This case involves an elderly male patient who died while receiving treatment at a dialysis center. The patient presented to the dialysis center with an elevated heart rate and a prescription for antibiotics, which was suggestive of an active infection for which he was receiving treatment. He was not seen by his physician on arrival to the dialysis facility and, as a result, the physician did not evaluate his physical condition before dialysis treatment was begun. At some point while he was receiving treatment the patient went into cardiac arrest. Neither the physician nor any of the other personnel at the treatment center checked on the patient during the time he was there receiving treatment, which took several hours. Additionally, the patient’s vital signs were not monitored during the treatment. Staff at the dialysis center only discovered that the patient had died hours after he had begun treatment. It was alleged that the facility failed to adequately evaluate the patient’s condition, both during his arrival at the facility and during his dialysis treatment.