Doe, age 60 fell at home, suffering a femur fracture. Following surgery, he was a high aspiration risk when admitted to Woe nursing center for rehab. An NPO order (nothing by mouth) was entered by the staff of Woe into Doe’s chart. 5 days after admission Doe, who had dementia and was confused, was given a food tray and the staff watched him as he ate the food presented to him and did not intervene. Plaintiff’s experts would have testified that a patient such as Doe with an NPO status should have never been presented with a food tray. Depositions of the staff show that the nursing home did not follow the order of NPO because of miscommunication between the nursing staff and kitchen, which issued a dietary slip for the food tray. After eating his spaghetti lunch, Doe aspirated the food from his stomach and into his lungs and was sent to the hospital where a CT scan showed aspiration pneumonia and mucous plugging caused by his aspiration pneumonia of food into his lungs. Doe died of acute respiratory failure and aspiration pneumonia the next day.