This case involves an obese 65-year-old male patient in Texas with a history of obstructive sleep apnea with CPAP treatment, COPD, and hypertension who underwent a hip replacement procedure at a surgical center. In advance of the procedure, the nursing staff instructed the patient not to bring his CPAP machine to the surgical center. The patient’s COPD and sleep apnea were not addressed in the orthopedic surgeon’s pre- or post-operative treatment plan. After the surgery, the patient received hydromorphone and oxycodone by mouth over the course of 12 hours. On the first postoperative day, the patient required oxygen via nasal cannula to maintain oxygen saturation. He continued to receive opiate pain medications without CPAP. The patient was later found by the nursing staff unresponsive and in cardiac arrest. The patient was resuscitated, intubated, and admitted to the ICU. In spite of this emergency response, the patient developed anoxic brain injury and was declared brain dead.