Opinion
CIVIL NO. 19-1850 (PAD)
2022-03-31
Alba I. CINTRÓN, et al., Plaintiffs, v. HOSPITAL COMUNITARIO EL BUEN SAMARITANO, INC., et al., Defendants.
Glenda Labadie, San Juan, PR, Paul Rodriguez-Velez, PRV Law Office, Guaynabo, PR, for Plaintiffs. Carlo Giuseppe Agrelot-Aponte, De Corral & De Mier, LLP, Jeanette Rodriguez-De Leon, Calderon & Arroyo Law Offices, Michelle Pirallo-DI Cristina, Pirallo-Di Cristina Law Offices, Nanette Alomar-Camacho, Quinones Tridas Law Office, PSC, San Juan, PR, for Defendant Hospital Comunitario El Buen Samaritano, Inc. Marta E. Vila-Baez, Sanchez-Betances, Sifre & Munoz-Noya Law Offices, PSC, San Juan, PR, for Defendant Professional Hospital Guaynabo, Inc. Luis F. Montijo, Brenda L. Santana-Dieppa, Montijo & Montijo Law Office, San Juan, PR, for Defendant Southwest Emergency, Corp. Eugene F. Hestres-Velez, Bird, Bird & Hestres, Old San Juan, PR, for Defendant Puerto Rico Medical Defense Insurance Corp.
Glenda Labadie, San Juan, PR, Paul Rodriguez-Velez, PRV Law Office, Guaynabo, PR, for Plaintiffs.
Carlo Giuseppe Agrelot-Aponte, De Corral & De Mier, LLP, Jeanette Rodriguez-De Leon, Calderon & Arroyo Law Offices, Michelle Pirallo-DI Cristina, Pirallo-Di Cristina Law Offices, Nanette Alomar-Camacho, Quinones Tridas Law Office, PSC, San Juan, PR, for Defendant Hospital Comunitario El Buen Samaritano, Inc.
Marta E. Vila-Baez, Sanchez-Betances, Sifre & Munoz-Noya Law Offices, PSC, San Juan, PR, for Defendant Professional Hospital Guaynabo, Inc.
Luis F. Montijo, Brenda L. Santana-Dieppa, Montijo & Montijo Law Office, San Juan, PR, for Defendant Southwest Emergency, Corp.
Eugene F. Hestres-Velez, Bird, Bird & Hestres, Old San Juan, PR, for Defendant Puerto Rico Medical Defense Insurance Corp.
OPINION AND ORDER
Delgado-Hernández, District Judge. Before the court are plaintiffs’ "Motion for Partial Summary Judgment as to EMTALA Claims Against Hospital Buen Samaritano" (Docket No. 179) and "Motion for Partial Summary Judgment as to EMTALA Claims Against Professional Hospital Guaynabo" (Docket No. 181), Hospital Comunitario Buen Samaritano, Inc.’s "Motion Requesting Summary Judgment" (Docket No. 177), and Professional Hospital Guaynabo, Inc.’s "Motion for Partial Summary Judgment" (Docket No. 184). For the reasons explained below, the motions are denied.
I. BACKGROUND
On September 10, 2019, plaintiffs, the widow and daughters of the deceased, Ramón L. Nieves-Guzmán, initiated this action against Hospital Comunitario Buen Samaritano, Inc. ("HCBS") and Professional Hospital Guaynabo, Inc. ("PHG") for alleged failure to screen and stabilize, and appropriately transfer of an unstable patient, under the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. § 1395dd, as well as medical malpractice under articles 1802 and 1803 of Puerto Rico Civil Code, P.R. Laws Ann. tit 31 §§ 5141 - 5142 (Docket No. 1). On October 3, 2019, plaintiffs amended their complaint (Docket No. 10 88), and on August 5, 2020, filed a second amended complaint (Docket No. 88).
The second amended complaint included medical malpractice claims under Puerto Rico law against Southwest Emergency Corp. ("SEC"), which operated HCBS's emergency room at the time of the events leading to this action, and SEC's insurer, Puerto Rico Medical Defense Insurance Company (Docket No. 88).
Following discovery, plaintiffs and HCBS and PHG filed cross-motions for summary judgment as to the alleged EMTALA violations. Plaintiffs contend that the uncontested facts show that they are entitled to summary judgment holding HCBS and PHG liable for EMTALA violations. In turn, HCBS and PHG contend that (1) the EMTALA claims, which give rise to federal jurisdiction in this case, should be dismissed with prejudice, and (2) the remaining, supplemental state claims should be dismissed without prejudice. Plaintiffs opposed HCBS's and PHG's motions (Docket Nos. 191 and 193), and HCBS and PHG opposed plaintiffs’ motions (Docket Nos. 190 and 194).
Except otherwise noted, the facts included in this section are drawn from the well-pleaded facts asserted in the second amended complaint (Docket No. 88) and the parties’ Local Rule 56 submissions (Docket Nos. 177-2; 179-1; 180; 181-1; 190-1; 191, pp. 2-9; 193, p. 2; and 194-1). Local Rule 56 is designed to "relieve the district court of any responsibility to ferret through the record to discern whether any material fact is genuinely in dispute." CMI Capital Market Inv. v. González-Toro, 520 F.3d 58, 62 (1st Cir. 2008). It requires a party moving for summary judgment to accompany its motion with a brief statement of facts, set forth in numbered paragraphs and supported by specific citations to the record, that the movant contends are uncontested and material. Local Rule 56(b) and (e). The opposing party must submit with its opposition a separate, short, and concise statement of material facts admitting, denying or qualifying, with record support, and paragraph by paragraph, the facts supporting the motion for summary judgment. Id. 56(c) and (e). While the district court may "forgive" a violation of Local Rule 56, litigants who ignore the rule do so "at their peril." Mariani-Colón v. Dep't of Homeland Sec. ex rel. Chertoff, 511 F.3d 216, 219 (1st Cir. 2007). The court has reviewed every factual statement and counterstatement that the parties submitted, and it has included in this Opinion and Order only those facts that are material to the case and that were submitted in statements that comport with summary judgment principles.
A. Mr. Nieves's Visit to HCBS on November 22, 2018
Ramón L. Nieves Guzmán ("Mr. Nieves"), 77 years old at the time of the events averred in the second amended complaint, lived in Luquillo, Puerto Rico, with his wife, Alba I. Cintrón ("Ms. Cintrón") and their two daughters, Vivianna and Michelle. See, Plaintiffs’ "Statement of Uncontested Material Facts for Motion for Partial Summary Judgment as to EMTALA Claims Filed Against Hospital Buen Smaritano" ("PSUMF HCBS") (Docket No. 179-1) ¶¶ 4-5; "Opposition to Statement of Facts Submitted by Plaintiffs in support of Motion for Partial Summary Judgment" ("HCBS OSUMF") (Docket No. 190-1) ¶¶ 4-5.
On November 22, 2018, Mr. Nieves, Ms. Cintrón and Vivianna drove to Aguadilla, to take a flight to Orlando, Florida. See, PSUMF HCBS ¶ 8; HCBS OSUMF ¶ 8. Upon arriving to the airport, Mr. Nieves felt pain in his left leg. See, PSUMF HCBS ¶ 9; HCBS OSUMF ¶ 9. Mr. Nieves, Ms. Cintrón and Vivianna decided to cancel their flight. See, PSUMF HCBS ¶ 10; HCBS OSUMF ¶ 10. Instead, they went to HCBS, where they arrived at some time between 3:00am and 4:00am. See, PSUMF HCBS ¶¶ 10-11; HCBS OSUMF ¶¶ 10-11.
HCBS is a general hospital in Aguadilla and a "covered entity," as that term is defined in EMTALA. See, PSUMF HCBS ¶¶ 1-2; HCBS OSUMF ¶¶ 1-2.
