This case involves the death of a developmentally disabled resident, Mr. Kenny Salamino, at a group home due to lack of adequate nursing care and supervision over several months. A licensed practical nurse and registered nurse consultant were responsible for care but did not properly assess and address Mr. Salamino's 40 pound weight loss, failing to intervene until he was hospitalized and later died. An investigation found the nurses responsible due to insufficient oversight of resident care needs.

1. Logistics
you will apply concepts learned in this module (CIFFA
etextbook, CIFFA elearning, Lesson: Module 5) around Terms
of Trade / Incoterms® 2020.
You are asked to manage the following two shipments of
intermodal cargo going by TEU (sea) or ULD (air).
SHIPMENT A
SHIPMENT B
Origin:
Shipper’s Plant
Budd’s BMW Canada,
Oakville, ON, CA
VW, Taubaté, Brazil
Terminal & customs
Schenker Whse,
Montreal, Quebec
Sao Paulo International Airport
Port – seller’s side
Port of Halifax, NS
Port of Santos, Brazil
Port – buyer’s side
Port of Antwerp, Belgium
Port of Miami, Florida
Terminal & customs
Schenker Whse,
Munich, Germany
YYZ, Toronto

2. Destination:
Buyer’s Warehouse
BMW,
Munich, Germany
VW, 550 Adelaide St E., Toronto, Canada,
Use Shipments A and B (above) to completely label the diagram
with locations of delivery and shade the seller’s obligations for
the following containerized shipments:
1. (1 mark) Shipment B – Incoterm® is EXW
||
Cost
Transportation
Insurance

3. Risk of ownership
pre-carriage
main carriage
on-carriage
2. (1 mark) What is the complete Incoterm®?
3. (1 mark) Shipment A – Incoterm® is CPT
||

4. Cost
Transportation
Insurance
Risk of ownership

5. pre-carriage
main carriage
on-carriage
4. (1 mark) What is the complete Incoterm®?
5. (1 mark) Shipment B – Incoterm® is CIF port
||
Cost
Transportation
Insurance

6. Risk of ownership
pre-carriage
main carriage
on-carriage
6. (1 mark) What is the complete Incoterm®?
7. (1 mark) Shipment A – Incoterm® is DPU port
||

7. Cost
Transportation
Insurance
Risk of ownership
pre-carriage
main carriage
on-carriage

8. 8. (1 mark) What is the complete Incoterm®?
9. (1 mark) DAP is best for a contract in which the buyer is a
large international company?
a. true
b. false
10. (1 mark) Why? Or Why not? Justify your choice for
question 9.
11. (1 mark) What potential problem is there with EXW that
makes FCA a better selection in most cases?
12. (1 mark) Using FOB “named port” in your Sales Contract
shows interested parties that (select all that apply):
a. The freight costs must be prepaid up to the port of arrival
b. The seller must arrange and pay for marine insurance
c. It is a marine bulk shipment
d. The seller must arrange and pay for any documentation or
export declaration formalities in the country of origin
e. The seller must arrange and pay for main-carriage
13. (1 mark) I am responsible for paying all the bills at my
company. I notice that we, the buyers, have received a shipment
for which the bill of lading says, “freight prepaid”. Am I correct
that we will be receiving an invoice from a carrier or freight
forwarder for the freight charges for this shipment?
a. Yes
b. No
c. Sometimes
d. I need more information

9. 14. (1 mark) List the Incoterm(s) ® acronyms used for
shipments in which the truck bill of lading delivering the
product to final destination is for the seller’s account.
15. (1 mark) List all the Incoterms® in which responsibility for
costs and risks are divided at two different places:
16. (1 mark) Incoterms® 2020 made a clarification about where
delivery takes place. For the terms in “D.” above, which “place”
is where the seller is considered to have completed “delivery.”
a. where the costs divide
b. where the risks transfer
c. both places
d. in this case, no named place is required
Compare and contrast the following two terms: (2 marks
each)
CPT
CIF
17. Mode(s) of transportation
18. Place of division of cost obligations
19. Place of transfer of responsibility for risk of loss

10. 20. Insurance requirements
21. (2 marks) Sammy is a freight forwarder arranging shipping
of goods via air from Place A to Place B. It is agreed that the
Seller will arrange pre-carriage and deliver the goods to
Sammy’s warehouse. The rest of the costs and risks are for
Sammy’s customer, the Buyer. What is the FULL Incoterm®?
Excellent Exporters, in Brampton, Ontario sells products to
Toys R US in Tehran, Iran under a clean, onboard bill of lading.
Terms of sale: CPT, Designated Port, Incoterms® 2020
Cargo: 22 wooden pallets of toys loaded in one 20-ft ocean
container
Terms of delivery: consolidated container, ocean freight
Terms of payment: open account, net 60 days
22. (1 mark) Who selects the freight forwarder and pays the
ocean freight charges?
Buyer � Seller �
23. (1 mark) The place where the risk transfers from the seller
to the buyer is the “Designated Port”
True � False �
24. (1 mark) There are goods of U.S. origin in the consignment
and a general export permit is required. However, this GEP 12
was not entered on the export declaration (CAED). Who is
responsible for paying the administrative penalty to the CBSA?
Buyer � Seller �

