Gonzalez-Morales v. Presbyterian Community Hospital, Inc. et al

Filing 71

OPINION AND ORDER granting in part and denying in part 66 Motion to Dismiss for Failure to State a Claim. Plaintiff's EMTALA stabilization claims are hereby dismissed. Signed by Judge Juan M. Perez-Gimenez on 11/17/2015. (PMA)

UNITED STATES DISTRICT COURT FOR THE
DISTRICT OF PUERTO RICO
ZORAIDA GONZALEZ-MORALES,
Plaintiff,
v.

CIV. NO. 13-1906 (PG)

PRESBYTERIAN COMMUNITY HOSPITAL,
INC., ET AL.,
Defendants.

OPINION AND ORDER
Pending before the court is co-defendant Presbyterian Community Hospital,
Inc.’s motion to dismiss (Docket No. 66). For the reasons set forth below, the
court GRANTS IN PART AND DENIES IN PART the co-defendant’s motion.
I. BACKGROUND
On December 11, 2013, plaintiff Zoraida Gonzalez Morales (hereinafter
referred to as “Plaintiff” or “Gonzalez”) filed the above-captioned claim
against defendants Presbyterian Community Hospital, Inc. (“PCH” or “the
Hospital”); Dr. Raul Vale-Flores, his wife and the conjugal partnership
constituted between them; Dr. Lope M. Gómez-Homrazabal, his wife and the
conjugal partnership constituted between them; Dr. Jose Dueño-Quiñones, his
wife and the conjugal partnership constituted between them and Dr. Rosangel
Santiago-Perez, his wife and the conjugal partnership constituted between them
for the failure to screen, treat and stabilize Plaintiff in violation of the
Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C. §
1395dd. The complaint includes a supplemental cause of action for medical
malpractice pursuant to Article 1802 of the Puerto Rico Civil Code, P.R. LAWS
ANN. tit. 31, § 5141 (“Article 1802”).
On February 10, 2014, Gonzalez filed an amended complaint, see Docket
No. 3, and on July 7, 2014, PCH filed a third party complaint against Global
Emergency Services, Inc., a company hired to provide services for PCH’s
Emergency Department, and its unknown insurance company. see Docket No. 35.
Plaintiff alleges that on December 15, 2011, she was taken to the
Hospital’s emergency room presenting symptoms of swelling and redness of the
left arm, a recent insect bite to the left hand, and severe right hip pain.
See Docket No. 3, ¶¶ 3.1-3.2. Plaintiff’s vital signs were taken, such as her

CIV. NO. 13-1906 (PG)

Page 2

temperature, blood pressure, heart rate and respiratory rate, and laboratory
blood tests were performed. Id. at ¶¶ 3.3-3.5. Co-defendant Dr. GomezHornazabal prescribed intravenous antibiotics and pain medication, and she was
eventually discharged in the early hours of December 16th, 2011 and prescribed
oral antibiotics and pain medication. Id. at ¶¶ 3.6-3.7. Gonzalez claims that
although the pain in her left arm had subsided, she had continued to complain
of right hip pain and difficulty walking prior to being discharged. Id. at
¶ 3.9. Therefore, Gonzalez alleges that the hospital did not perform the
appropriate medical screening nor provided the essential stabilizing treatment
for her condition. Id. at ¶ 3.10.
A day later, on December 17, 2011, the Plaintiff claims she returned to
the Hospital with symptoms of severe right hip pain, epigastric pain and
diarrhea.

Her

vital

signs

were

taken

and

co-defendant

Dr.