At HCBS, Ms. Cintrón handed Mr. Nieves's private insurance card and his card from Veterans Hospital to a hospital clerk. See, PSUMF HCBS ¶ 13; HCBS OSUMF ¶ 13. HCBS admits the statement propounded by plaintiffs, but argues that the statement is misleading as an artifice to impute that HCBS was or should have been aware that Mr. Nieves was a veteran. See, HCBS OSUMF ¶ 13. However, HCBS's arguments, and the materials cited by HCBS, do not respond to or refute plaintiffs’ statement, that is, that Ms. Cintrón handed Mr. Nieves's medical cards to a hospital clerk. Therefore, the fact is deemed admitted. See, Fed.R.Civ.P. 56(c) and (e)(2) ; Local Rule 56(e).
At 4:05 a.m., Mr. Nieves was triaged by a HCBS nurse, who noted that his chief complaint was "pain and loss of motion in the left leg" and "weakness." See, HCBS's "Statement of Uncontested Material Facts" ("HCBS SUMF") (Docket No. 177-2) ¶ 4; Plaintiffs’ "Opposition to Motion for Partial Summary Judgment Filed by Hospital el Buen Samaritano" ("POSUMF HCBS") (Docket No. 191, pp. 2-9) ¶ 1. The nurse also took Mr. Nieves's vital signs and noted that Mr. Nieves had prior heart surgery. See, HCBS SUMF ¶ 6; POSUMF HCBS ¶ 1.
At 4:14 a.m., emergency room physician Dr. Norberto García Carrero ("Dr. García"), examined Mr. Nieves. See, HCBS SUMF ¶ 7; POSUMF HCBS ¶ 1. Dr. García observed that Mr. Nieves complained of pain and coldness in his left leg and noted his medical history, which included hypertension, chronic kidney disease, ischemic heart disease, peripheral vascular disease, as well as prior heart stent placement surgery. See, HCBS SUMF ¶ 8; POSUMF HCBS ¶ 1. Dr. García then physically examined Mr. Nieves, who showed symptoms of calf pain when walking, claudication, swelling in his extremities, leg cramps, blood clots, tachycardia, and obesity, among others. See, PSUMF HCBS ¶¶ 18-19; HCBS OSUMF ¶¶ 18-19; HCBS SUMF ¶ 10; POSUMF HCBS ¶ 1. Dr. García's initial diagnostic impression was a deep vein thrombosis ("DVT"). See, HCBS SUMF ¶ 15; POSUMF HCBS ¶ 1.
At 4:24 a.m., Dr. García ordered a round of tests, including a "CBC, BMP, D Dimer Quantitative, PT, Sed Rate Automated RBC, PTT, CRP, Arterial Duplex (Lower Extremity), Venous Duplex Uni. (Lower Extremity)" and the administration of a 4mg/ml injection of morphine, 80mg/0.8ml injection of enoxaparin (or, "Lovenox"), and 900mg/0.8ml of clindamycin (or, "Cleocin"), intravenously. See, HCBS SUMF ¶ 12. Nursing personnel received and executed Dr. García's orders. See, HCBS SUMF ¶ 15; POSUMF HCBS ¶ 1.
In POSUMF HCBS ¶ 3, plaintiffs deny HCBS's statement of fact, alleging that it is unsupported by the medical record and that Dr. García signed the order at 4:14 p.m. on November 25, 2018, instead of 4:24 a.m. on November 22, 2018. However, plaintiffs’ latter contention is a straw man, given that HCBS did not state that Dr. García signed the order at 4:24 a.m. More importantly, HCBS's statement is supported by the record, and the evidence referred to by plaintiffs does not dispute it. HCBS's statement is deemed admitted.
Plaintiffs’ expert concedes that "Lovenox" is administered to decrease the risk of developing DVT and that "Cleocin" is an antibiotic. See, HCBS SUMF ¶¶ 13-14; POSUMF HCBS ¶ 1.
The lower extremity venous and arterial duplex studies were performed at around 8:00 a.m. See, PSUMF HCBS ¶¶ 20-21; HCBS OSUMF ¶¶ 20-21. Later that morning, Dr. José J. Ocasio Meléndez ("Dr. Ocasio") took over Mr. Nieves's care. See, PSUMF HCBS ¶¶ 26-27; HCBS OSUMF ¶¶ 26-27. When Dr. Ocasio received Mr. Nieves as a patient, he was aware that he had been diagnosed with a vascular occlusion that needed to be transferred for vascular surgery evaluation. See, Docket No. 179-8, p. 170. Dr. Ocasio ordered the administration of 25mg of "Aldactone" (daily), 50mg of "Metoprolol" (daily); 100mg/400mg of "Gabapentin" (daily), 20mg of "Lasix" tablets (daily), 40mg of "Pepcid" (daily), and 5mg of "Norvasc" (daily). Nursing staff received and executed Dr. Ocasio's orders. See, HCBS SUMF ¶ 18; POSUMF HCBS ¶ 1.
At around midday, Dr. Ocasio examined Mr. Nieves and concluded that he had an arterial obstruction and DVT in his left leg. See, PSUMF HCBS ¶¶ 31-32; HCBS OSUMF ¶¶ 31-32; HCBS SUMF ¶ 28; POSUMF HCBS ¶ 1. In Dr. Ocasio's view, Mr. Nieves's condition required the immediate attention and expertise of a vascular surgeon, which HCBS did not carry in their roster of physicians. See, HCBS SUMF ¶¶ 22, 27; POSUMF HCBS ¶ 1; Docket No. 179-8, pp. 9-10; 19; 24. Accordingly, Dr. Ocasio called multiple hospitals, including Manatí Medical Center, Centro Médico de Río Piedras, Cardiovascular Hospital in Centro Médico de Río Piedras, Hospital San Lucas, with the aim of transferring Mr. Nieves to an institution that had a vascular surgeon. See, HCBS SUMF ¶ 19; POSUMF HCBS ¶ 1; Docket No. 179-8, pp. 9-10; 19; 24. Dr. Ocasio noted in Mr. Nieves's medical record that Dr. Suárez accepted Mr. Nieves's case in PHG, but that the transfer had to wait until November 25, 2018, to be completed. See, HCBS SUMF ¶ 25; POSUMF HCBS ¶ 1. In the meantime, Dr. Ocasio placed a consult for an internal medicine physician at HCBS, Dr. Mario Román ("Dr. Román"), for a recommendation on how to treat Mr. Nieves, but the consult was never answered. See, HCBS SUMF ¶¶ 20-21; POSUMF HCBS ¶ 1.
Plaintiffs’ expert agrees that the diagnosis of arterial obstruction and DVT in the left leg was correct. See, HCBS SUMF ¶ 29; POSUMF re: HCBS ¶ 1.
PHG is a general hospital in Guaynabo, Puerto Rico, and a covered entity under EMTALA. See, Docket Nos. 88, ¶¶ 13-14; 123, ¶¶ 13-14.
According to the medical record, at 8:11 p.m., another physician, Dr. Wilfredo Girona Rivera ("Dr. Girona"), examined Mr. Nieves and wrote that his condition had "not improved" and that he was "restless but [s]table." See, HCBS SUMF ¶ 33; POSUMF HCBS ¶ 11; Docket No. 177-3, pp. 19-20. Dr. Girona's notes also indicate that Mr. Nieves's case had been presented to PHG and "accepted by Dr. Román to be transferred on Sunday AM." See, Docket No. 177-3, p. 19. The medical record also shows that other medications were ordered and that the patient was relocated to the intermediate care area in HCBS. Id.