11. 25. (1 mark) The shipment was delayed at the arrival port due to
customs clearance problems. Storage charges were US $600.00.
Who is responsible to pay for the storage?
Buyer � Seller �
26. (1 mark) When the container was unloaded at the
consignee’s door, the contents of eight pallets were damaged.
Who bears the loss?
Buyer � Seller �
27. (1 mark) What would be your recommendation about
Incoterm® named place in this problem?
You are shipping 5 skids of sulfuric acid from a “Montreal
Manufacturer”, sold FCA Montreal Incoterms® 2020. This is an
incorrect use of Incoterms® because a specific named location
is not given. After the sulfuric acid was loaded into the Cartage
company truck, at the plant, the driver on the way to the export
terminal in Montreal has an accident on the expressway. His
truck “jackknifes”, tips, and crashes against the steel guardrail,
busting the trailer doors open and spilling sulfuric acid cans all
over the highway, closing it for hours in both directions.
This leaves us with two possible situations:
28. (2 marks) Situation #1: If the buyer’s “nominated carrier”
was moving the sulfuric acid to the export terminal Montreal,
then the buyer bears the risk. Please note that “nominated
carrier” may also mean “local forwarder”, or “forwarder’s agent
overseas giving instructions to their local agent” to collect the
freight. A proper description of the Incoterm® for this case
would be:
Full Incoterm®:

12. 29. (2 marks) Situation #2: The seller decides to use their own
in-house trucks to deliver the cargo to the export terminal. The
only information provided to the seller are the booking details
for the move. In this situation the seller has yet to deliver the
goods in accordance with the Incoterm® used. Thus, the seller
has the risk of loss. The proper Incoterm® for this situation
would be
Full Incoterm®:
You are employed by YYJ Exports, Victoria, BC. Your
company wants to export electrical supplies to Hotwire
Electrical Inc. in Tokyo, Japan. Shipping instructions are as
follows:
The goods are to be shipped from YYJ Exports by PRO NORTH
Trucking (175 Apple Ave., Victoria, B.C.) by truck on the ferry
to Vancouver Airport and loaded onto a JL flight to Tokyo
From Tokyo Airport’s Freight Terminal NIPPON Trucking will
deliver the goods to Hotwire Electrical Inc. Main Warehouse,
123 ABC Street, Tokyo, Japan.
The buyer has asked that you quote prices under various
alternatives. What complete Incoterms® would apply for the
following scenarios?
30. (2 marks) The buyer wants the goods delivered, insured, to
Tokyo Terminal, but they are willing to assume risk for the
goods once they are given to Pro North Trucking in Victoria.

13. 31. (2 marks) The buyer wants you to deliver the goods to the
Freight Terminal HND Tokyo Airport. The buyer will make
their own insurance arrangements, and is willing to assume risk
for the goods once they are loaded on to PRO NORTH
Trucking’s trailer.
32. (2 marks) The buyer wants you to deliver the goods packed
and loaded to PRO NORTH Trucking at your plant in Victoria.
The buyer will accept the risk and cost for the goods once they
are in the possession of PRO NORTH Trucking and will make
all the necessary arrangements to bring them to Osaka.
33. (2 marks) The buyer wants you to deliver the goods to JL at
the Freight Terminal, Vancouver International where they will
accept the risk and cost for the goods and make the necessary
arrangements to transport the goods to Tokyo and beyond.
34. (2 marks) The buyer wants you to deliver the goods to their
agent, Schenker Logistics, Tokyo Airport where they will
assume risk for the goods, account for them to customs, and pay
duties and taxes and handle the final delivery.
35. (2 marks) Compare and contrast the insurance rules from
Incoterms® 2010 to Incoterms® 2020.

