This case involves a 75-year-old male patient who had two back surgeries for degenerative disease and was sent to a rehabilitation hospital. Given his immobility, the patient was placed on deep vein thrombosis (DVT) prophylaxis and given a subcutaneous anticoagulant injection. When his rehabilitation progress plateaued, the decision was made to send him to a nursing facility. On the day of transfer, the anticoagulant was discontinued and never restarted. Subsequently, at the nursing home, the patient fell and was found to have very low blood pressure. The medical director was notified and gave the patient fluids, but no further workup was done. Not long after, the patient went into cardiac arrest and was found to have bilateral pulmonary embolisms. He survived but sustained optical infarcts which caused the patient to go blind. An expert internist or physical medicine and rehabilitation physician with experience in rehabilitation facilities was sought to speak to policies of DVT prophylaxis as well as proper evaluation of hemodynamic collapse.