Rosangel

Santiago-Perez ordered laboratories and x-rays. Id. at ¶¶ 3.11-3.12. After Dr.
Santiago’s shift ended, Dr. Jose Dueño-Quiñones remained in charge of her
treatment. Despite complaining of right hip pain, he eventually discharged her
without admitting her. Id. at ¶ 3.14.
On December 19th, 2011, Gonzalez was transported via ambulance to the
University of Puerto Rico Medical Center in Carolina, Puerto Rico, where she
was evaluated for right hip pain and referred to a physiatrist after being
evaluated by the medical personnel of said institution. Id. at ¶¶ 3.17-3.18.
Three days later, on December 22, 2011, the Plaintiff returned to PCH for
a third time complaining of right hip pain. Dr. Raul Vale Flores evaluated
her, diagnosed her with right hip bursitis and ordered Toradol 60mg. Id. at
¶¶ 3.19-3.20. Her vital signs during this visit showed a fever of 38.4C, a
blood pressure of 140/69, a heart rate of 106 and a respiratory rate of 21.
Despite this, Plaintiff claims she was once again discharged without being
admitted. She thus contends that the Hospital and its providers failed to
provide the adequate medical screening and stabilization for a patient with
her condition. Id. at ¶ 3.22.
In January of 2012, Gonzalez eventually visited physiatrist Dr. Olga
Bermudez as she continued to suffer pain in her right hip. Id. at ¶¶ 3.233.24. Further evaluations and tests showed a “destruction and widening of the
right sacroiliac joint with imaging findings consistent with septic arthritis,
or a bacterial infection in her right hip.” Id. at ¶ 3.26. As a result of this
condition, Gonzalez claims to have suffered destruction of her right hip bone,
chronic pain and difficulty walking. Id. at ¶ 3.29.

CIV. NO. 13-1906 (PG)

Page 3

It is the Plaintiff’s contention that the absence of an adequate medical
screening, coupled with her three premature discharges, prevented a timely
identification of the critical medical condition she was suffering from. Id.
at ¶¶ 3.23-3.24.
The Hospital now moves to dismiss the Plaintiff’s EMTALA claims with
prejudice and her state law medical malpractice claims without prejudice. See
Docket No. 66. In light of the Plaintiff’s failure to timely file a response,
the court ruled that this motion shall be deemed unopposed. See Docket No. 68.
II. STANDARD OF REVIEW
Federal Rule of Civil Procedure 12(b)(6) authorizes the dismissal of a
complaint that fails to state a claim upon which relief could be granted. “To
avoid dismissal, a complaint must provide ‘a short and plain statement of the
claim showing that the pleader is entitled to relief.’” Garcia-Catalan v.
U.S., 734 F.3d 100, 102 (1st Cir.2013) (quoting FED.R.CIV.P. 8(a)(2)). When
ruling on a motion to dismiss for failure to state a claim, a district court
must “ask whether the complaint states a claim to relief that is plausible on
its face, accepting the plaintiff’s factual allegations and drawing all
reasonable

inferences

in

the

plaintiff’s

favor.”

Cooper

v.

Charter

Communications Entertainments I, LLC, 760 F.3d 103, 106 (1st Cir.2014) (citing
Maloy v. Ballori–Lage, 744 F.3d 250, 252 (1st Cir.2014)) (internal quotation
marks omitted). Additionally, courts “may augment these facts and inferences
with data points gleaned from documents incorporated by reference into the
complaint, matters of public record, and facts susceptible to judicial
notice.” A.G. ex rel. Maddox v. v. Elsevier, Inc., 732 F.3d 77, 80 (1st
Cir.2013) (citing Haley v. City of Boston, 657 F.3d 39, 46 (1st Cir.2011)).
“To cross the plausibility threshold, the plaintiff must ‘plead[ ]
factual content that allows the court to draw the reasonable inference that
the defendant is liable for the misconduct alleged.’” Cooper, 760 F.3d at 106
(citing Maloy, 744 F.3d at 252). See also Ashcroft v. Iqbal, 556 U.S. 662, 678
(2009). That is, “[f]actual allegations must be enough to raise a right to
relief above the speculative level, … , on the assumption that all the
allegations in the complaint are true (even if doubtful in fact) … .” Bell
Atlantic Corp. v. Twombly, 550 U.S. 544, 555 (2007) (internal citations and
quotation marks omitted).
“In resolving a motion to dismiss, a court should employ a two-pronged
approach. It should begin by identifying and disregarding statements in the
complaint that merely offer legal conclusions couched as fact or threadbare

CIV. NO. 13-1906 (PG)

recitals

of

the

Page 4

elements

of

a

cause

of

action.”

