Grenier v. Stamford Hospital et al
Filing
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ORDER denying Defendants' 24 Motion to Dismiss. See attached memorandum of decision. Signed by Judge Vanessa L. Bryant on 9/29/2015. (Nadler, S.)
UNITED STATES DISTRICT COURT
DISTRICT OF CONNECTICUT
MARC J. GRENIER,
AS ADMINISTRATOR OF THE
ESTATE OF LAURA D. SHEEHAN,
Plaintiff,
v.
THE STAMFORD HOSPITAL
STAMFORD HEALTH SYSTEM,
INC., AND EMERGENCY MEDICINE
PHYSICIANS OF FAIRFIELD,
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CIVIL ACTION NO.
3:14-cv-0970 (VLB)
September 29, 2015
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Defendants.
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MEMORANDUM OF DECISION DENYING DEFENDANTS’ MOTION TO DISMISS
AMENDED COMPLAINT [Dkt. #24]
Plaintiff Marc Grenier (“Grenier”), in his capacity as administrator of the
estate of Laura D. Sheehan (“Sheehan”), brings claims against Defendants
Stamford Hospital and Stamford Health System, Inc. (collectively the “Stamford
Defendants”) under the Emergency Medical Treatment and Active Labor Act
(“EMTALA”), 42 U.S.C. § 1395dd., et seq., and a medical malpractice claim against
the Stamford Defendants and Defendant Emergency Medicine Physicians of
Fairfield (“EMP”) under Connecticut law, for injuries and the ultimate death of
Sheehan while in the care of Defendants.
Plaintiff filed his initial Complaint on July 3, 2014. See [Dkt. #1]. On
October 7, 2014, Plaintiff filed an Amended Complaint, which, among other
things, added a malpractice claim against Defendant EMP. See [Dkt. #10]. On
December 1, 2014, the Stamford Defendants moved to dismiss Count One of the
1
Amended Complaint. See [Dkt. #24]. For the reasons that follow, Defendant’s
Motion to Dismiss is DENIED.
I.
Background1
In the early morning hours of July 7, 2012, Sheehan was transported by
Defendant EMP to the Emergency Department of Defendant Stamford Hospital.
[Dkt. #10, Am. Compl. at ¶ 22]. At 1:30 am, Sheehan was admitted. [Id.]. Upon
arrival, Sheehan was evaluated by members of the Stamford Defendants, who
determined that she was in “no acute distress and arousable to touch and name.”
[Id.]. Sheehan also appeared to be “heavily intoxicated.” [Dkt. #10, Ex. B to Am.
Compl. at 16]. Sheehan had a documented history of alcohol intoxication, and
one nurse noted that Sheehan was “[s]een [at the hospital] multiple times in the
1
For the purposes of Defendants’ motion, the Court gleans the facts of this case
from the Amended Complaint and all documents attached thereto. See [Dkt. #
10, Am. Compl. and Exs. A and B]; see also Chambers v. Time Warner, Inc., 282
F.3d 147, 152 (2d Cir. 2002) (“[T]he complaint is deemed to include any written
instrument attached to it as an exhibit or any statements or documents
incorporated in it by reference.”). However, the Court does not consider the July
2, 2013 report by the State of Connecticut Department of Public Health (“Health
Report”), which Plaintiff attached as an exhibit to an affidavit submitted in
support of his Opposition to the motion to dismiss. See [Dkt. #27-1, Ex. 1 to
Burke Aff.]. This Report was neither attached to nor referenced in the Amended
Complaint, nor was it integral to the Complaint. See B.V. Optische Industrie De
Oude Delft v. Hologic, Inc., 909 F. Supp. 162, 167 (S.D.N.Y. 1995) (to “reference”
a document such that it may be considered at the pleading stage, complaint
must contain “clear,” “definite,” and substantial references to the “extraneous
submissions”); Chambers, 282 F.3d at 153 (mere notice or possession of report
not enough to render it integral to complaint). That the Report was briefly
mentioned as a point of reliance in a document attached as an exhibit to the
Complaint does not alter this conclusion. See Thomas v. Westchester Co.