14. 36. (2 marks) Given that the Incoterm® used in a contract is
CIF (port of arrival), what advice would you, as a freight
forwarder, give your client, the consignee with respect to
insurance?
1
4
Historical Case Study #1: When Nursing Care and More
Complex and Adequate Training and Supervision Are Absent
ENVIRONMENT AND HISTORY
This case took place in a small rural community of 8000 people.
Mr. Kenny Salamino was a developmentally and physically
disabled 32-year-old man. He had lived most of his life in a
group home with seven other residents and was cared for by a
staff of two unlicensed assistive personnel (UAP) 24 hours a
day.
Ms. Marsha Mitchell, a licensed practical nurse whose title was
“Medical Director,” had worked at the group home Monday
through Friday, 8 am to 5 pm, for 7 years. Ms. Rose Sinclair, a
registered nurse, served as “Consultant.” Nurse Sinclair was
employed to “be a resource” and provide a course entitled
“Assistance With Medications Course for Unlicensed Assistive

15. Personnel.” The owner of the facility, Mr. Brian Adams, did not
live at or maintain an office at the facility. He hired the staff
and expected the registered nurse and the licensed practical
nurse to manage the resident care.
The state board of nursing in which the facility was located
received a complaint from the Department of Health and
Welfare. Mr. Salamino had died after admission to the hospital,
and the state's surveyors from the Bureau of Facility Standards
had investigated the circumstances of his death. Over a period
of 6 months, Mr. Salamino had lost 40 pounds during which
time the nurses had not assessed his health care needs or
provided for adequate medical or nursing interventions. The
bureau's investigation determined that the events that led to Mr.
Salamino's death were due to lack of fiduciary responsibility of
Practical Nurse Mitchell and Nurse Sinclair who, the report
asserted, should be held accountable for Mr. Salamino's death.
THE NURSES' STORY
I have been a registered nurse for 10 years. I worked full time
in a small hospital in a nearby town for 9 years as the
supervising registered nurse. When I decided to work part-time,
I chose to drop back and work in a less restricted environment
than the hospital. The administrator of the group home hired me
as the “Registered Nurse Consultant,” and my responsibilities
included teaching to new unlicensed assistive personnel a
course entitled “Assistance With Medications Course” and
providing to the licensed practical nurse 24/7 support face to
face or by cellular phone.
My contract specified that I was to be paid for 24 hours of work
every 3 months. I did not receive an orientation to residential
care/group home, federal, and/or state regulations.
The first indication I had that Mr. Salamino was having a
problem was when Practical Nurse Mitchell called me and said
that Mr. Salamino had just returned from the hospital with a
new jejunostomy tube (J-tube). She said that she thought Mr.
Salamino should have been discharged to a skilled nursing
facility, but his physician, Dr. Fred Stark, sent him back to the

16. group home because he thought Mr. Salamino would receive
better care there. Dr. Stark worked with Practical Nurse
Mitchell and the patients in the group home. They knew and
loved Mr. Salamino.
I asked Practical Nurse Mitchell if she could handle the J-tube.
She said she could, and thus I did not go to the group home to
assess Mr. Salamino or to confirm Practical Nurse Mitchell's
competency. I did not believe this was part of my job.
THE LICENSED PRACTICAL NURSE'S PERSPECTIVE
I could tell Mr. Salamino was losing weight over several
months. I didn't become concerned at first because he continued
to feed himself and didn't appear to be hungry. After several
months, I called his doctor and he told me to bring Mr.
Salamino in for a checkup. Dr. Stark was concerned about Mr.
Salamino's weight loss and ran some tests. He had something
wrong with his digestive tract and wasn't absorbing his food.
Dr. Stark arranged for a consult with a surgeon and that's when
they decided to insert a stomach tube. Mr. Salamino was in the
hospital for 2 days and was then transferred back to the group
home. He was able to swallow and drink liquids. He didn't have
a pump for his feedings when he arrived, so I called and ordered
the pump and the liquid feeding solution that Dr. Stark had
ordered. I didn't worry too much about the fact it took 4 days to
start the feedings because Mr. Salamino continued to drink
liquids.
When the pump and feeding solution arrived, I hooked it up but
couldn't get the pump to run. I called Dr. Stark who arranged
for me to take Mr. Salamino to the emergency room and meet
the surgeon, Dr. Hari Harimoto. Dr. Harimoto discovered that
something was wrong at the insertion site on his stomach. He
repaired the insertion site and sent Mr. Salamino back to the
group home. The aides and I gave Mr. Salamino his feedings as
Dr. Harimoto ordered, but he developed a fever, was readmitted
to the hospital about 2 weeks later, and died the same day.
When I looked back on the events that took place, I felt I was
left to do everything myself. I wished Nurse Sinclair would