Ocasio-Hernandez

v.

Fortuno-Burset, 640 F.3d 1, 12 (1st Cir.2011) (citing Twombly, 550 U.S. at
555) (internal quotation marks omitted). That is, the court “need not accept
as true legal conclusions from the complaint or naked assertions devoid of
further factual enhancement.” Maldonado v. Fontanes, 568 F.3d 263, 266 (1st
Cir.2009) (citing Iqbal, 556 U.S. at 678). “A complaint ‘must contain more
than a rote recital of the elements of a cause of action,’ but need not
include ‘detailed factual allegations.’” Rodriguez-Vives v. Puerto Rico
Firefighters Corps, 743 F.3d 278, 283 (1st Cir.2014) (citing Rodríguez–Reyes
v. Molina–Rodríguez, 711 F.3d 49, 53 (1st Cir.2013)). “Non-conclusory factual
allegations in the complaint must then be treated as true, even if seemingly
incredible.” Ocasio-Hernandez, 640 F.3d at 12 (citing Iqbal, 556 U.S. at 681).
“Determining whether a complaint states a plausible claim for relief will
… be a context-specific task that requires the reviewing court to draw on its
judicial

experience

and

common

sense.”

Iqbal,

556

U.S.

at

664-664.

Nevertheless, when evaluating the plausibility of a legal claim, a court may
not “attempt to forecast a plaintiff’s likelihood of success on the merits;
a well-pleaded complaint may proceed even if … a recovery is very remote and
unlikely.” Ocasio-Hernandez, 640 F.3d at 12-13 (citing Twombly, 550 U.S. at
556). As a result, courts should read the complaint “as a whole” and be
cautious not to apply the plausibility standard “too mechanically.” See
Rodriguez-Vives, 743 F.3d at 283 (citing Garcia–Catalan, 734 F.3d at 101,
103).
III. DISCUSSION
A. EMTALA Claims
“Congress enacted EMTALA in 1996 in response to claims that hospital
emergency rooms were refusing to treat patients with emergency conditions but
no medical insurance. … EMTALA therefore ‘is a limited anti-dumping statute,
not a federal malpractice statute.’” Ramos-Cruz v. Centro Medico del Turabo
642 F.3d 17, 18 (1st Cir.2011) (citing Reynolds v. MaineGeneral Health, 218
F.3d 78, 83 (1st Cir.2000)). “To this end, 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.’” Alvarez–Torres v. Ryder
Memorial Hosp., Inc., 582 F.3d 47, 51 (1st Cir.2009) (citing 42 U.S.C.

CIV. NO. 13-1906 (PG)

Page 5

§ 1395dd(a), (b)(1)(A); López-Soto v. Hawayek, 175 F.3d 170, 172-73 (1st
Cir.1999)). To establish an EMTALA violation, a plaintiff must show that:
(1) the hospital is a participating hospital, covered
by EMTALA, that operates an emergency department (or an
equivalent facility); (2) the patient arrived at the
facility 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.
Correa v. Hospital San Francisco, 69 F.3d 1184, 1190 (1st Cir.1995) (internal
citations omitted).
In the case at hand, the Hospital does not contest that the Plaintiff
properly alleged the first and second elements of an EMTALA cause of action.
That is, the Plaintiff arrived at the emergency room of the Hospital, a
participating EMTALA facility, seeking medical care for a medical condition.
The issue thus turns on the remaining elements.
1. Duty to Screen
In the motion to dismiss, the Hospital argues that Gonzalez failed to
properly set forth a plausible EMTALA claim for which relief could be granted.
See Docket No. 66-1. According to the Hospital, the Plaintiff relies on
conclusory statements and omits to allege any facts supporting a claim that
her

screening

was

“somehow

different

or

less

than

similarly

situated

patients.” Id. at page 12.
With regards to a participating hospital’s medical screening requirement
under EMTALA, subsection (a) of the statute establishes that:
In the case of a hospital that has a hospital emergency
department, if any individual … 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 … exists.
42 U.S.C.A. § 1395dd(a). “EMTALA does not define the term ‘appropriate medical
screening examination.’ However, it does indicate that the purpose of the
screening is to identify an ‘emergency medical condition.’” del Carmen
Guadalupe v. Negron Agosto, 299 F.3d 15, 19 (1st Cir.2002). The statute
defines the term “emergency medical condition” as:

