consultant Pharmacist to cross-check admission medication orders for accuracy. Despite these expectations, the error went undetected through the facility's entire verification system.
The Administrator, interviewed the same day, described the transcription process to inspectors. Nurses were supposed to enter orders from the hospital discharge summary into the medical record. The Unit Manager would then check these entries. Finally, the Medical Director would sign the orders to ensure accuracy.
The Administrator acknowledged that Resident #6's Finasteride order was indeed a transcription error when inspectors brought it to her attention.
The breakdown represented a complete failure of the facility's medication safety protocols. The hall nurse missed it. The Unit Manager missed it. The second Unit Manager missed it. The pharmacy's alert system didn't trigger. The admission Audit Checklist either wasn't completed or went missing. The Medical Director signed off without catching the discrepancy.
Federal regulations require nursing homes to ensure that residents receive the correct medications in the correct dosages as prescribed by their physicians. The multi-layered verification system at Cabarrus Health was designed specifically to prevent transcription errors that could harm residents.
Each safety check that failed represented another opportunity to catch the mistake before it reached the resident. The missing audit checklist suggests the facility's documentation problems may extend beyond the initial transcription error.
The Medical Director's assertion that the incorrect Finasteride dosage would not have caused harm to Resident #6 doesn't address the broader safety implications. If the facility's three-level checking system failed for one resident's medications, other patients could face similar risks.
The incident occurred during what should be one of the most carefully monitored periods of a nursing home stay. New admissions typically receive heightened attention as staff work to ensure continuity of care from the hospital setting.
Resident #6's experience reveals how quickly multiple safety systems can fail simultaneously, leaving vulnerable patients at risk for medication errors that could have been easily prevented with proper attention to established protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cabarrus Health and Rehabilitation Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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