Dr. Román was on call and physically present in HCBS at the time Dr. Ocasio placed the consult (his shift commenced at 8:00 a.m. on November 22 and ended at 8:00 a.m. on November 23, 2018). On November 22, Dr. Román examined two other patients in HCBS's emergency room, but did not examine Mr. Nieves. See, generally, PSUMF HCBS ¶¶ 49-63; HCBS OSUMF ¶¶ 49-63. HCBS admits most of the foregoing statements of fact but qualifies others with irrelevant or argumentative counterstatements unsupported by the record. Because plaintiffs’ statements are supported by the record (Dr. Román's deposition testimony), they are deemed admitted.
In plaintiffs’ OSUMF HCBS ¶ 11, they admit in part and deny in part HCBS SUMF ¶ 33 but fail to refer to any evidence to contradict the statement of fact. Because the statement is supported by the record, it is deemed admitted.
B. Mr. Nieves's Condition on November 23 and 24, 2018
The parties largely dispute what happened on these dates. The record supports the view that the medical staff was monitoring Mr. Nieves's condition. For example, on the morning of November 23, nursing personnel discovered that Mr. Nieves's vital signs were abnormal, took measures to address the situation, and consulted with at least Dr. Girona on one occasion. See, HCBS SUMF ¶¶ 36-37; POSUMF HCBS ¶¶ 1, 14. During the late afternoon, nursing personnel again discovered that the patient's vitals were abnormal. See, HCBS SUMF ¶¶ 36-37; POSUMF HCBS ¶¶ 15. Then, on November 24, nurses noted that Mr. Nieves's vitals were again abnormal and notified Dr. García less than an hour thereafter. See, HCBS SUMF ¶ 39; POSUMF HCBS ¶¶ 16. Then, at 1:00 p.m., nurses received complaints from Mr. Nieves that he was in pain, notified Dr. García about the situation, and Dr. García ordered the administration of medications. See, HCBS SUMF ¶ 40; POSUMF HCBS ¶ 1.
Notwithstanding these efforts, Mr. Nieves's condition did not seem to improve. From November 23 to 24, Mr. Nieves's urinary function became impaired, he became disoriented and weak, with bodily rigidity and limited mobility, had an undetectable or altered pulse, and his left leg developed hematomas, blood blisters, and necrosis. See, PSUMF HCBS ¶¶ 76-84; HCBS OSUMF ¶¶ 76.
C. Transfer on the Morning of November 25, 2018
HCBS contends that Mr. Nieves was transferred at 9:45 a.m., with a final diagnosis of arterial obstruction and chronic DVT of the left leg, and that, "according to the medical evaluation performed at said time, [he] was found to be with no pain and blood pressure within normal parameters," with a blood pressure of 153/79, pulse of 179, respiratory rate of 20, and body temperature of 36.1 degrees. See, HCBS SUMF ¶¶ 42, 44. HCBS relies on the Consent to Transfer Patient Form ("Consent Form") (see, Docket No. 177-4, pp. 34-35) to support these contentions. Moreover, HCBS claims the Consent Form shows that radiological images, a medical summary, electrocardiogram results and other documents were provided by HCBS to the paramedics for Mr. Nieves's transfer to PHG. See, HCBS SUMF ¶ 45.
Although plaintiffs concede that Mr. Nieves was transferred at around mid-morning on November 25, they claim that the transfer was improper and the circumstances around the transfer dubious. To this end, plaintiffs state that the medical record does not show that Mr. Nieves was evaluated at the time of his transfer. See, POSUMF HCBS ¶ 18. Moreover, they dispute the truth of the contents of the Consent Form because: 1) it was dated November 22 (the day Mr. Nieves arrived in HCBS's emergency room) instead of November 25 (the date of transfer to PHG); 2) it does not state that either Dr. Ocasio or Dr. García examined Mr. Nieves at the time of transfer; 3) it is contradicted by the 9:10 a.m. time annotated by the paramedics in a Service Incident Sheet they prepared; 4) although Dr. Ocasio signed the Consent Form, the Service Incident Sheet states that it was Dr. García, not Dr. Ocasio, who referred Mr. Nieves; 5) Dr. Ocasio's shift on November 25 had long been over by 9:45 a.m.; and 6) the vital signs written in each document were incongruent. See, POSUMF HCBS ¶¶ 18-19.
See, Docket No. 177-4, pp. 34-35.
Id.
Compare, Docket No. 177-4, pp. 34-35, with, Docket No. 179-13.
Id.
On this point, plaintiffs’ concern is that the Consent Form appears to have been signed by Dr. Ocasio at 9:45 a.m. on November 25, 2018. See, Docket No. 177-4, pp. 34-35. But, it is undisputed that Dr. Ocasio's shift had ended by that time. See, PSUMF HCBS ¶ 85; HCBS OSUMF ¶ 85.
See, note 13, supra.
Nevertheless, there is no contention that, around mid-morning on November 25, 2018, paramedics picked up Mr. Nieves from HCBS's emergency room to be transferred in their ambulance to PHG. Upon receiving Mr. Nieves, the paramedics observed that his left leg was necrotic from the area below the knee down to the foot. Dr. García signed the Service Incident Sheet as the HCBS doctor who referred the transfer to PHG. See, generally, PSUMF HCBS ¶¶ 93-97; HCBS OSUMF ¶ 93-97.
D. Arrival to PHG
What transpired in PHG is also contested to an extent. To illustrate, there is conflicting testimony from the PHG physician, Dr. Jorge C. Suárez Colón ("Dr. Suárez") and one of the paramedics that transported Mr. Nieves, as to whether Mr. Nieves was physically brought inside PHG's emergency room. See, PSUMF PHG ¶¶ 11-12, 18; OSUMF PHG ¶¶ 11-12, 18. On this point, Dr. Suárez recalled during his deposition that the hospital clerk informed him that Mr. Nieves was in the hospital's receiving area, but there is no evidence that confirms whether the receiving area was within the emergency room. See, PSUMF PHG ¶ 18; OSUMF PHG ¶ 18; Docket Nos. 181-4, p. 3; 181-7, pp. 90-92. Notably, Dr. Suárez stated that, contrary to Dr. Ocasio's assertions, he never accepted the transfer of Mr. Nieves to PHG. See, PSUMF PHG ¶ 12; OSUMF PHG ¶ 12.
Even so, the record is clear insofar as Dr. Suárez spoke briefly with Mr. Nieves to ask him if he knew where he was, what happened to him and if he knew his condition, to which Mr. Nieves responded that he had been in Aguadilla for several days because of a problem with the circulation in his leg, and that he was taken to another hospital to treat it. See, PSUMF PHG ¶¶ 19-22; OSUMF PHG ¶¶ 19-22. Still, Dr. Suárez did not ask Mr. Nieves about his preexisting medical conditions and did not take his vital signs, pulse, respiratory rate, heart rate or temperature. See, PSUMF PHG ¶¶ 22-27; OSUMF PHG ¶¶ 22-27. Neither did Dr. Suárez conduct a physical examination of Mr. Nieves, palpate his extremities or ask him to move them, or inquire if he was in pain. See, PSUMF PHG ¶¶ 28-31; OSUMF PHG ¶¶ 28-31. Further, Dr. Suárez did not order any medical tests or open a medical record for Mr. Nieves. See, PSUMF PHG ¶¶ 33-34; OSUMF PHG ¶¶ 33-34. In all, Mr. Nieves was never admitted to PHG's emergency room. See, PSUMF PHG ¶ 36; OSUMF PHG ¶ 36.
