This case involves an eighty-two-year-old male patient who was a nursing home resident. He had a past medical history of dementia and severe falls which prompted his family to seek 24-hour care for the patient. The patient suffered a fall in his bedroom at the nursing home when he slipped on the hardwood floor. The patient was discovered by a member of the nursing staff and was rushed to hospital via ambulance. An X-ray revealed that the fall had resulted in a fracture of the right femoral head. The patient required surgery to replace the hip. The patient underwent the procedure which was successful. He was discharged back to the nursing home following the surgery. Several days after discharge the patient began complaining of fever and pain in his right hip. The patient returned to hospital where investigations revealed he was suffering from osteomyelitis. The patient underwent treatment for the infection but did not survive. He died two days after hospitalization. The family of the deceased alleged that the nursing home did not take adequate measures for fall risk reduction. They believe that the facility should have taken various precautions, for instance: putting down mats. This was never done until after the incident.