17. have been more involved in what was going on, but she said she
was not hired to see the residents. I know we gave Mr. Salamino
better care than he would have gotten at the nursing home. They
have too many patients and not enough nurses.
THE ADMINISTRATOR'S PERSPECTIVE
I have owned this facility for 15 years and never had a problem
until this happened. Practical Nurse Mitchell is a good licensed
practical nurse and handles things perfectly fine. I don't see any
reason to have to pay a registered nurse to do what Practical
Nurse Mitchell, a licensed practical nurse, can do on her own. I
didn't see any reason to orient the registered nurse or licensed
practical nurse to residential care/group home regulations. They
are supposed to take care of the residents.
CASE ANALYSIS
This case demonstrates the classic example of the common
expectation that residential/group home care does not require
the level of nursing skill and attentiveness that is required in a
hospital or skilled nursing facility. This expectation persists
despite the fact that residents change in their care needs, and
the home may not be able to keep up with the technical care
demands of these changes. This owner-established care
supervision plan was inadequate given the nature of the changes
in the care the patient required. Several actions were inadequate
in this series of events regarding the decisions that affected the
patient's well-being. The practice breakdown elements included
the following:
1The administrator of the group home did not provide
orientation for the registered nurse immediately after her
arrival. Consequently she was unaware that the State
Regulations for Residential Care Facilities required that a
registered nurse assesses patients on a regular basis to identify
any health care needs that may be developing and to refer the
patient for medical care as needed. It was only when the patient
died that the state surveyed the facility and discovered the lack
of supervision of a registered nurse.

18. 2The administrator failed to provide adequate resources for
the registered nurse and licensed practical nurse in their
respective roles. The registered nurse was only paid for 24
hours of work in a 3-month period. She understood that her role
was to provide the course “Assistance With Medications
Course” for newly hired unlicensed assistive personnel, but this
responsibility alone took more than the 24 hours for which she
was paid. She did not understand that she was in a role that
required her participation and direction for the care of the
patients in the facility. She did not recognize her role as a
“registered nurse consultant” to be “anything more than a
registered nurse available on the cellular phone 24 hours per
day.” She was not expected by administration to assume
responsibility for assessment of the patients and/or to
collaborate with the licensed practical nurse and physician.
3Practical Nurse Mitchell had the title “Medical Director,”
which led her to believe that she was to make all decisions
related to patient care. The licensed practical nurse was
reluctant to call the registered nurse when she had concerns.
She did contact the physician, but she did not identify the
patient's health issues until the patient required hospitalization.
The health care system in which the licensed practical nurse and
registered nurse practiced did not design, mandate, or pay for
the support and guidance that a registered nurse should have
provided.
4After the first hospitalization, the patient's physician
discharged his patient to the group home. The physician
believed that the patient would receive better care in his
“home,” where the staff was familiar with him, rather than refer
him to a skilled nursing facility that could provide the skilled
care he required. However, this group home was not adequately
prepared to provide the skilled nursing care he needed.
The licensed practical nurse did not doubt her ability to
administer medications by common routes and to provide care
to two or more patients. But the evidence in this case did not

19. address the competencies required for tube feeding and
recognizing malnutrition. Further, the licensed practical nurse
was slow to contact the physician regarding the patient's
emerging physical changes, which could have been due to either
a reluctance to call the physician and/or her lack of assessment
or awareness of the dangerous level of weight loss and
malnourishment.
Both nurses in this case were not aware that their individual
levels of nursing education applied in this setting. The
descriptions of their positions defined the relationship between
the registered nurse and the licensed practical nurse. The
licensed practical nurse was “in charge,” and the registered
nurse was hired as a figurehead to meet the administrator's
interpretation of the requirements for licensure of a group
facility. These institutional policies established the scenario
that eventually resulted in a patient's death. The licensed
practical nurse assumed responsibility for all patient care but
did not have the skills or support from the registered nurse to
identify the patient's initial life-threatening weight loss, and
later the need for timely initiation of his tube feedings. She
continued to deal with the situation alone rather than contact
and consult with the registered nurse and physician to determine
the actions needed. Because the registered nurse had never
worked in residential care before and was unaware of the
federal and state requirements for residential care, she assumed
that the duties as written in her position description were
appropriate. Based on these duties, she did not assume a
supervisory or active collaborative role to support the licensed
practical nurse. The registered nurse and the licensed practical
nurse did not question the scope of the duties in descriptions of
their respective positions, nor did they look to the Nurse
Practice Act and Administrative Rules to identify the roles their
state board required for each respective nursing license or
question their “positions” at the time they were hired. The
registered nurse was content to have minimal collaborative
responsibility and limited hours. The licensed practical nurse

20. did not recognize that she lacked sufficient knowledge and
training to provide the more skilled nursing care involved in
tube feeding a patient through a jejunostomy. Further, the
licensed practical nurse was flattered by her title and did not
question the fact that she was not appropriately educated and
competent to manage and provide adequate nursing care without
support.