Cruz et al v. Hospital Episcopal San Lucas, Inc. et al
Filing
124
OPINION AND ORDER: Denied 79 Motion for summary judgment. Signed by US Magistrate Judge Marshal D. Morgan. (GDM)
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 1 of 17
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
NEIDA CRUZ; MIRTA CRUZ; CARLOS
CRUZ; MOISÉS CRUZ,
Plaintiffs,
v.
CIV. NO. 16-2959 (MDM)
HOSPITAL EPISCOPAL SAN LUCAS,
INC.; GUILLERMO BOLAÑOS, ET.AL.,
Defendants.
OPINION AND ORDER
Plaintiffs, the sons, and daughters of a deceased patient, filed a medical
malpractice suit under Puerto Rico law against various defendants, namely, the
treating hospital, treating physicians, and the hospital’s home care unit, claiming
negligence and deviation from the standard of care required of medical professionals
under Articles 1802 and 1803 of the Puerto Rico Civil Code, P.R. Laws Ann. tit. 31,
§§ 5141 & 5142.
Presently before the Court is co-defendant San Lucas Episcopal Home Care
Inc.’s (hereinafter “San Lucas Home Care”) Motion for summary judgment in which
San Lucas Home Care moves to dismiss the medical malpractice claims asserted
against it. (Docket No. 79). With its motion, San Lucas Home Care issued a proposed
statement of uncontested material facts. (Docket No. 79-1). In turn, Plaintiffs filed a
memorandum opposing the entry of summary judgment (Docket No. 111) and offered
their respective statement of uncontested material facts (Docket No. 110). San Lucas
Home Care did not offer a reply to the arguments raised by Plaintiffs, nor did it admit,
deny, or qualify the additional facts proffered by Plaintiffs. 1 After a close examination
Pursuant to Local Rule 56(e) of the Local Rules of the United States District Court for the
District of Puerto Rico “[f]acts contained in a supporting or opposing statement of material facts, if
1
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 2 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 2Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
of the filings, the evidence on record, and the applicable law, the Court DENIES San
Lucas Home Care’s motion for summary judgment.
I.
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 a judgment as a matter of law.” See, Fed. R. Civ. P. 56(c); Celotex Corp. v.
Catrett, 477 U.S. 317, 322 (1986); Sands v. Ridefilm Corp., 212 F.3d 657, 660 (1st Cir.
2000). A factual dispute is “genuine” if ‘it may reasonably be resolved in favor of either
party at trial” and “material” if it potentially affects the outcome of the case. Iverson
v. City of Boston, 452 F.3d 94, 98 (1st Cir. 2006).
The party moving for summary judgment has the initial burden of
“demonstrat[ing] the absence of a genuine issue of material fact” with definite and
competent evidence. Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S. Ct. 2548,
91 L. Ed. 2d 265 (1986); Maldonado–Denis v. Castillo–Rodríguez, 23 F.3d 576, 581
(1st Cir. 1994). Thus, the moving party bears the initial burden of showing a lack of
evidence to support the non-moving party’s case. Id. at 325. It must identify “portions
of ‘the pleadings, depositions, answers to interrogatories, and admissions on file,
together with the affidavits, if any’” which support its motion. Catrett, 477 U.S. at
323, 106 S. Ct. 2548 (citing Fed. R. Civ. P. 56(c)). Only when a properly supported
motion has been presented does the burden shift to the non-moving party
“to demonstrate
that
a
trier
of
fact
reasonably
could
find
in
[its]
favor.” Santiago-Ramos v. Centennial P.R. Wireless Corp., 217 F.3d 46, 52 (1st Cir.
2000) (internal citation omitted). If the non-movant generates uncertainty as to the
true state of any material fact, the movant’s efforts should be deemed unavailing.
Suarez v. Pueblo Int’l, 229 F.3d 49, 53 (1st Cir. 2000). As such, to defeat summary
supported by record citations as required by this rule, shall be deemed admitted unless properly
controverted.”
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 3 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 3Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
judgment, the non-moving party must “set forth specific facts showing that there is a
genuine issue for trial.” Fed. R. Civ. P. 56(e).