Health Care Corp., 232 F.Supp. 2d 273, 276 (S.D.N.Y. 2002) (finding one brief
reference to a document in a single paragraph of complaint insufficient to
permit court to consider document on motion to dismiss); Madu, Edozie &
Madu, P.C. v. SocketWorkds Ltd. Nigeria, 265 F.R.D. 106, 124 (S.D.N.Y. 2010)
(extrinsic documents including affidavit and email correspondence not integral
because complaint failed to quote or mention email).
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past for same issue.” [Id.; Dkt. #10, Am. Compl. at ¶ 22]. Other than these visual
observations and noting Sheehan’s prior history of heavy intoxication, upon
admission, the Defendants did not perform any internal examination of Sheehan,
such as a blood alcohol test.
Throughout the early morning hours, Sheehan was monitored by staff of
Defendant Stamford. A test of her glucose level was performed, and two reports
were generated, one of which concluded that Sheehan was “in no acute distress,
arousable to touch/name.” [Dkt. #10, Ex. B to Am. Compl. at 16].
By approximately 7:00 am, the Stamford Defendants determined that
Sheehan had ‘“sobered appropriately . . . ‘move[d] all four extremities purposely
and symmetrically, that she possessed ‘5/5 motor strength’ and walked with a
‘normal gait’.” [Dkt. #10, Am. Compl. at ¶ 23]. At 7:18 AM, Sheehan was awake,
responsive, requested food, and then fell back asleep. [Id.]. Eight minutes later,
Sheehan was given discharge instructions and discharged. [Dkt. #10, Ex. B to
Am. Compl. at 17]. At the time of her discharge, the Stamford Defendants
reported that Sheehan was “alert and oriented as to person, place, time, and
walked with a steady gait.” [Dkt. #10, Am. Compl. at ¶ 23]. However, despite their
knowledge of Sheehan’s history of alcoholism and her admission for extreme
alcohol intoxication, the Stamford Defendants did not conduct a blood alcohol
test prior to her discharge.
Just minutes later, at 7:43 AM, Sheehan was readmitted to the emergency
department, upon the Stamford Defendants’ staff’s observations that Sheehan
was “stumbling and walking with an unsteady gait.” [Id. at ¶ 25]. The Stamford
3
Defendants then conducted a blood alcohol level test “and other laboratory
work.” [Id. at Ex. B at 17]. Hours later, the test results revealed that Sheehan had
an “elevated” blood alcohol level of “261.” [Id.]. No subsequent blood tests were
performed.
As the morning of July 7 progressed, Sheehan’s condition appeared to
worsen. Defendants’ staff noted that she appeared “disoriented,” that she
“needed assistance eating breakfast,” and was speaking incomprehensibly. [Id.
at ¶¶ 26-27]. To relieve her agitation, the Defendants administered a sedative
drug, Ativan. [Id. at ¶ 28]. The Defendants did not, however, perform a
subsequent blood alcohol test or otherwise assess Sheehan’s level of
intoxication on July 7. Nor did they perform any cognitive tests or other
evaluative procedures.
Throughout the remainder of July 7, Defendants’ emergency staff
continued to observe Sheehan’s condition. During this time, they noted that she
continued to have difficulty speaking and walking, although she was reported as
awake, alert and responsive to questions. [Id. at ¶¶ 29-32]. No diagnostic tests
were performed and no treatment was administered.
Defendants’ staff continued to observe Sheehan throughout the early
morning hours of July 8, 2012. Around 3:15 am, Defendants’ staff observed that
Sheehan “remained unable to ambulate.” [Id. ¶ 35]. Shortly thereafter, and in
response to Sheehan’s “loud moaning,” at 4:30 am, Defendants’ staff sent for
additional labs and ordered a CT scan of Sheehan’s head. [Id. at ¶ 36; Dkt. #10,
Ex. B to Am. Compl. at 18]. The medical evaluation revealed Sheehan was
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suffering from a stroke, and that her blood alcohol level was zero. [Id.]. Prior to
this evaluation, the Defendants had not diagnosed Sheehan as having had a
stroke. [Id. at ¶ 37]. Sheehan remained in the care of Defendants, but by the time
her stroke was diagnosed, Sheehan could not be revived. [Id. at ¶ 38]. Three
days later, on July 11, 2012 at 12:32 pm, Sheehan died. [Id. at ¶ 39]. On July 15,
2012, an autopsy was performed. [Id. at ¶ 40]. Sheehan’s cause of death was
identified as a cerebrovascular attack of the left cerebral area, due to thrombosis
of her left internal carotid artery and left middle cerebral artery, and left cerebellar
infarct, due to distal segment thrombosis of the left vertebral artery. [Id.].