It is undisputed, though, that, Dr. Suárez observed a discoloration, edema, and swelling in Mr. Nieves's leg and read the documentation provided by the paramedics, indicating that Mr. Nieves was afflicted by an arterial occlusion of the leg, and concluded that Mr. Nieves required consultation with a vascular surgeon. See, PSUMF PHG ¶¶ 37, 39; OSUMF PHG ¶¶ 37, 39; Docket No. 181-7, p. 23. Later, Dr. Suárez called and spoke with a vascular surgeon from PHG, Dr. Leonardo Valentín ("Dr. Valentín"), who informed that neither he nor the other PHG vascular surgeons were available until the following week, and that they did not accept Mr. Nieves as a patient. See, PSUMF PHG ¶ 40; OSUMF PHG ¶ 40.
See also, PHG's "Statement of Uncontested Material Facts ("PHG SUMF") (Docket No. 180) ¶¶ 6-8, and plaintiffs’ "Opposition to Motion for Partial Summary Judgment Filed by PHG Hospital Guaynabo (Docket No. 193, p. 2) ("POSUMF PHG") ¶¶ 6-8. Here, plaintiffs object that Dr. Suárez's testimony, on which PHG's statements are based, is inadmissible hearsay because it relates to "statements allegedly made over the phone" to Dr. Suárez by Dr. Valentín regarding the latter's and the other vascular surgeons’ availability to receive Mr. Nieves as a patient until the week thereafter. While PHG's statements may be based on hearsay, plaintiffs have not proved that such information cannot be presented in an admissible form at trial. An objection as to the admissibility of evidence must "not [be] that the material ‘has not’ been submitted in admissible form, but that it ‘cannot’ be." S.E.C. v. Ramírez, 2018 WL 2021464, at *6 (D.P.R. Apr. 30, 2018) (internal citations omitted); Parker Waichman LLP v. Salas LC, 320 F.Supp.3d 327, 332 (D.P.R. 2018) (similar). Dr. Valentín could be called as a witness at trial in order to testify about the call with Dr. Suárez and be crossed examined by plaintiffs. As such, a district court "may consider hearsay evidence submitted in an inadmissible form at the summary judgment stage where the content of the evidence proffered could later be provided in an admissible form at trial." Ramírez, 2018 WL 2021464, at *6 (citations omitted). Accordingly, the statement is deemed admitted.
After this conversation, Dr. Suárez called HCBS and spoke with the emergency physician that was on call. Dr. Suárez explained that he had a patient that was transferred by HCBS, Mr. Nieves, that PHG did not have vascular services available, and that the case had not been accepted at PHG. In response, the HCBS physician instructed Dr. Suárez to send Mr. Nieves back to HCBS and told Dr. Suárez that HCBS would try to transfer Mr. Nieves to another institution that has a vascular surgeon. Dr. Suárez then told the paramedics that they had to return Mr. Nieves to HCBS. See, generally, PSUMF PHG ¶¶ 46-49; OSUMF PHG ¶¶ 46-49; Docket No. 181-1, pp. 112-116.
Dr. Suárez testified that he did not call other hospitals to try to find Mr. Nieves other vascular doctors, because he was not accepted as a patient in PHG. See, SUMF PHG ¶ 44; OSUMF PHG ¶ 44; Docket No. 181-7, pp. 114-115. In its OSUMF, PHG "qualifies" plaintiffs’ statement but fails to respond with its own counterstatement of facts. Instead, PHG simply responds "[q]ualified," followed by a citation to the record, without additional explanation. Accordingly, plaintiffs’ statement is deemed admitted.
1. PHG's General Emergency Room Practices
Dr. Luis Forti, PHG's emergency room director, testified that the procedure that PHG follows regarding patients who visit the emergency room is to have their vital signs checked. This is so even when patients from other hospitals are transferred to PHG's emergency room. Moreover, a medical record is opened for anyone who has requested medical services in the emergency room or who has been transferred from another hospital and arrives via ambulance. See, PSUMF PHG ¶¶ 61-64; OSUMF PHG ¶¶ 61-64. In the instant case, PHG's staff did not take Mr. Nieves's vital signs, did not open a medical record for him, and PHG has no record showing that he was ever at their facilities. See, PSUMF PHG ¶¶ 34, 53, 55; OSUMF PHG ¶¶ 34, 53, 55; Docket No. 181-11, pp. 1-6.
Again, PHG "qualifies" plaintiffs’ statements but either fails to respond with its own counterstatements of facts or includes argumentation that does not respond to or controvert the facts set forth by plaintiffs. Rather, PHG mostly responds with nonspecific qualifications and then proceeds to cite the record, with no further development. Thus, plaintiffs’ statements are deemed admitted.
E. Return to HCBS on November 25, 2018, and Transfer to Veterans Hospital
On November 25, 2018, about 30 to 40 minutes after arriving to PHG, paramedics began the journey of transporting Mr. Nieves back to HCBS in Aguadilla. Once back to HCBS, Dr. Jaime A. Soto Carril ("Dr. Soto") examined Mr. Nieves at around 3:46 p.m., observing that he had become septic. Dr. Soto noted that Mr. Nieves's left leg was ischemic, without a pulse or temperature, had blood blisters that were suppurating, and that his right leg was also presenting ischemic changes. See, generally, PSUMF HCBS ¶¶ 112-117; HCBS OSUMF ¶ 112-117. Dr. Soto also remarked that amputation could be required, and that Mr. Nieves showed a bad prognosis. See, HCBS SUMF ¶¶ 48-49; POSUMF HCBS ¶¶ 48-49.
At 5:16 p.m., Dr. Soto spoke with staff from Veterans Hospital, and at 6:35 p.m., that hospital accepted Mr. Nieves's transfer to their facility. At around 7:23 p.m., Mr. Nieves was transferred to and accepted in Veterans Hospital. See, generally, PSUMF HCBS ¶¶ 122-125; HCBS OSUMF ¶¶ 122-125. Yet, on November 27 and 28, 2018, both of Mr. Nieves's legs were amputated. And, on December 4, 2018, Mr. Nieves died while hospitalized at Veterans Hospital. See, generally, PSUMF HCBS ¶¶ 127-129; HCBS OSUMF ¶¶ 127-129.
III. SUMMARY JUDGMENT STANDARD
Summary judgment is appropriate when "the pleadings, depositions, answers to interrogatories and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(c). The party moving for summary judgment bears the initial responsibility of demonstrating the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). A factual dispute is "genuine" if it could be resolved in favor of either party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). It is "material" if it potentially affects the outcome of the case in light of applicable law. Calero-Cerezo v. U.S. Dep't of Justice, 355 F.3d 6, 19 (1st Cir. 2004).
As to issues on which the nonmovant has the burden of proof, the movant need do no more than aver absence of evidence to support the nonmoving party's case. Celotex Corp., 477 U.S. at 325, 106 S.Ct. 2548 ; Mottolo v. Fireman's Fund Insurance, 43 F.3d 723, 725 (1st Cir. 1995). All reasonable factual inferences must be drawn in favor of the party against whom summary judgment is sought. Shafmaster v. United States, 707 F.3d. 130, 135 (1st Cir. 2013).
IV. DISCUSSION
A. The Emergency Medical Treatment and Active Labor Act (EMTALA)
1. Generally
Congress enacted EMTALA in response to claims that hospital emergency rooms were refusing to accept or treat patients with emergency conditions but no medical insurance. See, H.R. Rep. No. 241, 99th Cong. 1st Sess. 27 (1985), 605. "EMTALA therefore ‘is a limited anti-dumping statute, not a federal malpractice statute.’ " Ramos-Cruz v. Centro Médico del Turabo, 642 F.3d 17, 18 (1st Cir. 2011) (citing Reynolds v. MaineGeneral Health, 218 F.3d 78, 83 (1st Cir. 2000) ).