When considering a motion for summary judgment, the Court must view the
evidence in the light most favorable to the non-moving party and give that party the
benefit of all reasonable inferences. See, Liberty Lobby, Inc., 477 U.S. at 255. In
addition, the Court must review the record “taken as a whole,” and “may not make
credibility determinations or weigh the evidence.” Reeves v. Sanderson Plumbing
Products, Inc., 530 U.S. 133, 135, 120 S. Ct. 2097, 147 L. Ed. 2d 105 (2000). Fed. R.
Civ. P. 56 does not ask which party’s evidence is more plentiful, or better
credentialed, or stronger weighted, because summary judgment “admits no room for
credibility determinations, no room for the measured weighing of conflicting evidence
such as the trial process entails.” Id. (citing Greenburg v. Puerto Rico Maritime
Shipping Authority, 835 F.2d 932, 936 (1st Cir. 1987)). See, also, Cortés–Irizarry v.
Corporación Insular, 111 F.3d at 187; see, also, Casas Office Machines, Inc. v. Mita
Copystar America, Inc., 42 F.3d 668 (1st Cir. 1994). If the court finds that some
genuine factual issue remains, the resolution of which could affect the outcome of the
case, then the court must deny summary judgment. Liberty Lobby, Inc., 477 U.S. at
248.
II.
Factual Allegations
Plaintiffs Neida Cruz, Mirta Cruz, Moisés Cruz, and Carlos Cruz (collectively
“Plaintiffs”) brought this action against Hospital Episcopal San Lucas, Inc.,
Dr. Guillermo Bolaños (“Dr. Bolaños,”) Dr. Aurelio Collado (“Dr. Collado,”) and San
Lucas Home Care for the damages they allegedly suffered as a result of the negligent
acts and omissions of all defendants, which they claim, caused the untimely death of
their father. (Docket No. 1). 2
The Court had to turn to the complaint to summarize the factual background of this case
because the moving party, San Lucas Home Care, did not offer the necessary facts to shed light into
what happened to Mr. Cruz Colón. (See, Docket No. 1). In the upcoming discussion, moreover, it will
become clear that San Lucas Home Care’s motion for summary judgment and proposed statement of
uncontested material facts are insufficient to support the relief requested.
2
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 4 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 4Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
Mr. Carlos Cruz Colón (“Mr. Cruz Colón”) was a 68-year-old male with history
of diabetes, end-stage renal disease, congestive heart failure, obesity, and multiple
abdominal surgeries. Mr. Cruz Colón was admitted to the facilities of Hospital San
Lucas on August 5, 2015, for a ventral hernia repair under the medical care of
Dr. Guillermo Bolaños. Mr. Cruz Colón was discharged home on August 10, 2015,
with a follow-up appointment with Dr. Bolaños.
On August 11, 2015, Mr. Cruz Colón visited the Emergency Room of Hospital
San Lucas with complaints of abdominal pain and discharge from his surgical wound.
His abdomen was distended with moderate tenderness and oozing seroussanguineous fluid from midline. He developed respiratory failure, septic shock, and
was hospitalized in the Intensive Care Unit of Hospital San Lucas on mechanical
ventilation. Mr. Cruz Colón’s condition gradually stabilized, and he was weaned off
the respirator and inotropic agents. He was discharged home on August 27, 2015.
On August 30, 2015, he returned to the Emergency Room of Hospital San
Lucas with complaints of yellow-brown material discharge from the wound for the
prior two days. Mr. Cruz Colón was re-admitted to Hospital San Lucas with a
diagnosis of enterocutaneous fistula and was started on total parental nutrition per
central line. Fistula was of high output causing malnutrition and electrolyte
abnormalities. During the subsequent two months, there was no improvement or
decrease in the output from the fistula.