The Complaint further alleges that, while in the Stamford Defendants’ care,
the Stamford Defendants had a duty to ensure that their medical professionals
“rendered patient care in compliance with applicable standards of care,
guidelines, policies, protocols, rules and regulations on a twenty-four hour
basis.” [Id. at ¶ 16]. In particular, it was the Defendants’ duty to establish,
implement and enforce rules, guidelines, and standards of care regarding the
treatment of patients, and to take steps to ensure that all physicians evaluating
and treating patients complied with these rules and standards of care. [Id. at ¶¶
17-18]. Plaintiff also alleges, through the opinion of a reviewing physician, that
“there was a departure from the standard of practice by Stamford Hospital staff
with respect to Ms. Sheehan’s treatment while she was in the Emergency
Department.” [Dkt. #10, Ex. B. to Am. Compl. at 16]. Specifically, Plaintiff
contends that hospital staff “failed to recognize a change in status of a
hospitalized patient with a previously normal gait and comprehensible speech to
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one with an inability to walk and garbled speech caused by a devastating
cerebrovascular accident.” [Id.].
II.
Standard of Review
To survive a motion to dismiss, a complaint must contain sufficient factual
matter, accepted as true, to state a claim to relief that is plausible on its face.
Sarmiento v. U.S., 678 F.3d 147 (2d Cir. 2012) (quoting Ashcroft v. Iqbal, 556 U.S.
662, 678 (2009)). While Rule 8 does not require detailed factual allegations, “[a]
pleading that offers ‘labels and conclusions’ or ‘formulaic recitation of the
elements of a cause of action will not do.’ Nor does a complaint suffice if it
tenders ‘naked assertion[s]’ devoid of ‘further factual enhancement.’” Iqbal, 556
U.S. at 678 (citations and internal quotations omitted). “Where a complaint
pleads facts that are ‘merely consistent with’ a defendant's liability, it ‘stops short
of the line between possibility and plausibility of ‘entitlement to relief.’” Id.
(quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 557 (2007)). A claim has facial
plausibility when the plaintiff pleads factual content that allows the court to draw
the reasonable inference that the defendant is liable for the misconduct alleged.
Id. (internal citations omitted).
In considering a motion to dismiss for failure to state a claim, the Court
should follow a “two-pronged approach” to evaluate the sufficiency of the
complaint. Hayden v. Paterson, 594 F.3d 150, 161 (2d Cir. 2010). “A court ‘can
choose to begin by identifying pleadings that, because they are no more than
conclusions, are not entitled to the assumption of truth.’” Id. (quoting Iqbal, 556
U.S. at 679). “At the second step, a court should determine whether the ‘well-
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pleaded factual allegations,’ assumed to be true, ‘plausibly give rise to an
entitlement to relief.’” Id. (quoting Iqbal, 556 U.S. at 679). “The plausibility
standard is not akin to a probability requirement, but it asks for more than a sheer
possibility that a defendant has acted unlawfully.” Iqbal, 556 U.S. at 678 (internal
quotations omitted).
In general, the Court’s review on a motion to dismiss pursuant to Rule
12(b)(6) “is limited to the facts as asserted within the four corners of the
complaint, the documents attached to the complaint as exhibits, and any
documents incorporated by reference.” McCarthy v. Dun & Bradstreet Corp., 482
F.3d 184, 191 (2d Cir. 2007). In addition, at this stage, all factual allegations in the
complaint are accepted as true and all reasonable inferences are drawn in the
plaintiff’s favor. Ruotolo v. City of New York, 514 F.3d 184, 188 (2d Cir. 2008).
III.
