A woman with dementia that was confined to a wheelchair was living in a nursing home. She had fallen out of her wheelchair in the nursing home multiple times without serious injury. To prevent future falls, her doctor ordered a special seat belt with a Velcro release to keep her in her chair. The records from the nursing home documented the Velcro lap belt was not consistently used. In addition the family testified they would often find their mother in her wheelchair without the belt. Several months after the belt was ordered, she was found at the base of her wheelchair with a broken femur at the hip.