On November 3, 2015, Mr. Cruz Colón was discharged and sent home on total
parental nutrition under the supervision of co-defendants, Dr. Collado and San Lucas
Home Care. He was discharged with leukocytosis and fever. Dr. Collado never visited
Mr. Carlos Cruz Colón while on home care nor treated him after his discharge from
Hospital San Lucas. On November 10, 2015, Mr. Cruz Colón was again brought to
Hospital San Lucas with fever and chills, decreased urine output and history of
increased output from the enterocutaneous fistula. He was hypoactive and on BIPAP
with clinical signs of sepsis. On November 13, 2015, Mr. Cruz Colón was found
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 5 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 5Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
unresponsive, pulseless and did not respond to CPR measures. Mr. Cruz Colón died
that day at the hospital. (See, Docket Nos. 1; 110-3).
III.
Relevant Facts
The parties’ summary judgment pleadings, and the evidentiary record, reveal
the following uncontested material facts. 3
Dr. José Ortiz Feliciano (“Dr. Ortiz Feliciano”) is the expert witness for
Plaintiffs. He is a general surgeon who deals with pre-operative, operative and postoperative treatment. Dr. Ortiz Feliciano has dealt with multiple cases of recurrent
hernia, like the present case.
In his expert report, Dr. Ortiz Feliciano’s only allegation of negligence against
San Lucas Home Care is included in item number 6, which states as follows:
Permitted to develop the classic triad of enterocutaneous
fistula of sepsis, fluid and electrolyte imbalance during the
period of 11/3/2015-11/10/2015 while at home care under
the supervision of Dr. Collado. The above stated actions
and therapeutic omissions are a departure from accepted
medical practice by Dr. Bolaños, Dr. Collado, Hospital San
Lucas and Hospital San Lucas Home Care.
(See, Exhibit 1 of Docket No. 79 at 3).
During his deposition, Dr. Ortiz Feliciano attested to the following:
Q: Do you know what kind of services were specifically
requested from the home care?
Pursuant to Local Rule 56, the Court will only deem as genuinely opposed those statements
of material facts which the objecting party properly denied or qualified in strict compliance with Local
Rule 56(c). The Court also credits only facts properly supported by accurate record citations. See, Local
Rule 56(e). The Court has disregarded all arguments, conclusory allegations, speculation, and
improbable inferences disguised as facts. See, Forestier Fradera v. Municipality of Mayaguez, 440 F.3d
17, 21 (1st Cir. 2006); Medina-Muñoz v. R.J. Reynolds Tobacco Co., 896 F.2d 5, 8 (1st Cir. 1990).
In this case, as noted above, Plaintiffs issued their own statement of uncontested material
facts with their opposition to the motion for summary judgment. San Lucas Home Care did not offer a
response to the statements either admitting, denying, or qualifying each statement so, the Court
deemed as admitted the facts that were supported by the record citations. Pursuant to Local Rule 56(e)
of the Local Rules of the United States District Court for the District of Puerto Rico “[f]acts contained
in a supporting or opposing statement of material facts, if supported by record citations as required by
this rule, shall be deemed admitted unless properly controverted.”
3
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 6 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 6Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
Dr. Ortiz Feliciano: The only thing I know based on the
resident’s notes [is] that it was contingent on the
supervision by those two physicians.
(Docket No. 79-5).
Q: From there did you find out what kind of services were
requested for the home care?
Dr. Ortiz Feliciano: Wound care.
Q: Are you aware that the patient was discharged on
November 3, 2015?
Dr. Ortiz Feliciano: Yes.
Q: And that the first visit by the nurse was on November
4, 2015? . . . [O]n the 4th.
Id. at 85.
Q: On the 4th. So, the day after he was discharged the
nurse went for the initial evaluation, correct?
Dr. Ortiz Feliciano: Yes.
Q: Do you agree with me that in this case the nurses from
San Lucas Home Care performed what they were supposed
to do and complied with what was required from them?
Dr. Ortiz Feliciano: Complied with his wound healing,
yes.
Q: So specifically[,] you cannot say that the personnel from
the home care did not perform what they were supposed to
do.
Dr. Ortiz Feliciano: No because and I cite, “Patient’s TPN
was changed, managed the medication and we are waiting
for the surgeon’s evaluation.” So, they were managing the
TPN and the medication. That is the note.
Id. at 86.
Wound healing[,] I have no complaints.
Id. at 87.
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 7 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 7Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
Q: In order for me to be clear[,] as part of your opinion[,]
you don’t have any complaints regarding any deviation
from the standard of home care by any of the personnel of
the San Lucas Home care?