Discussion
Count one of Plaintiff’s Amended Complaint alleges that the Defendants
violated the Emergency Medical Treatment and Active Labor Act (“EMTALA”)
when they “fail[ed] to properly screen or stabilize the plaintiff’s decedent or
otherwise fail[ed] to treat her emergency condition.” [Dkt. #10, Am. Compl. at ¶
5]. For the reasons that follow, the Court finds that the Complaint states claims
under both prongs of the statute.
A.
EMTALA
The EMTALA was enacted in 1986 in response to a growing concern of
“‘patient dumping,’ the practice of refusing to provide emergency medical
treatment to patients unable to pay, or transferring them before their emergency
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conditions are stabilized.” Hardy v. New York City Health & Hosps. Corp., 164
F.3d 789, 792 (2d Cir. 1999). To prohibit such discrimination, hospital emergency
rooms are subject to two obligations under the EMTALA: (i) to perform an
appropriate medical screening and (ii) to stabilize the patient. The screening and
stabilization requirements are two separate and distinct obligations. Brown v. St.
Mary’s Hosp., No. 3:14-cv-228 (DJS), 2015 WL 144673, at *2 (D. Conn. Jan. 12,
2015). Thus, to state a claim under the EMTALA, a plaintiff must allege that he
“(1) went to the Defendant’s emergency room (2) suffering from an emergency
medical condition, and that the Hospital either (3) failed to adequately screen him
to determine whether he had such a condition or (4) discharged or transferred
him before the emergency condition was stabilized.” Eads v. Milford Hosp., No.
3:10-cv-1153 (VLB), 2011 WL 873313, at *2 (D. Conn. Feb. 23, 2011) (citing Hardy,
164 F.3d at 792).
On the other hand, the EMTALA is not intended to ensure that each
emergency room patient receives a correct diagnosis or otherwise avoids
medical negligence. Indeed, it “is not a substitute for state law on medical
practice.” Hardy, 164 F.3d at 792.
B.
Plaintiff’s Complaint States a Claim Under the
EMTALA for Failure to Screen
To satisfy its screening duty, when an individual “comes to the emergency
department and a request is made on the individual’s behalf for examination or
treatment of a medical condition, the hospital must provide an appropriate
medical screening examination within the capability of the hospital’s emergency
department . . . to determine whether or not an emergency medical condition . . .
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exists.” 42. U.S.C. § 1395dd(a). An emergency medical condition is defined 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 . . . placing the health of the individual .
. . in serious jeopardy, . . . serious impairment to bodily functions, or . . . serious
dysfunction of any bodily organ or part.” 42 U.S.C. §§ 1395dd(e)(1)(A)(i)-(iii).
The EMTALA does not define the term, “appropriate medical screening.”
However, courts consistently construe this phrase as requiring hospitals to
perform “uniform or even-handed screening examinations” that are “consistent
with their own polices.” Brown, 2015 WL 144673, at *2 (quoting Macmaux v. Day
Kimball Hosp., No. 3:09-cv-164 (JCH), 2011 WL 4352007, at *3 (D. Conn. Sept. 16,
2011) (citing cases)) (emphasis added). In other words, the screening
examination must be “equal, as opposed to treatment that meets professional
standards of competence.” Fisher v. New York Health & Hosps. Corp., 989 F.
Supp. 444, 449 (E.D.N.Y. 1998). Accordingly, “a hospital fulfills the appropriate
screening requirement when it conforms to its standard screening procedures.
By the same token, any departure from standard screening procedures
constitutes inappropriate screening in violation of the EMTALA.” Id. (quoting
Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1041 (D.C. Cir. 1991)).
Here, the Stamford Defendants do not contend that the Complaint fails to
plead the first two elements of an EMTALA claim, namely, that the Plaintiff went
to the Defendant’s emergency room suffering from an emergency condition as
defined by the EMTALA. Nor would such a contention be well-founded. See [Dkt.
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#10, Am. Compl. at ¶ 22]. However, the Stamford Defendants assert that the
Complaint fails to plead a claim of inadequate screening because the Complaint
“contains no allegation of disparate treatment.” [Dkt. #25, Def.’s Memo. at 8].
Construing the Complaint and the attached Physician’s Opinion in a light most
favorable to Plaintiff, but mindful of the Rule 8 pleading requirements, the Court
disagrees.
