This case involves the incorrect use and positioning of a continuous passive motion device on a patient’s leg following a total right knee replacement surgery. The medical records showed that the patient’s leg was placed into the device without a foam boot and, as a result, her leg was not maintained in a neutral position while the device was in operation. Furthermore, the patient was not given a control to stop the device, which caused the patient to receive therapy for longer periods than originally intended. The patient was discharged from the hospital with an area of redness and induration that eventually progressed to a full thickness wound. The patient had to undergo several rounds of surgical debridement and extensive, year-long treatments by a plastic surgeon to close the wound. An expert in decubitus ulcer care was considered to opine on this issue.