Dr. Ortiz Feliciano: The nursing personnel no.
Q: Did any other personnel deal with the patient?
Dr. Ortiz Feliciano: That is the only personnel identified.
The nursing.
Q: Then all the personnel of San Lucas Home care who
went and provided home care you do not have any
complaints regarding any deviation from the standard?
Dr. Ortiz Feliciano: No.
(Docket No. 79-5 at 87-88).
Dr. Collado stated during his deposition that when a patient is referred to
“Home Care,” “Home Care’s” personnel evaluates the patient and refers the notes of
what they do to the physician. Dr. Collado admitted under oath that he signed a plan
of care for Mr. Cruz Colón that was not discussed with him by San Lucas Home Care.
Dr. Collado signed a medical order for San Lucas Home Care so that the
institution could charge Mr. Cruz Colón’s medical health plan. Dr. Collado admitted
that he signed medical orders for the services provided by San Lucas Home Care to
Mr. Cruz Colón after Mr. Cruz Colón had died in order for San Lucas Home Care to
bill the insurance company and collect payment. San Lucas Home Care, in turn,
charged the medical health plan of Mr. Carlos Cruz for the medical services offered
to the patient in November 2015 before he passed away.
IV.
Discussion
The motion for summary judgment currently before the Court concerns the
post-operative medical care that Mr. Cruz Colón received from San Lucas Home Care
at his home from November 3, 2015, through November 10, 2015, after which he had
to be rushed to Hospital San Lucas where he passed away three days later. San Lucas
Home Care alleges that Plaintiffs cannot make a showing of the institution’s liability
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 8 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 8Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
for its alleged malpractice in the medical treatment provided to the patient. More
specifically, San Lucas Home Care maintains that the evidence of record shows that
the actions of its nurses and personnel did not deviate from the required standard of
care and, therefore, they are entitled to summary judgment on all claims against it.
A.
Medical Malpractice Liability in Puerto Rico
In this jurisdiction, tort liability for medical malpractice arises under Article
1802 of the Puerto Rico Civil Code, P.R. Laws Ann. tit. 31, Section 5141. Medical
malpractice liability in Puerto Rico is negligence and fault based. Rodríguez-Díaz v.
Seguros Triple–S, 636 F.3d 20, 23 (1st Cir. 2011) (internal citation omitted). To
establish a prima facie case of medical malpractice a party must establish: (1) the
duty owed (i.e., the minimum standard of professional knowledge and skill required
in the relevant circumstances); (2) an act or omission transgressing that duty; and (3)
a sufficient causal nexus between the breach and the harm. Otero v. United
States, 428 F. Supp. 2d 34, 45–46 (D.P.R. 2006) (citing Rivera v. Turabo Med. Ctr.
P’ship, 415 F.3d 162, 167 (1st Cir. 2005)). Torres–Lazarini v. United States, 523 F.3d
69, 72 (1st Cir. 2008).
Under Puerto Rico law, a hospital can be held liable to its patients for
malpractice when there has been negligence on the part of the hospital’s
employees. Márquez Vega v. Martínez Rosado, 116 D.P.R. 397, 405, 16 P.R. Offic.
Trans. 487, 495 (1985). Thus, the hospital’s liability is based on the vicarious liability
doctrine. Id. See, Morales v. Monagas, 723 F. Supp. 2d 416, 419 (D.P.R. 2010). Given
the evolutionary nature of hospitals, courts in Puerto Rico also extend vicarious
liability “to situations where a patient seeks medical aid directly from a hospital and
the hospital provides the treating physician—regardless of the physician’s
employment relationship with the hospital.” Casillas–Sánchez v. Ryder Mem. Hosp.,
Inc., 960 F. Supp. 2d 362, 366 (D.P.R. 2013) (Besosa, J.). Furthermore, because a
hospital also owes an independent duty of care to patients, it may face liability for its
own negligence as well. Márquez Vega, supra; Casillas–Sánchez, 960 F. Supp. 2d at
366. With respect to a hospital’s liability towards its patients, the Supreme Court of
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 9 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 9Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
Puerto Rico has also firmly established that hospitals owe their patients that degree
of care that would be exercised by a reasonable and prudent person in the same
conditions and circumstances. See, Márquez Vega, 116 D.P.R. at 404–405 (internal
quotations omitted).