Taken together, these documents state a claim for failure to screen in at
least three ways. First, the initial failure to perform any blood work or internal
examination upon Sheehan’s admission to the Emergency Department would
support such a claim. See [Dkt. #10, Am. Compl. at ¶ 22]. Second, the fact that
Sheehan was discharged without any blood work or physical examination beyond
observing her movements would also appear to support a failure to screen claim.
[Id. at ¶ 23]. Third, upon her readmission, the Stamford Defendants performed
only one blood alcohol test, which revealed an extremely high level of
intoxication, and performed no other internal tests for nearly a twenty-four hour
period, during which time, Sheehan’s condition was deteriorating and her blood
alcohol level was necessarily dropping. [Dkt. #10, Ex. B to Am. Compl. at 17; Dkt.
#10, Am. Compl. at ¶¶ 26-32, 36-37].2
2
The Court recognizes that these facts appear only in Count Two of the Amended
Complaint, which concerns Plaintiff’s state law medical malpractice claim. See
[Dkt. #10, Am. Compl. at ¶¶ 10-43]. While “[t]raditionally, in each count of a
complaint, a plaintiff states the facts constituting his legal right to relief of a
given kind, and separates out different kinds of legal rights into different counts
. . . [w]e are past the days of code pleading and the concomitant construction of
complaints against the plaintiff.” Bakhit v. Safety Markings, Inc., 33 F. Supp. 3d
99, 106 (D. Conn. 2014). Accordingly the Court construes the Complaint “so as
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The Stamford Defendants’ sole argument in response is that Plaintiff’s
EMTALA count “contains no allegation of disparate treatment. Rather, read in the
light most favorable to the plaintiff, they allege that the hospital defendants failed
to properly screen, stabilize and/or treat decedent.” [Dkt. #25 at 8]. The Stamford
Defendants are mistaken.
First, the Complaint fairly alleges that “the various testing and screening
done by the Hospital . . . deviated from the type of examination normally
performed . . . on patients with similar symptoms and/or history.” [Id.] For
instance, the allegations concerning the initial screening examination clearly
suggest that it was influenced by the fact that Sheehan “had been ‘seen here
multiple times in the past for [the] same issue.’” [Dkt. #10, Am. Compl. at ¶ 22].
Thus, Sheehan did not receive a standard examination, but one performed in light
of her prior treatment, and which did not include any diagnostic examination.
The facts pled regarding Sheehan’s hasty discharge, the incredibly short period
of time between it and her readmission, and the administration of a blood alcohol
test upon her return to the Emergency Department, further intimate that the
examination she received leading up to her discharge did not conform to the
Hospital’s standard practices and policies. Moreover, the details concerning
Sheehan’s declining condition coupled with the passage of nearly a day in
between medical testing plainly raise the inference of disparate treatment.
Second, the Complaint pleads facts concerning the duty of the Stamford
Defendants to adhere to “guidelines, policies, protocols, rules and regulations”
to do justice” and considers the factual allegations pled under Plaintiff’s
medical malpractice claim under the EMTALA. Id.
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and elsewhere alleges that “there was a departure from the standard of practice
by Stamford Hospital staff with respect to Ms. Sheehan’s treatment.” [Id. at ¶ 16;
Dkt. #10, Ex. B to Am. Compl. at 16]. Combined with the specific allegations
concerning the examinations Sheehan received, the Complaint states a failure to
screen claim.
Third, none of the cases raised by the Stamford Defendants undercuts this
conclusion. All but one was decided at the summary judgment stage, and they
therefore do not concern the pleading standards of an EMTALA claim. See
Brenord v. Catholic Med. Ctr. of Brooklyn & Queens, Inc., 133 F. Supp. 2d 179
(E.D.N.Y. 2001); Fisher v. New York Health & Hosps. Corp., 989 F. Supp. 444
(E.D.N.Y. 1998); Macamaux v. Day Kimball Hosp., No. 3:09-cv-164, 2011 WL
4352007 (D. Conn. Sept. 16, 2011); Gatewood v. Washington Healthcare Corp., 933
F.2d 1037 (D.C. Cir. 1991). The lone case decided on a motion to dismiss,
Vazquez v. New York City Health & Hosps. Corp., No. 98 Civ. 7922 (DAB), 2000
U.S. Dist. LEXIS 5614 (S.D.N.Y. Feb. 4, 2000) is readily distinguishable from the
present matter, as the complaint failed to allege that the patient was “treated in
the [defendant hospital’s] emergency room” and offered “no facts to suggest
disparate treatment.” Id. at *10.
