This case involves an elderly female patient who had a tracheostomy tube placed following a neck surgery. The patient was transferred to a skilled nursing facility and placed under the care of a nurse practitioner. The nurse practitioner did not inform the team that the patient’s airway was tenuous due to her recent surgery. The nurse practitioner also failed to formulate a plan for handling potential airway problems in this particular patient. During the patient’s time at the facility, a floor nurse suspected that the patient’s tracheostomy tube had become displaced. In spite of this suspicion, no X-rays were taken. The floor nurse called the respiratory therapist about the displaced tube and the respiratory therapist attempted to advance the tube. The nurse practitioner was present for this. The patient began to desaturate and a code was called but the nurse practitioner did not arrive. In spite of resuscitation attempts, the patient passed away.