In terms of the standard of care owed specifically by nurses, the Puerto Rico
Supreme Court has established that a nurse must use a degree of reasonable care to
avoid causing unnecessary harm to the patient, and such degree of care must be equal
to the degree of care exercised by other nurses in the locality or similar localities. Blas
Toledo Y Otros v. Hospital Nuestra Señora De La Guadalupe, 146 D.P.R. 267, 307
(1998), (citing Castro v. Municipio De Guánica, 87 D.P.R. 725, 728–729 (1963)).
In Puerto Rico, nurses and paramedic personnel have the unavoidable duty to fulfill
medical orders with the required urgency and in accordance with each patient’s
particular circumstances. Ponce v. Ashford Presbyterian Community Hosp.,
189 F.R.D. 31, 33 (D.P.R. 1999) (internal citations omitted).
Turning to the causation element, the law of Puerto Rico dictates that to
establish causation, a plaintiff must prove by a preponderance of the evidence, that
“the [medical provider’s] negligent conduct was the factor that ‘most probably’ caused
harm to the plaintiff.” Rivera v. Turabo Med. Ctr. P’ship, 415 F.3d 162, 168 (1st Cir.
2005). Causation usually cannot be found based on mere speculation and conjecture.
Expert testimony is generally essential in order to clarify complicated medical issues
that are more prevalent in medical malpractice cases than in standard negligence
cases. Otero, 428 F. Supp. 2d at 46. Pages-Ramírez v. Hosp. Espanol Auxillo Mutuo
De Puerto Rico, Inc., 547 F. Supp. 2d 141, 149 (D.P.R. 2008).
B.
Liability of San Lucas Home Care
San Lucas Home Care alleges that the evidence it has submitted with its
motion for summary judgment shows the absence of material issues of fact with
respect to its liability for the alleged malpractice in the treatment of Mr. Cruz Colón.
San Lucas Home Care premises its theory on the deposition testimony of Plaintiff’s
expert, Dr. Ortiz Feliciano. To demonstrate a lack of liability, San Lucas Home Care
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 10 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 10Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
points to Dr. Ortiz Feliciano’s statement during his deposition that the nurses from
San Lucas Home Care performed what they were supposed to perform and complied
with what was required of them when caring for the patient. San Lucas Home Care
also relies on Dr. Ortiz Feliciano’s statement that there were no deviations from the
standard of care by the nurses of San Lucas Home Care that provided services to
Mr. Cruz Colón at his home. Moreover, San Lucas Home Care points to Dr. Ortiz
Feliciano’s testimony that he did not expect from a nurse to be able to tell if a patient
is septic, which the patient became in this case while under the care of San Lucas
Home Care, before having to be swiftly transported to the hospital where he died soon
thereafter. Relying on such testimony from Plaintiffs’ expert, San Lucas Home Care
argues that Plaintiffs cannot establish a prima facie case of medical malpractice
against it and that such proof is dispositive of the inquiry into its potential liability
in this case.
By contrast, Plaintiffs contend that summary judgment is improper in this case
because they have offered sufficient evidence to create triable issues of material fact
as to whether San Lucas Home Care violated its duty of care, and, if so, whether its
negligent actions caused and/or contributed to Mr. Cruz Colón’s demise. Because the
parties’ respective positions rely almost entirely on the deposition testimony of
Plaintiff’s expert, in addition to reviewing the parties’ evidence, the Court conducted
an independent examination of the important deposition. After a close review of the
evidence, the Court agrees with Plaintiffs that there are genuine issues of material
fact for a jury to decide concerning whether San Lucas Home Care and/or its staff
deviated from the applicable standard of care owed to the patient Mr. Cruz Colón.
To begin with, Plaintiff’s expert, Dr. Ortiz Feliciano, testified that the nursing
staff of San Lucas Home Care complied with what they were required to do with the
patient, in terms of wound care, specifically. To that effect, he testified:
Q: Do you agree with me that in this case the nurses from
San Lucas Home Care performed what they were supposed
to do and complied with what was required from them?