Fourth, during the entire time she was hospitalized, Sheehan received only
palliative care for her persistent symptoms, in the form of Ativan. See [Dkt. #10,
Am. Compl. at ¶ 28].
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For these reasons, Plaintiff is entitled to proceed with discovery to
determine whether and to what extent the screening Sheehan received was
consistent with the Stamford Defendants’ standard screening procedures.
C.
The Complaint States a Failure to Stabilize Claim
If a hospital determines that an individual has an emergency medical
condition, the hospital’s second duty under the EMTALA, the duty to provide
stabilizing treatment prior to discharge or transfer, is triggered. See 42 U.S.C. §
1395dd(b)(1). The EMTALA defines “to stabilize” as “to provide such medical
treatment of the [emergency medical] condition as may be necessary to assure,
within reasonable medical probability that no material deterioration of the
condition is likely to result from or occur during the transfer of the individual
from a facility . . . .” 42 U.S.C. § 1395dd(e)(3)(A). The duty to stabilize is a
“distinct obligation[]” from a hospital’s screening duty, and “it has been
determined by some courts that ‘the stabilization requirement is not met by
simply dispensing uniform stabilizing treatment, but rather, by providing the
treatment necessary ‘to assure within reasonable medical probability, that no
material deterioration of the condition is likely to result . . . .’” Brown, 2015 WL
144673, at *2 (quoting Eberhardt v. City of Los Angeles, 62 F.3d 1253, 1259 n. 3
(9th Cir.1995)).
However, a hospital’s stabilization duty applies “only where the hospital
‘determines’ that the individual has an emergency medical condition.”
Macamaux, 2011 WL 4352007, at *6 (quoting 42 U.S.C. § 1395dd(b)). Thus, the
hospital must have “actual knowledge,” or diagnosis, of the emergency medical
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condition.” Id. (citations omitted); see also Brenord, 133 F. Supp. 2d at 191 (“[A]
hospital’s duty to stabilize is not triggered unless the hospital has actual
knowledge of the individual’s unstabilized emergency medical condition.”)
(quotation and citations omitted). On the other hand, a hospital’s deliberate
blindness to the existence of an emergency medical condition, such as by failing
to perform its standard diagnostic tests to detect such a condition, that is, a
failure to screen, could not absolve a hospital of liability for failure to stabilize a
patient. See Morgan v. N. Mississippi Med. Ctr., Inc., 458 F. Supp. 2d 1341, 1352,
n. 18 (S.D. Ala. 2006) (noting that EMTALA “analysis might be different if [plaintiff]
had mustered evidence that [defendant doctor] . . . turned a blind eye” to
plaintiff’s condition).
The allegations in the Complaint sufficiently plead (and the Stamford
Defendants do not contest) that Sheehan suffered from an “emergency
condition” as defined by the EMTALA when she was admitted to the Emergency
Department. The Complaint further alleges that within minutes of her discharge,
Sheehan was readmitted and observed “stumbling and walking with an unsteady
gait.” [Dkt. # 10, Am. Compl. at ¶ 25]. Whereas at the time of her discharge,
medical entries prepared by the Stamford Defendants stated that Sheehan was
“alert and oriented . . . and walked with a steady gate.” [Id. at ¶ 23]. The short
passage of time and the striking contrast between these two entries plainly
implies that the Stamford Defendants discharged Sheehan prior to stabilizing her
known emergency condition. The Complaint therefore pleads a viable failure to
stabilize claim.
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IV.
Conclusion
For the reasons set forth above, Defendants’ Motion to Dismiss is DENIED
and this case shall proceed in accordance with the Court’s Scheduling Order.
IT IS SO ORDERED.
________/s/______________
Hon. Vanessa L. Bryant
United States District Judge
Dated at Hartford, Connecticut: September 29, 2015
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