The avowed purpose of EMTALA "was not to guarantee that all patients are properly diagnosed, or even to ensure that they receive adequate care, but instead to provide an ‘adequate first response to a medical crisis’ for all patients and ‘send a clear signal to the hospital community ... that all Americans, regardless of wealth or status, should know that a hospital will provide what services it can when they are truly in physical distress.’ " Reynolds, 218 F.3d at 83 (quoting Baber v. Hosp. Corp. of America, 977 F.2d 872, 880 (4th Cir. 1992) ) (emphasis added).
With this purpose in mind, EMTALA imposes duties on covered facilities to: (a) provide an "appropriate medical screening examination" for those who come to an emergency room seeking treatment, and (b) provide, in certain situations, "such further medical examination and such treatment as may be required to stabilize the medical condition." Álvarez-Torres v. Ryder Memorial Hosp., Inc., 582 F.3d 47, 51 (1st Cir. 2009) (citing 42 U.S.C. §§ 1395dd(a) and (b)(1)(A) ).
2. Prima Facie Case
To establish an EMTALA violation, a plaintiff must show that: (i) the hospital is a participating hospital, covered by EMTALA, that operates an emergency department (or an equivalent facility); (ii) the patient arrived at the hospital seeking treatment; and (3) the hospital either (a) did not afford the patient an appropriate screening in order to determine if she had an emergency medical condition, or (b) bade farewell to the patient (whether by turning her away, discharging her, or improvidently transferring her) without first stabilizing the emergency medical condition. See, Cruz-Vázquez v. Mennonite Gen. Hosp., 717 F.3d 63, 68-69 (1st Cir. 2013) (stating test) (citation omitted); Vázquez-Rivera v. Hosp. Episcopal San Lucas, Inc., 620 F.Supp.2d 264, 268 (D.P.R. 2009) ("A plaintiff can bring a cause of action under either the screening or stabilization provisions of EMTALA, or both")(citation omitted); López-Soto v. Hawayek, 175 F.3d 170, 177 (1st Cir. 1999) (noting that subsections (a) and (b) of EMTALA "operate disjunctively"). Whether an EMTALA violation has occurred "is essentially a fact-based reasonableness inquiry." Deberry v. Sherman Hosp. Ass'n, 741 F.Supp. 1302, 1305 (N.D. Ill. 1990).
3. EMTALA Claims Against HCBS
It is undisputed that HCBS is a participating hospital under EMTALA, and that Mr. Nieves went to HCBS seeking medical treatment. Notably, plaintiffs do not contend that Mr. Nieves was not adequately screened or that physicians from HCBS failed to discover that he had an emergency medical condition. Rather, plaintiffs’ contentions are that HCBS failed to stabilize Mr. Nieves and improperly transferred him to PHG in an unstable medical condition by failing, among other things, to secure PHG's acceptance of the patient prior to transfer. See, Docket Nos. 88, pp. 9-11; 179, pp. 12-24. Importantly, plaintiffs’ claims against HCBS are centered on the transfer to PHG, given that plaintiffs concede that the transfer to the Veterans Hospital complied with EMTALA. The court construes plaintiffs’ motion against HCBS accordingly.
See, HCBS SUMF ¶¶ 54, 58; POSUMF HCBS ¶ 1.
4. EMTALA Claims Against PHG
It is likewise undisputed that PHG is a hospital covered under EMTALA, and that Mr. Nieves arrived to PHG seeking medical treatment. Plaintiffs allege that PHG violated EMTALA by failing to: 1) accept Mr. Nieves's transfer; 2) screen him upon arrival to PHG; and 3) stabilize him before transferring him back to HCBS, all in violation of Sections 1395dd(a) and (b) (Docket No. 88, pp. 11-13). As to the first point, plaintiffs assert that PHG "refused to accept" Mr. Nieves's transfer, first on November 22, 2018, and then on November 25, 2018. Id. at p. 11. As to the second, they aver that PHG merely provided a "superficial eyeball examination" of Mr. Nieves, even though he was septic and his leg clearly necrotic and blistered, and, this way, failed to provide him a "proper medical screening" as required by EMTALA. Id. at p. 12. And, regarding the last point, they contend that on November 25, 2018, PHG had specialized surgeons available, and although hospital staff noticed that Mr. Nieves needed emergency vascular surgery, they still failed to provide him with any medical treatment and dispatched him back to HCBS without first stabilizing his condition. Id. at p. 13. Through the foregoing alleged acts, plaintiffs posit that PHG violated EMTALA's "reverse antidumping" provisions. Id. at pp. 11-12.
That said, plaintiffs do not develop their argument as to what constitutes a failure or refusal to "accept" a patient, whether hospitals such as PHG are required, pursuant to EMTALA, to "accept" patients in their emergency rooms, and whether PHG was required, but failed, to "accept" Mr. Nieves as an emergency room patient. Alto, plaintiffs do not elaborate as to exactly what constitutes "reverse antidumping," as alleged in the second amended complaint, explain why they believe that PHG incurred in such conduct, or provide any legal authorities to support their theory in this regard.
Furthermore, even though plaintiffs allege in the amended complaint that PHG failed to stabilize Mr. Nieves before transferring him back to HCBS, in their motion for summary judgment, they do not expound on PHG's violations in this sense. Rather, plaintiffs’ arguments focus on PHG's supposed failure to screen Mr. Nieves as the hospital would screen other similarly situated patients, and its noncompliance with the hospital's procedures. To make matters worse, albeit plaintiffs also claim in their motion that PHG improperly transferred Mr. Nieves back to HCBS in violation of Section 1395dd(c), the second amended complaint is devoid of any allegations against PHG in that regard.
Accordingly, the court disregards plaintiffs’ claims against PHG for its supposed failure to "accept" Mr. Nieves an emergency room patient and stabilize him, as well as for "reverse antidumping." See, Higgins v. New Balance Athletic Shoe, Inc., 194 F.3d 252, 260 (1st Cir. 1999) (noting that district courts are free to disregard arguments not adequately developed on summary judgment motion); U.S. v. Zannino, 895 F.2d 1, 17 (1st Cir. 1990) (holding that undeveloped arguments not supported by legal authorities are deemed waived or abandoned). So, I plaintiffs’ request for summary judgment, on grounds that PHG allegedly failed to transfer Mr. Nieves in accordance with Section 1395dd(c), must be denied. See, In re Díaz Cruz, 2013 WL 3153993, *6-7 (Bankr. D.P.R. June 19, 2013) (denying motion for summary judgment as to new claims brought for the first time at the summary judgment stage). Moving forward, the court evaluates plaintiffs’ motion against PHG solely as to the alleged screening violations.
B. Duty to Screen
Regarding a hospital's screening requirements under EMTALA, 42 U.S.C. § 1395dd(a) states:
In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists.
Id. As relevant herein, 42 U.S.C. § 1395dd(e)(1)(A) defines an "emergency medical condition" as:
[A] medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in (a) placing the health of the individual ... in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part ....
Id. (emphasis added). A hospital "fulfills its statutory duty to screen patients in its emergency room if it provides for a screening examination reasonably calculated to identify critical medical conditions that may be afflicting symptomatic patients and provides that level of screening uniformly to all those who present substantially similar complaints." Correa v. Hosp. San Francisco, 69 F.3d 1184, 1192 (1st Cir. 1995). In simpler terms, the essence of the screening requirement is "that there be some screening procedure, and that it be administered even-handedly." Id.