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 11 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 11Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
Dr. Ortiz Feliciano: Complied with his wound healing,
yes.
(See, Docket No. 79-5 at 85).
Dr. Ortiz Feliciano: Wound healing[,] I have no
complaints.
Id. at 86. After closely reviewing his testimony, Plaintiff’s expert did not clear the
nursing staff from liability in this case. While such testimony is significant indeed, it
is not enough to let San Lucas Home Care off the liability hook. To be sure, Plaintiff’s
expert did not opine that the nurses of San Lucas Home Care complied with the
applicable standard of care in an all-encompassing manner with respect to the duty
owed to the patient in this case. Dr. Ortiz Feliciano’s testimony was limited only to
the nursing staff and their specific duty of wound care. To that effect, there are
missing pieces to this liability puzzle. For instance, San Lucas Home Care did not
offer evidence to show what were the nursing staff’s duties with respect to the patient.
While it is true that Plaintiff’s expert testified that based on one medical note, the
nursing staff was tasked with “wound care” for the patient, it is unclear whether, in
addition to the post-operative wound care, the nursing staff was tasked with
additional duties. San Lucas Home Care thus failed to offer conclusive evidence
showing that its nurses were solely tasked with providing wound care for the patient
and nothing more. Without that information, the Court cannot determine whether
there was a deviation from the standard of care by the nursing staff of San Lucas
Home Care. The Court finds that such information is crucial in determining San
Lucas Home Care’s liability.
Next, it is unclear to the Court who were the specific staff members from San
Lucas Home Care tasked with the patient’s medical care. In other words, San Lucas
Home Care failed to explain who exactly were the members of its staff that were
responsible for caring for Mr. Cruz Colón at his home. Were nurses from San Lucas
Home Care the only ones tasked with caring for the patient? Did other staff members
intervene with, or assist, the patient? And, if so, who were those people and what
were their duties? The Court believes all of this information is critical to determining
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 12 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 12Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
whether San Lucas Home Care is liable in this case, and, at the moment, it is
unknown.
Furthermore, there are questions of fact concerning San Lucas Home Care’s
rules regarding physician’s orders and the manner in which the orders are carried
out by their nursing staff. Although nurses need to comply with physician’s orders,
under Puerto Rico law, nurses are also compelled to meet “certain independent
standards of care.” Pages–Ramírez, 547 F. Supp. 2d at 149. Similarly, nurses must
use a certain degree of care to avoid causing unnecessary harm to the patient. Blas
Toledo, 146 D.P.R. at 307. Here, the evidence offered by San Lucas Home Care does
not show that the nursing staff met this standard.
In addition to the above, Plaintiffs have introduced evidence suggesting that
San Lucas Home Care was (perhaps) negligent in the care and treatment of Mr. Cruz
Colón. For example, Plaintiff’s point to the following portions of their expert, Dr. Ortiz
Feliciano’s, deposition testimony.
Dr. Ortiz Feliciano: The record states that Dr. Bolaños
and Dr. Collado accepted to manage this patient at the
nursing home and supervise that [sic] when he was
discharged. The patient [however] returned in extremely
septic conditions [to Hospital San Lucas] and the records
that I was submitted from the nursing home have no
evidence that they supervised or evaluated that patient at
that time.
(Docket No. 79-5 at 78).
Q: Where did you get the information that Dr. Aurelio
Collado had the obligation, that he had to supervise the
home care treatment?
Dr. Ortiz Feliciano: The discharge note from the hospital
by the resident says that Dr. Collado and Dr. Bolaños
accepted to supervise the management of this case at the
nursing home. That is the extent.
…
Dr. Ortiz Feliciano: In this specific case[,] I can only state
from the record that this is clear that the resident in this
discharge note specifies the name of Dr. Bolaños and Dr.
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 13 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 13Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
Collado a[re] the supervising physicians in the
management of this case at home.
…
Dr. Ortiz Feliciano: I am saying that the record says that
he will supervise[,] and I found no instance either visiting
or written of supervision. So, I cannot state that there was
this supervision.
