The baby was seen by a primary care physician two days after discharge and there were no concerns during that visit. One week later, the baby was rushed to a local emergency room after becoming profoundly lethargic, blue in the skin, and hypothermic. The baby also had a dramatic drop in urinary output and had a reported body temperature of 90 degrees. Aggressive resuscitation efforts were started to get her stabilized for transfer to a PICU at another facility with IVF via IO’s. Antibiotics were not administered nor were labs and cultures drawn prior to transfer. The baby died several days later due to sepsis. A blood culture that had been drawn came back positive for coagulase-negative staphylococci.