Here, there is not enough evidence to support a finding that PHG failed to screen Mr. Nieves as required by EMTALA, or that a screening was required considering the circumstances of the case. Although the record thus far indicates that Dr. Suárez did not ask Mr. Nieves about his preexisting medical conditions, take his vitals, conduct a physical examination, ask about his pain level, order studies, or start a medical record–all of which suggest that he failed to screen Mr. Nieves–said physician did, however, observe that Mr. Nieves's leg was discolored, swollen, and edematous. Moreover, Dr. Suárez reviewed the documents provided by the paramedics regarding Mr. Nieves's vascular occlusion and found that he needed to be examined by a vascular surgeon, essentially agreeing with HCBS's diagnosis and recommendations as to what and who was required to properly treat that condition (i.e., consultation with a vascular surgeon regarding possible surgery). In this sense, the court cannot determine at this stage whether any further screening was necessary or if doing so would have been superfluous. After all, a "hospital fulfills its statutory duty to screen patients in its emergency room if it provides for a screening examination reasonably calculated to identify critical medical conditions that may be afflicting symptomatic patients ," and here, it seems obvious that Dr. Suárez was well-aware of Mr. Nieves's particular vascular affliction. See, Correa, 69 F.3d at 1192 (1st Cir. 1995) (emphasis added). Plaintiffs’ expert agrees that Mr. Nieves was, in fact, suffering from such condition.
It remains to be seen whether PHG failed to provide a level of screening on par with other patients who presented substantially similar complaints or in compliance with the hospital's procedures. However, at this point, the court cannot say if it would have been necessary at all for PHG to strictly adhere to the standard procedures or screen Mr. Nieves as it would any other patient in like circumstances, given that it is apparent that Dr. Suárez quickly and correctly identified Mr. Nieves's vascular problem. Id.
As to Mr. Nieves's sepsis, the record so far is silent as to whether he was septic when he left HCBS to PHG. Rather, the available evidence shows that Mr. Nieves was septic upon his return to HCBS. And, while the evidence confirms that Dr. Suárez did not take Mr. Nieves's vital signs or open a medical record for him–which may have contravened PHG's standard policies–there is no evidence to indicate that Mr. Nieves was showing symptoms of sepsis when Dr. Suárez encountered him. This alone could exonerate PHG of liability as to screening. Id. (noting that screening objective is to "identify critical medical conditions that may be afflicting symptomatic patients") (emphasis added); Reynolds, 218 F.3d at 84 (declining to find liability against hospital for failing to screen patient for a specific medical condition when plaintiffs failed to proffer evidence that the patient showed symptoms of such condition). In the end, it will be up to the jury to decide whether PHG failed to screen Mr. Nieves as required by EMTALA.
C. Duty to Stabilize an Emergency Medical Condition
EMTALA guarantees patients, if a hospital determines that an emergency medical condition exists, the right "to have that condition stabilized before discharge or transfer to another hospital." Reynolds, 218 F.3d at 84 (emphasis added). Specifically, Section 1395dd(b)(1) provides, as relevant, that:
If any individual ... comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either–
(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.
42 U.S.C. § 1395dd(b)(1). However, "the duty to stabilize is only triggered when it has been determined that the patient is suffering from an emergency medical condition." Vázquez-Rivera, 620 F.Supp.2d at 269 ; 42 U.S.C. § 1395dd(b) ; (same). Consistent with EMTALA's statutory definition, "a patient will suffer from an emergency medical condition if he is in ‘imminent danger of death or serious disability.’ " Pagán-Pagán v. Hosp. San Pablo, Inc., 97 F.Supp.2d 199, 203 (D.P.R. 2000) (quoting Thornton v. Southwest Detroit Hosp., 895 F.2d 1131, 1134 (6th Cir. 1990) ). Thus, once a hospital receives a patient with an emergency medical condition and has actual knowledge of such condition, the hospital would be liable under EMTALA if it fails to "stabilize the condition prior to releasing the plaintiff." Pagán-Pagán, 97 F.Supp.2d at 203 (citing Deberry, 741 F.Supp. at 1305 ). The burden is on the plaintiffs to prove that the patient had an emergency medical condition and that the hospital had actual knowledge of it. See, Torres Otero v. Hosp. Gen. Menonita, 115 F.Supp.2d 253, 259 (D.P.R. 2000) (so recognizing).
Moreover, the stabilization requirement only applies to patients who, "suffering from an emergency medical condition, were transferred (or discharged) away from the treating hospital." Álvarez-Torres v. Ryder Mem'l Hosp., Inc., 576 F.Supp.2d 278, 284 (D.P.R. 2008), aff'd, 582 F.3d 47 (1st Cir. 2009) (citing Harry v. Marchant, 291 F.3d 767, 775 (11th Cir. 2002) (noting that "[t]here is no duty under EMTALA to provide stabilization treatment to a patient with an emergency medical condition who is not transferred"); Bryan v. Rectors & Visitors of the Univ. of Virginia, 95 F.3d 349, 352 (4th Cir. 1996) ("The stabilization requirement is thus defined entirely in connection with a possible transfer and without any reference to the patient's long-term care within the system"); Torres Otero, 115 F.Supp.2d at 260 ("the duty to stabilize exists not in a vacuum, but rather in reference to a transfer of the patient from the hospital")) (citations omitted). Importantly, the duty to stabilize under EMTALA "does not impose a standard of care prescribing how physicians must treat a critical patient's condition while he remains in the hospital , but merely prescribes a precondition the hospital must satisfy before it may undertake to transfer the patient." Fraticelli-Torres v. Hosp. Hermanos, 300 Fed.Appx. 1, 4 (1st Cir. 2008) (emphasis added). Thus, "[t]he relevant consideration as to the condition of stability of the patient under EMTALA is whether the treatment and discharge were reasonable in view of the circumstances that existed at the moment of the discharge " or transfer. See, Heirs of Medero v. Susoni, 281 F.Supp.2d 352, 361 (D.P.R. 2003) (citation omitted) (emphasis added), vacated on other grounds, Heirs of Medero v. Hosp. Dr. Susoni, Inc., 122 F.App'x 521 (1st Cir. 2004) (so noting).
Pursuant to EMTALA, "stabilize" means "to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability , that no material deterioration is likely to result from or occur during the transfer of the individual from a facility." 42 U.S.C. § 1395dd(e)(3)(A) (emphasis added). In turn, "transfer" means the movement of a patient outside of a hospital at the direction of a hospital employee. 42 U.S.C. § 1395dd(e)(4).
1. Emergency Medical Condition
Here, it cannot be reasonably disputed that HCBS was not aware that Mr. Nieves suffered an emergency medical condition within the meaning ascribed by EMTALA. When he arrived to HCBS's emergency room early in the morning of November 22, 2018, Dr. García noted that he had calf pain when walking, claudication or leg cramps, swelling in the extremities, and blood clots. When Dr. Ocasio received and took over Mr. Nieves's care later that morning, Dr. Ocasio already knew that the patient had been diagnosed a vascular occlusion that required further examination by a vascular surgeon. And, at around midday, Dr. Ocasio confirmed that Mr. Nieves had an arterial obstruction as well as DVT in his left leg.
Notably, Dr. Ocasio testified at deposition that he knows that DVT is a potentially life-threatening condition. More to the point, he stated that he is familiar with the symptoms of and knows how to diagnose DVT in patients, having seen more than ten cases of DVT during his time as an emergency room physician. See, Docket No. 179-8, pp. 4-5. He added that DVT, left untreated, could cause complications resulting in vascular congestion or occlusion, loss of musculature, necrosis, amputation, sepsis and fatal pulmonary embolism. PSUMF HCBS ¶ 34; Docket No. 179-8, at pp. 73-83.
In OSUMF HCBS ¶ 34, HCBS deny plaintiffs’ statement because HCBS disagrees with plaintiffs’ supposed characterization of the evidence. However, HCBS fails to bring forth any evidence that controverts the statement of fact. Regardless, the statement is supported by the record cited (Dr. Ocasio's deposition testimony), and therefore, the statement is deemed admitted.
