Joanne was seen by her PCP provider Dr. Smith in August of 2013. During this visit she was diagnosed with atrial fibrillation and was started on Coumadin. She was told to return in two days to have her INR checked. When she returned the INR value was normal. Joanne was told to return again in a week to to follow up on her treatment. When she returned to the clinic to see Dr. Smith, the INR was not performed, although other lab tests were performed.
She did not have another INR performed until about two and one-half months later. Joanne returned to the office in mid-November 2013, and was seen by AGNP Nancy, who worked with Dr. Jones, who was covering for Dr. Smith who was out on maternity leave.
During the November visit, Joanne complained of bruising and dizziness and was seen by the certified registered nurse practitioner. An INR was drawn that revealed a value of 34.2. The certified registered nurse practitioner instructed Joanne not take the Coumadin for four days and to have the INR level rechecked on the fifth day. The NP did not collaborate with Dr. Jones regarding the INR value.
The patient returned to the office the next day with nausea and vomiting. She was also still bleeding from the site where her blood had been drawn the day before.
The certified registered nurse practitioner drew another INR, which was 44.8. The nurse practitioner showed the latest INR value to Dr. Jones who instructed her to refer Joanne to a hematologist. An appointment was made with the hematologist the next day, but the patient was found unresponsive by a friend prior to the appointment.
Joanne was taken by ambulance to an emergency room, where a CAT scan showed a subdural hematoma with a midline shift. She died soon after that.
