Abstract: On October 23, 2003, Employee #1, a records clerk, fell while carrying her lunch tray from the dietary facility to her office. The employee was 87 years old and had worked for the facility for approximately 33 years. There were no witnesses to the fall. A coworker, a registered nurse, administered aid within several minutes of the fall. The nurse stated that the employee had sustained a laceration to the back of her head and that her leg was positioned in an unnatural position which indicated a possible hip fracture. The employee was transported to a local hospital and underwent surgery however, she developed pneumonia and her kidneys began to fail. Employee #1 was transferred to hospice care within the hospital and died from her injuries eighteen days after the accident.