CIV. NO. 13-1906 (PG)

Page 6

(A) 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-(i) placing the health of the individual
(or, with respect to a pregnant woman, the
health of the woman or her unborn child) in
serious jeopardy,
(ii)
serious
impairment
to
bodily
functions, or
(iii) serious dysfunction of any bodily
organ or part[.]
42 U.S.C. § 1395dd(e)(1)(A).
“For an EMTALA screening violation, a plaintiff need not prove that she
actually suffered from an emergency medical condition when she first came
through the portals of the defendant’s facility … .” Cruz-Vazquez v. Mennonite
Gen. Hosp., Inc., 717 F.3d 63, 69 (1st Cir. 2013) (internal quotation marks
and citations omitted). “Moreover, whereas malpractice liability usually
attaches

when

a

health

care

provider

fails

to

adhere

to

a

‘general

professional standard’ of care, … , EMTALA only requires an appropriate
medical

screening

examination

within

the

capability

of

the

hospital’s

emergency department.” del Carmen Guadalupe, 299 F.3d at 21 (internal citation
and quotation marks omitted). “A claim of inappropriate medical screening
based on a failure to provide certain diagnostic tests must at least address
whether the hospital was capable of performing such tests.” Id. at 22.
In the complaint, the Plaintiff essentially alleges that the Hospital
failed to provide her with the appropriate and necessary medical screening
that was required under EMTALA in light of the critical medical condition she
was in. See Docket No. 1. According to Gonzalez, the physical examination she
received was inadequate for a patient presenting the set of symptoms and vital
signs recorded during her three visits to PCH.1 Id. To that effect, Plaintiff
particularly alleges that the Hospital “failed to provide an adequate medical
screening exam that was required of patients with substantially similar
symptoms.” Id. at ¶ 3.22.
When evaluating the plausibility of the Plaintiff’s claims, it is
uncertain at this point whether the tests and treatment that Gonzalez needed
were in fact within the Hospital’s capability, as it is neither alleged or

1
The court notes that the Plaintiff unequivocally stated that her vital signs were
taken every time she visited the Hospital, and that both blood laboratory tests and x-rays
were ordered and performed. She was given antibiotics and pain medication on her December
16th visit. Six days later, on her third and last visit on December 22nd , she was prescribed
Toradol. See Docket No. 1.

CIV. NO. 13-1906 (PG)

Page 7

denied by PCH. Moreover, the Hospital failed to counter Plaintiff’s allegation
that the screening she was provided during her three visits was not uniform
to the level of screening PCH provides other patients presenting similar
complaints or symptoms. In fact, the Plaintiff alleges that she lacks the
Hospital’s relevant protocols, which are necessary for this determination. See
Docket No. 3 at ¶ 3.33.
Because at this stage reasonable inferences are taken in favor of the
pleader,

the

court

hereby

finds

that

the

Plaintiff

has

sufficiently

articulated a cause of action under EMTALA for failure to screen. Accordingly,
the Hospital’s request for dismissal of Plaintiff’s EMTALA screening claim is
DENIED.
2. Duty to Stabilize
The Hospital also requests the dismissal of Gonzalez’s stabilization
claim under EMTALA. It argues that the Plaintiff failed to allege that she was
suffering from an emergency medical condition during any of her three visits
or at the time of any of her discharges from PCH. See Docket No. 66-1 at page
12. PCH also contends that Plaintiff’s EMTALA stabilization claim fails
because she doesn’t allege that the Hospital had knowledge that an emergency
condition existed before discharging her. Id. at 17-18.
“As a corollary to the right to be appropriately screened, EMTALA
guarantees patients the right, if an emergency medical condition is determined
to exist, to have that condition stabilized before discharge or transfer to
another hospital.” Reynolds, 218 F.3d at 84 (emphasis ours). To that effect,
the statute provides, in relevant part, 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 … .
42 U.S.C. § 1395dd(b)(1). EMTALA defines the term “to stabilize” as “to
provide such medical treatment of the 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