(Docket No. 79-5 at 80).
Dr. Ortiz Feliciano: I cannot state as a matter of fact that
there was supervision. . . . Supervision means you see the
patient and you follow what is going on. But the record is
silent of that.
Id. at 81.
Q: How did that lack of supervision as to the 7 days of home
care treatment contribute[,] if in any manner, to the
patient’s demise?
Dr. Ortiz Feliciano: Completely.
Q: Why?
Dr. Ortiz Feliciano: The patient had a percutaneous
fistula. One of the problems that you have is that they will
go into liquid. . . They have a large output for the fistula.
So, you have fluid imbalance. If you are not on top of that
you will develop a fluid imbalance and you will develop
sepsis and an electrolyte imbalance. Frankly, and I will
state again what I stated before. This patient should not
have been sent [to home care], I would not have sent him to
simplify them to home care. That is impossible. The patient
had a fistula output of over 500 cc. You have to monitor
them daily. How much is he putting in, how much am I
giving to him. How is [sic] the electrolytes. That is a
hospital-based patient. It is physically impossible to
manage him at home.
Id. at 82.
Dr. Ortiz Feliciano: If he was supervising him after the
first day or the second day[,] he would have sent this patient
back to the hospital.
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 14 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 14Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
(Docket No. 79-5 at 82-83).
Dr. Ortiz Feliciano: He shouldn’t have been sent for home
care. I think sending him to home care contributed to his
death.
Q: And for sure the usual home care that could be provided
to the patient it was not going to get him stabilized nor
improve his condition?
Dr. Ortiz Feliciano: I don’t know how home care accepted
it. There is no way that he [Mr. Cruz Colón] should have
been accepted.
Id. at 84.
Like Plaintiffs submit, the deposition testimony from Plaintiffs’ expert raises
several questions of fact regarding whether San Lucas Home Care complied with its
obligations and legal duty to protect the health of its patient, Mr. Cruz Colón.
Significantly, for instance, Dr. Ortiz Feliciano opined that he doesn’t know how, given
the patient’s complications and symptoms, San Lucas Home Care accepted Mr. Cruz
Colón for home care in the first place. To that effect, there is expert testimony in this
case suggesting that because of Mr. Cruz Colón’s condition and the fact that he had
a percutaneous fistula, he should not have been sent to home care and San Lucas
Home Care should never have accepted the patient. A trier of fact might find that
such expert opinion is indicative of negligence on the part of San Lucas Home Care.
There is also expert testimony affirming that Mr. Cruz Colón did not receive adequate
medical attention or supervision while under the care of San Lucas Home Care. More
specifically, Dr. Ortiz Feliciano stated in no uncertain terms during his deposition
that the lack of supervision by the medical staff and supervising personnel during the
seven (7) days that Mr. Cruz Colón was under the care of San Lucas Home Care
“completely” contributed to his death. Based on that evidence, Plaintiffs maintain
that if San Lucas Home Care did not have the resources or personnel to provide the
necessary care and supervision to Mr. Cruz Colón, San Lucas Home Care should not
have accepted the patient.
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 15 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 15Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
Plaintiffs have also raised material issues of fact with respect to who was
ultimately responsible for supervising the patient while under the medical care of San
Lucas Home Care. For example, there is an issue of fact as to who was responsible
for drafting the medical care plan of the patient for home care and who was
responsible for supervising the patient while at San Lucas Home Care. It is
noteworthy that Dr. Collado admitted under oath that he signed a plan of care for
Mr. Cruz Colón that was not discussed with him by San Lucas Home Care. Does this
constitute a breach of the duty of care owed by San Lucas Home Care to the patient?
There are also questions of fact concerning who was responsible for executing the
patient’s medical plan at San Lucas Home Care, and who was responsible for
communicating the treatment notes and the progress of the patient to the supervising
physician to ensure proper care of the patient. To illustrate this point further, based
on the Court’s independent review of Dr. Collado’s deposition testimony, there is
conflicting testimony from Dr. Collado himself concerning his own supervising role
with respect to the patient while placed in the care of San Lucas Home Care. On one
hand, he testified that he was tasked with the patient’s supervision. On the other
hand, he testified that he never visited the patient, that he had no duty to visit him,
nor did he have a duty to communicate with the nursing staff to check on the patient.
