Gillo Porcello, a dementia patient lived at Wedgewood Nursing Pavillion. During his stay he began to engage in acts of physical aggression resulting in a cuts and bruises, as well as fractures to his humerus, hip and three ribs. Mr. Porcello's father was never contacted and a psychiatric evaluation was never performed. He later died of cardiac arrest. Stress and blood loss from the hip fracture were contributing factors to the cardiac arrest.