Against this backdrop, it can be concluded without much difficulty that Mr. Nieves had acute and severe symptoms that required immediate medical attention, and if left untreated, his condition could worsen considerably. This is consistent with Dr. Ocasio's opinion that Mr. Nieves's condition required immediate attention by a vascular surgeon and is consistent with Dr. Ocasio's actions calling multiple hospitals in order to transfer Mr. Nieves to an institution with an on-call vascular surgeon. Therefore, in the court's view, HCBS knew of Mr. Nieves's emergency medical condition. See, Vázquez-Rivera, 620 F.Supp.2d at 270 (noting that plaintiffs’ allegations that hospital staff was aware that patient had vaginal bleeding and complained of severe abdominal pain was sufficient to satisfy the emergency medical condition element of EMTALA); Pagán-Pagán v. Hosp. San Pablo, Inc., 97 F.Supp.2d 199 (D.P.R. 2000) (observing that defendant conceded that infant diagnosed with an acute broncho spasm and cyanosis was suffering from an emergency medical condition within the meaning of EMTALA); Est. of Robbins v. Osteopathic Hosp. Founders Ass'n, 178 F.Supp.2d 1221, 1224 (N.D. Okla. 2000) (holding that medical records reporting that patient arrived to hospital with spontaneous arterial bleeding from femoral/popliteal surgery site, subsequently diagnosed with pseudoaneurysm and spontaneous hemorrhage in surgery site, were sufficient to show that hospital knew of patient's emergency medical condition).
2. Stabilization
Plaintiffs argue that Mr. Nieves was left in HCBS's emergency room for about three and a half days, "practically unattended" or receiving "scant medical attention" (Docket No. 88, pp. 9-10). Additionally, they maintain that Mr. Nieves did not receive treatment "necessary for stabilization," such as "anti-coagulation treatment," whilst he was in HCBS's emergency room, and that his transfer was "improperly delayed," causing leg gangrene and blisters, sepsis, and eventual death. Id. Furthermore, they state that this alleged abandonment by HCBS violated EMTALA's stabilization requirements. Id.
To the extent plaintiffs base their motion for summary judgment on HCBS's alleged failure to keep Mr. Nieves in a stable condition during his time in HCBS, or on the hospital's supposed improper or delayed treatment of his medical condition, the request lacks merit. As mentioned above, EMTALA does not establish a standard of care on how hospitals should treat patients while they remain in the hospital. See, Fraticelli-Torres, 300 Fed.Appx. at 4 (so noting). Rather, EMTALA's stabilization requirement becomes relevant only in connection to, and at the time of, transfer of a patient from a hospital. See, Álvarez-Torres, 576 F.Supp.2d at 284 (observing that stabilization requirement applies in the context of a transfer); Harry, 291 F.3d at 775 (pointing out that EMTALA does not require stabilizing treatment of a patient who is not transferred); Bryan, 95 F.3d at 352 (recognizing that stabilization requirement does not extend to patient's long-term care in medical facilities); Torres Otero, 115 F.Supp.2d at 260 (indicating that the duty to stabilize is not gauged independently from a transfer). To hold otherwise would be to impose a federal standard of care on hospitals, which is not consistent with EMTALA's purpose or reach. Put simply, delayed medical care, or even improper medical care, is not actionable under EMTALA. See, Torres Otero, 115 F.Supp.2d at 260 (finding that allegations that treatment was "incorrect and/or delayed" constituted an attempt "to engraft an EMTALA failure to stabilize claim upon a medical malpractice claim"). Instead, the relevant consideration regarding stabilization "is whether the treatment and discharge were reasonable in view of the circumstances that existed at the moment of the discharge." Heirs of Medero, 281 F.Supp.2d at 361 (citation omitted). Whether a patient is "stable" for purposes of EMTALA depends on whether, at the time of transfer, the hospital determines that it is "within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer." 42 U.S.C. § 1395dd(e)(3)(A).
Parenthetically, neither plaintiffs nor HCBS address in their summary judgment submissions whether Mr. Nieves was formally or implicitly admitted as a patient in the days prior to his transfer to PHG. The record shows that, during this time, Mr. Nieves was screened, examined, tested, diagnosed, treated, monitored, and moved to the intermediate care area within the hospital while awaiting the day of transfer to PHG. This is a critical issue, given that EMTALA and the vast case law on the subject indicates that once a patient is admitted in good faith by a hospital for further treatment, EMTALA's stabilization requirements cease to apply. See, Benítez-Rodríguez v. Hosp. Pavía Hato Rey, Inc., 588 F.Supp.2d 210, 214 (D.P.R. 2008) (so noting and collecting cases); Bryant v. Adventist Health Sys./West, 289 F.3d 1162, 1167 (9th Cir. 2002) (acknowledging that the stabilization requirement "normally ends when a patient is admitted for inpatient care"); Ceballos-Germosen v. Doctor's Hosp. Ctr. Manatí, 62 F.Supp.3d 224, 232 (D.P.R. 2014) (recognizing that once a hospital admits an individual as an inpatient, it has no duty to stabilize under EMTALA); Loaisiga-Cruz v. Hosp. San Juan Bautista, 681 F.Supp.2d 130, 135-136 (D.P.R. 2010) (finding that plaintiff failed to state a stabilization claim where plaintiff spent a period of time in the emergency room, was assigned a room in the hospital, was treated by hospital nurses and received intravenous fluids); Vázquez-Rivera, 620 F.Supp.2d at 270 (observing that a hospital fulfills its statutory duties under EMTALA once it admits the patient); Nieves Florán v. Doctors’ Ctr. Hosp., Inc., 2020 WL 716669, **5-7 (D.P.R. Feb. 12, 2020), recons. denied sub nom. Florán v. Doctors’ Ctr. Hosp., Inc. (D.P.R. Mar. 11, 2020) (denying plaintiff's stabilization claims when she was admitted to the hospital for evaluation and treatment of bone fracture); 42 CFR § 489.24(d)(2)(i). And, such discontinuance of stabilization obligations under EMTALA could extend to a transferee hospital with "specialized capabilities." See, 42 U.S.C. § 1395dd(g) (describing hospitals with specialized capabilities or facilities); 42 C.F.R. § 489.24(f)(same) ; see also, Jeffrey C. Moffat , The EMTALA Answer Book , Ch . 5 Introduction (2022 ed.)(stating U.S. Department of Health and Human Services’ position that "if an individual comes to the hospital's dedicated emergency department, is determined to have an [emergency medical condition], is admitted as an inpatient, and continues to have an unstabilized [emergency medical condition], which requires the specialized capabilities of another hospital, the EMTALA obligation for the admitting hospital has ended and a hospital with specialized capabilities also does not have an EMTALA obligation toward that individual")(quoting Dep't of Health and Human Serv., Comments on 42 C.F.R. Part 489 and Applicability of EMTALA to Hospital Inpatients, 77 Fed. Reg. 5213, 5217 (Feb. 2, 2012) ), available at https://ps.vitallaw.com/wkshare/doclink.htp?dockey=25739418@USFR12 (last visited Mar. 31, 2022). Notwithstanding, these issues, too, should be evaluated by the jury, not the court.