The simple facts of this case are that on November 3, 2015, Mr. Cruz Colón
was discharged from Hospital San Lucas to his home under the care of San Lucas
Home Care. Mr. Cruz Colón was treated by unknown staff of San Lucas Home Care,
his condition worsened, he became septic, and on November 10, 2015, he had to be
rushed to the Emergency Room of Hospital San Lucas where he died shortly
thereafter. There are many unanswered questions of fact as to what happened to
Mr. Cruz Colón while under the care of San Lucas Home Care, such as, whether his
sepsis and deteriorated condition could have been avoided, and whether San Lucas
Home Care was in any way negligent. There are many parties here trying to wash
their hands of liability, but the evidence begs many questions with respect to who
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 16 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 16Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
owed a duty of care to the patient, what was that duty, and whether each party
complied with that duty?
Based on the foregoing, Plaintiffs have raised material questions of fact over
whether San Lucas Home Care failed in some way in providing Mr. Cruz Colón with
adequate post-operative care according to the applicable medical standards and
whether any deviation from the standard of care by its staff, if one can be found,
directly contributed to Mr. Cruz Colón’s death. Under these circumstances, and with
lack of evidence to the contrary, San Lucas Home Care has failed to place the Court
in a position to make a determination as to its liability (or lack thereof) at this
juncture. “In a medical malpractice case, issues of deviation from the medical care
are questions of fact that must be decided by the jury.” Morales v. Monagas, 723 F.
Supp. 2d 416, 423 (D.P.R. 2010) (Gelpi, J.) (citing Cortes–Irizarry, 111 F.3d at 189);
Morrissey v. Procter & Gamble Co., 379 F.2d 675, 677 n.2 (1st Cir. 1967) (“[I]ssues of
fact are not to be resolved on summary judgment.”). As such, because there is no
conclusive evidence suggesting that all personnel from San Lucas Home Care
complied with the required standard of care in treating Mr. Cruz Colón, the Court
cannot discard such party from being a joint tortfeasor in his death. Accordingly, the
question of whether San Lucas Home Care is liable in this case cannot be resolved on
summary judgment. 4
In the Court’s view, there is perhaps another matter precluding the entry of summary
judgment in favor of San Lucas Home Care. San Lucas Home Care failed to discuss the appropriate
standard of care for a home care facility. Without the benefit of the requisite standard of care, if it is
different from that of a hospital or a treating physician, and without well-developed argumentation
supporting a determination that San Lucas Home Care and the staff that treated Mr. Cruz Colón met
such applicable standard of care, summary judgment is inapposite.
4
Case 3:16-cv-02959-MDM Document 124 Filed 07/12/22 Page 17 of 17
Neida Cruz; Mirta Cruz; Carlos Cruz; Moisés Cruz v. Hospital Episcopal San Lucas, Inc., et. al
- 17Civil No. 16-2959 (MDM)
_____________________________________________________________________________________________________________________
V.
Conclusion
Plaintiffs have shown that there are genuine issues of material fact for a jury
to consider at trial that require the Court to deny San Lucas Home Care’s motion for
summary judgment. See, García Colón v. García Rinaldi, 340 F. Supp. 2d 113, 128
(D.P.R. 2004); Pages-Ramírez v. Hosp. Espanol Auxillo Mutuo De Puerto Rico, Inc.,
547 F. Supp. 2d 141, 152 (D.P.R. 2008). In the end, the issue of whether Mr. Cruz
Colón’s death was caused by either of the co-defendant physicians’ negligence, by the
negligence of Hospital San Lucas, San Lucas Home Care, or by a combination of all
the parties, is a question for the jury to answer and not a question for this Court. See,
Calcano-Lopez v. Canetti Mirabal, 106 F. Supp. 2d 200, 205 (D.P.R. 2000).
Accordingly, San Lucas Home Care’s Motion for summary judgment at
Docket No. 79 is DENIED.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 12th day of July 2022.
________________________________
MARSHAL D. MORGAN
United States Magistrate Judge
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?