This case involves a seventy-nine-year-old male patient who presented to the hospital with shortness of breath. The patient was worked up in the emergency room, where it was determined that he was suffering from congestive heart failure and pulmonary edema. The patient was transferred to the cardiac care unit and the physician’s orders to the nurses were to evaluate the patient every four hours. The patient was not checked until the tenth hour of admission due to an alleged shift-change miscommunication. When a nurse went to the patient’s bedside, he was unconscious and unresponsive. It took the nurse ten additional minutes to call a code blue. CPR was initiated and lasted forty-five minutes until the time of death was called. It was also alleged that the CCU monitors never went off when the patient went into cardiac arrest because the patient was not attached to the monitoring system.