On this point, plaintiffs ask the court to infer that Mr. Nieves's condition was unstable upon transfer because: 1) his condition worsened in the days preceding his transfer; 2) his condition was visibly poor on the morning of transfer to PHG; and 3) he returned from PHG in a septic state. See, Docket No. 179, pp. 16-20. But, as previously explained, what matters is his condition at the moment of transfer. Thus, even if Mr. Nieves's condition turned for the worse during the days leading up to his transfer, it would be irrelevant for the court's analysis. And, as a practical matter, Mr. Nieves could have been in critical condition for days, but nonetheless sufficiently stable for an EMTALA transfer. See, Brooker v. Desert Hosp. Corp., 947 F.2d 412, 415 (9th Cir. 1991) (ruling that a patient can be in critical condition and still be considered "stable" for transfer); St. Anthony Hosp. v. U.S. Dep't of Health & Hum. Servs., 309 F.3d 680, 695 (10th Cir. 2002) ("stability, as used in the medical profession, does not carry the same meaning as stability under EMTALA"). By extension, Mr. Nieves's condition after his transfer to PHG (i.e., his return to HCBS in septicemic condition) is also irrelevant. See, Torres Otero, 115 F.Supp.2d at 259-260 (specifying that "[l]iability under EMTALA does not hinge on the result of the plaintiff's condition after the release, but rather or whether the hospital would have considered another patient in the same condition as too unstable to warrant his or her release or transfer") (citation omitted) (emphasis added).
And, as previously delineated, the evidence as to Mr. Nieves's condition at the moment of transfer is contradictory or otherwise insufficient to grant summary judgment. For example, the contents of the Consent Form are contradicted by the contents of the paramedics’ Service Incident Sheet in some respects. Also, who authored the Consent Form, who examined Mr. Nieves (if anyone) prior to his departure from HCBS, and whether he was in a stable or unstable condition at that moment, are all unknown to the court. This alone is enough to preclude entry of summary judgment on the stabilization claim. See, Mercado v. Hosp. Cayetano Coll Y Toste, 2010 WL 3419969, *7 (D.P.R. Aug. 26, 2010) (failure to show additional facts surrounding preparation of doctor's report regarding patient's condition and treatment precludes consideration of such evidence in stabilization claim at summary judgment stage). Ultimately, in this setting, it is for the jury, not the court, to consider the credibility, probative value and inferences to be drawn from the evidence. See, Anderson, 477 U.S. at 255, 106 S.Ct. 2505 ("Credibility determinations, the weighing of the evidence, and the drawing of legitimate inferences from the facts are jury functions, not those of a judge").
The importance of this information cannot be understated. If a jury finds that Mr. Nieves was stable upon transfer, HCBS could be exonerated of liability. See, Heirs of Medero, 281 F.Supp.2d at 358 (if a hospital screens and stabilizes a patient before transfer as it would a paying patient, then "no cause of action can be brought under EMTALA") (citing Cleland v. Bronson Health Care Group, 917 F.2d 266 (6th Cir. 1990) ). Conversely, if Mr. Nieves was unstable at that time, then HCBS had the duty to transfer Mr. Nieves in accordance with the additional requirements set forth in Sections 1935dd(c)(1) and (2). See, 42 U.S.C. § 1935dd(c)(1) and (2)(listing requirements for transfers of unstable patients).
Lastly, plaintiffs contend that they are entitled to summary judgment on the stabilization claim, arguing that Mr. Nieves was not treated according to HCBS's standard procedures, which is supposedly evinced from the fact that the internist who was on call on November 22, 2018, Dr. Román, examined two other patients that day, but not him. But, the argument must also fail at this stage. First, the fact, by itself, that another doctor examined other patients, but not Mr. Nieves, is inconclusive as to liability for failure to stabilize, because plaintiffs have not provided any facts to explain why that doctor examined the other patients and not Mr. Nieves. See, Cruz-Vázquez v. Mennonite Gen. Hosp., Inc., 717 F.3d 63, 71-72 (1st Cir. 2013) (denying summary judgment because evidence was unclear as to whether physicians may have justifiably treated plaintiff differently from other patients presenting like symptoms as a result of additional information they may have had about the plaintiff or her particular condition). Second, plaintiffs fail to include a copy of HCBS's standard policies to permit the court to evaluate whether Mr. Nieves was treated disparately in failing to provide him examination by an internist or other specialized doctor, or otherwise treat him as it would similarly situated patients. Therefore, plaintiffs’ request for summary judgment on this ground must be denied.
Although plaintiffs include a copy of HCBS's policy for patient transfers, they only cite this document to support their contention that an informed consent form and physician certification were not included in Mr. Nieves's medical record. See, PSUMF ¶¶ 90, 92; Docket No. 179-16. Plaintiffs omit any argument that would lend support to their assertion that failure to provide an internist, or any other specialized physician, deviates in any way from HCBS's patient transfer policy (or any other hospital policy) or amounts to disparate treatment.
D. Inappropriate Transfer
Whether Mr. Nieves's condition was stable or unstable upon transfer to PHG has not been established by the record before the court. Because HCBS's potential liability under 42 U.S.C. § 1395dd(c) hinges on the answer to the foregoing–which, as explained above, must be decided by the jury–plaintiffs’ request for summary judgment as to inappropriate transfer must be denied.
E. PHG's Refusal of Mr. Nieves's Transfer
In PHG's memorandum of law in support of its motion for summary judgment, the hospital generally contends that it did not have "specialized capabilities or facilities," within the meaning of 42 U.S.C. § 1395dd(g) and 42 C.F.R. § 489.24(f), to treat Mr. Nieves and, therefore, "could refuse the transfer without incurring in liability" under EMTALA. See, Docket No. 183, pp. 3-5. However, as previously explained, there is a genuine dispute as to whether Dr. Suárez, on behalf of PHG, accepted Mr. Nieves's transfer from HCBS on November 22, 2018, and whether Mr. Nieves was stable at the time of his transfer to PHG on November 25, 2018. These issues must be resolved by the jury before PHG's contentions can be entertained, given that 42 U.S.C. § 1395dd(g) and 42 C.F.R. § 489.24(f) apply in the context of transfers of unstable patients pursuant to 42 U.S.C. §§ 1395dd(c)(1) and (2). Therefore, PHG's motion for summary judgment must be denied.
42 U.S.C. § 1395dd(g) states:
A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the Secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.
Id. (emphasis added).
42 C.F.R. § 489.24(f) states:
A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive case units, or, with respect to rural areas, regional referral centers (which, for purposes of this subpart, mean hospitals meeting the requirements of referral centers found at § 412.96 of this chapter)) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual.
Id. (emphasis added).
F. Plaintiffs’ Personal Claims Under EMTALA
HCBS requests summary judgment on what it characterizes as plaintiffs’ personal damages causes of action under EMTALA, arguing that "family members of deceased patients lack standing to claim for their own personal damages under EMTALA." See, Docket No. 177, pp. 19-23. However, in their response, plaintiffs clarify that their EMTALA claims are those they inherited from Mr. Nieves. See, Docket No. 191, p. 12.
See, PSUMF HCBS ¶ 7; OSUMF HCBS ¶ 7; Docket No. 179-15, p. 2 (declaration of heirship).
Those claims are permitted under both EMTALA and Puerto Rico law. See, Correa, 69 F.3d at 1196 (noting that causes of action for EMTALA violations extend to "individuals who are eligible to bring survivors’ actions under local law," which includes heirs of the decedent); Ríos v. Hosp. HIMA San Pablo Fajardo, 126 F.Supp.3d 237, 241 (D.P.R. 2015) (accepting that heirs of a deceased patient may inherit the decedent's EMTALA cause of action, which is a principle recognized by Puerto Rico law); Álvarez-Pumarejo v. Mun. of San Juan, 972 F.Supp. 86, 88 (D.P.R. 1997) (similar). Accordingly, HCBS's request for summary judgment in these respects is denied.
G. Supplemental State Law Claims
HCBS and PHG have requested dismissal of plaintiffs’ state-law claims if the court dismissed their EMTALA claims. Considering the preceding discussion, dismissal is not appropriate at this stage.
V. CONCLUSION
In light of the above, the motions for summary judgment at Docket Nos. 179, 181, 177 and 184, are DENIED.