CIV. NO. 13-1906 (PG)

Page 8

individual from a facility … .” 42 U.S.C. § 1395dd(e)(3)(A)(emphasis ours).
“The term ‘transfer’•means the movement (including the discharge) of an
individual outside a hospital’s facilities at the direction of any person
employed by (or affiliated or associated, directly or indirectly, with) the
hospital … .” 42 U.S.C.A. § 1395dd(e)(4)(emphasis ours).
Per the language of the statute, “the duty to stabilize is only triggered
when it has been determined that the patient is suffering from an emergency
medical condition.” Vazquez-Rivera v. Hosp. Episcopal San Lucas, Inc., 620 F.
Supp. 2d 264, 269 (D.P.R. 2009). Moreover, “[t]he 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.’” Alvarez-Torres, 582 F.3d at 51 (citing
Fraticelli-Torres v. Hosp. Hermanos, 300 Fed.Appx. 1, 4 (1st Cir.2008)
(unpublished)).
As the Hospital accurately points out in its motion, nowhere on the
complaint did the Plaintiff allege that she was suffering from - or even
diagnosed - with an emergency medical condition before discharge from her
three visits to PCH between December 15th and December 22nd of 2011. The
allegation that she was diagnosed with a bacterial infection in her right hip
over a month and a half after her visits to PCH is insufficient to establish
that at the time of her discharges from PCH she was in fact suffering from an
emergency medical condition. See Reynolds, 218 F.3d at 85 (affirming summary
dismissal of plaintiffs’ EMTALA stabilization claim for failure to satisfy a
necessary predicate to the duty to stabilize by showing that an emergency
medical condition was in existence at the time of patient’s discharge); Kenyon
v. Hosp. San Antonio, Inc., 951 F. Supp. 2d 255, 264 (D.P.R. 2013) (“[B]y its
plain language, the statute does not provide a cause of action when a hospital
does not stabilize an emergency medical condition that it negligently failed
to diagnose.”).
In fact, Plaintiff admits that the physicians at the Hospital failed to
diagnose her condition. See Docket No. 3 at ¶ 3.34. Yet, “the plain language
of the statute dictates a standard requiring actual knowledge of the emergency
medical condition by the hospital staff.” Colon-Ramos v. Clinica Santa Rosa,
Inc., 938 F. Supp. 2d 222, 225 (D.P.R. 2013) (internal citations omitted).
Gonzalez’s omission to allege a necessary predicate of her stabilization
claim under EMTALA proves fatal, and thus, it is hereby DISMISSED.

CIV. NO. 13-1906 (PG)

Page 9

B. Supplemental Claims
Finally, in its motions to dismiss, the Hospital requests that the state
law claims be dismissed without prejudice insofar as the court should dismiss
the federal claims. However, as discussed above, the Plaintiff has pleaded a
plausible screening claim under EMTALA. Because Plaintiff’s state-law claims
arise out of the same nucleus of operative facts as her claim under federal
law, it is in the interest of judicial efficiency that this court retain
jurisdiction over the supplemental state law claims. See Ortiz-Bonilla v.
Federacion de Ajedrez de Puerto Rico, Inc., 734 F.3d 28, 35 (1st Cir.2013) (“A
federal court that exercises federal question jurisdiction over a single claim
may also assert supplemental jurisdiction over all state-law claims that arise
from the same nucleus of operative facts.”). The Hospital’s request that the
court dismiss Plaintiff’s supplemental claims under Puerto Rico law is DENIED.
IV. CONCLUSION
For the reasons stated above, this court hereby GRANTS IN PART AND DENIES
IN PART the Hospital’s motion to dismiss (Docket No. 66), and the Plaintiff’s
stabilization claims under EMTALA are hereby DISMISSED.
IT IS SO ORDERED.
In San Juan, Puerto Rico, November 17, 2015.
S/ JUAN M. PEREZ-GIMENEZ
JUAN M. PEREZ-GIMENEZ
SENIOR U.S. DISTRICT JUDGE