An elderly woman with dementia living in a nursing home relied on a wheelchair to get around the nursing home. Her nursing home chart documented many falls from the wheelchair. No additional safety precautions were put in place as a result of the falls. Although her chart documented frequent and increasing complaints of shoulder pain and an inability to raise her arm, the complaints were not relayed to her doctor for several months. By the time the woman was sent to a shoulder surgeon her shoulder was froze and could not be repaired. The surgeon had to permanently fuse the woman’s shoulder so she could not move her arm at the shoulder. She also developed stage II pressure sores.