August 2018
Georgia was seen in the hospital by a team of healthcare providers, including an AGACNP, in August 2018 and was diagnosed with atrial fibrillation and treated with Coumadin. Prior to discharge, her INR level was normal. Georgia was discharged with instructions to follow up with her PCP within one week. Georgia was seen by her PCP five days after discharge, and her INR was normal. She was instructed to continue Coumadin and to follow up in three months.
November 2018
Georgia returned to her PCP in November 2018 and reported to be doing well, except for some dizziness and bruising. Her PCP ordered an INR, and Georgia was instructed to go to the ER with increased dizziness, bruising, or other concerns.
November 2018
Two days after her appointment with her PCP, the results of the INR was recorded as 34.2, and Georgia was called with the results. The patient revealed that she had increased bruising and dizziness. The PCP instructed Georgia to go to the ER for further evaluation because the office was closed for the next few days due to a holiday.
November 2018
Georgia went to the ER and was seen by an AGACNP. Georgia failed to report that she was taking Coumadin and stated that she had some increased bruising and dizziness, and her PCP wanted the ER to check her out.
The AGACNP ordered some lab tests, including an INR. The INR was 44.8. Upon review of the case, the AGACNP referred Georgia to a hematologist. Georgia was discharged and instructed to follow up with her PCP in the next few days.
December 2018
Georgia presented the next day to the ER via ambulance. A neighbor had checked on her this morning because Georgia had complained of nausea and vomiting, and the neighbor found her unresponsive. The AGACNP ordered a stat CAT scan, which showed a subdural hematoma with a midline shift. Georgia died soon after that.
