This case involves a patient that had a below the knee amputation which was uneventful during surgery. The patient suffered from COPD and was taking several respiratory medications, preoperatively. The patient was cleared by medical doctors for surgery and was labeled as a moderate risk. During the first, postoperative day, the respiratory therapist failed to administer the prescribed respiratory medications to the patient. One of the defendant nurses was expected to administer theophylline on an empty stomach; however, the medication was given to the patient with his breakfast. Throughout the course of the day, the patient’s respiratory therapist failed to administer more than half of his prescribed medications. Also, the patient became euphoric and began hallucinating. The patient’s wife left the hospital at 8 PM and requested the nursing staff look after him. At 8:30 PM, another family member arrived to visit the patient but found him unconscious and unresponsive. They alerted a nursing staff member, who advised the visitor that the patient was tired and needed rest. About thirty minutes later, the patient coded and died from cardio-respiratory arrest.