This case involves a man who was admitted to a hospital in Nebraska for treatment of severe pneumonia and was put on a ventilator. Initially, he responded well to treatment, and was plans were made for him to be discharged. However, hours before he was due to be discharged, he developed a sudden drop in his oxygen saturation. A nurse responded and suctioned the patient, and a respiratory therapist was called to assess and manage the airway. While managing the airway it is alleged that the respiratory therapist failed to monitor the patient’s vital signs, and his heart rate dropped and he went into respiratory arrest. Despite being successfully resuscitated he sustained brain damage from oxygen starvation.