This case involves a fifty-nine year old man with a history of COPD who was admitted to the hospital for an episode of shortness of breath and chest pain. The patient’s respiratory exacerbation was stabilized over a seven-day hospital stay, but the day before his discharge, the patient had a positive nasal culture for MRSA. The hospital staff neglected to change his medication to reflect his new status as a carrier for the resistant bacterial strain. After physicians performed a bronchoalveolar lavage, the patient began to decompensate over the following days that was also positive for MRSA. The patient became septic, went into shock, and died shortly thereafter.