United States District Court, N.D. California
September 6, 2005.
MARY LOU CAVENDER, Plaintiff,
SUTTER LAKESIDE HOSPITAL, INC., Defendant.
The opinion of the court was delivered by: MAXINE CHESNEY, District Judge
ORDER GRANTING IN PART AND DENYING IN PART DEFENDANT'S MOTION FOR
SUMMARY JUDGMENT; DENYING PLAINTIFF'S MOTION FOR PARTIAL JUDGMENT;
DISMISSING PLAINTIFF'S STATE LAW CLAIMS; VACATING HEARING.
Before the Court is defendant Sutter Lakeside Hospital, Inc.'s
motion for summary judgment, pursuant to Rule 56 of the Federal
Rules of Civil Procedure, and plaintiff Mary Lou Cavender's
motion for partial judgment of liability, pursuant to Rule 56.
Having reviewed the papers filed in support of and in opposition
to the motions,*fn1
the Court deems the matters suitable for
decision on the papers, VACATES the hearing scheduled for
September 2, 2005, and rules as follows. BACKGROUND*fn2
On July 30, 2003, at approximately 10:30 p.m., Roderick
Cavender ("Roderick") took his mother, plaintiff Mary Lou
Cavender, then 80 years of age, to defendant's emergency room
("ER"), because plaintiff had been slurring her speech during the
day. (See Roderick Decl. ¶¶ 1, 2.)*fn3 Roderick is not
plaintiff's legal guardian, nor does he hold a power of attorney.
(See Roderick Dep. at 12:3-5.)*fn4 Later that evening,
Roderick was informed that plaintiff had suffered a stroke, had
extremely high blood pressure and needed to be hospitalized
immediately. (See Roderick Decl. ¶ 2.) At 1:30 a.m. on July 31,
2003, plaintiff was admitted to defendant's medical/surgical ward
for "observation and cerebral vascular accident work-up." (See
Lovejoy Decl. ¶ 2.)
On July 31, 2003, plaintiff was given a chest x-ray, an
ultrasound and other tests. (See id. ¶ 4.) That same day,
plaintiff's physician, Kirk G. Andrus, M.D. ("Dr. Andrus"),
examined plaintiff and formed the opinion that her stroke
symptoms had "stabilized." (See Andrus Dep. at
28:20-23.)*fn5 In his notes, Dr. Andrus wrote that plaintiff
"does not go to physicians and wants to go home to be with her
grandson," (see Lovejoy Decl. Ex. A at 17th unnumbered page),
and that he had "spent a great deal of time" talking to plaintiff
about the need for her to stay in the hospital to receive
treatment, (see id. Ex. A at 19th unnumbered page). At his
deposition, Dr. Andrus was of the opinion that if plaintiff's
condition had remained stable for 24 hours, and had she wanted to
leave, she would have been discharged "within a day or two,"
provided that the results of a echocardiogram did not show
anything "really urgent." (See Andrus Dep. at 34:20-35:6.)
Roderick visited with plaintiff most of the day of July 31.
(See Roderick Decl. ¶ 3.) When Roderick left the hospital at approximately 10:00 p.m. that
evening, plaintiff was resting comfortably and was "hooked up" to
medical monitoring devices. (See id.) At 11:00 p.m. that
evening, defendant's nursing staff noted that plaintiff was in
bed, but at 1:00 a.m. on August 1, observed that plaintiff was
not in her room, and notified both plaintiff's physician and
plaintiff's daughter that plaintiff had left the hospital. (See
Lovejoy Decl. ¶ 4, Ex. A at 27th unnumbered page.) At
approximately 1:15 a.m., Roderick was notified by his sister,
plaintiff's daughter, that plaintiff was not at the hospital,
after which Roderick contacted Robert Cavender ("Robert"), who is
Roderick's father and plaintiff's ex-husband. (See Roderick
Decl. ¶¶ 4-5.) Robert and Roderick then went to the hospital.
(See id. ¶ 5.)
Meanwhile, at the hospital, Patricia Williams ("Williams"), a
certified nursing assistant, went to look for plaintiff by car
and, accompanied by another nursing assistant, found plaintiff in
a "ditch across the street from the back of the hospital," where
they waited until help arrived. (See Williams Dep. at
15:2-20.)*fn6 Plaintiff had dressed herself before leaving
the hospital and was not wearing a hospital gown. (See Smith
Dep. at 33:9-10.)*fn7 Two men arrived with an ambulance and
they, along with Williams, helped plaintiff up from the ditch and
set her down on a gurney. (See Williams Dep. at 21:2-23.)
Plaintiff, however, refused to get into the ambulance. (See
id. at 21:24.) At this point, Williams, in an effort to
convince plaintiff to get into Williams' car, told plaintiff that
if she got in, Williams would "try not to take her back there."
(See id. at 22:1-8.) After plaintiff got into the car,
Williams drove plaintiff back to the hospital and parked outside
of the ER door. (See id. at 22:1-2, 22-23.) Plaintiff stated
to Williams that she "didn't want to go back in there." (See
id. at 25:15-21.) The ER staff, including nurse Tina Smith
("Smith"), then came out of the ER with a wheelchair; Smith
helped plaintiff out of Williams' car and put plaintiff in the
wheelchair. (See id. at 23:1-18.) Smith, observing that plaintiff had a "hematoma" on her head,
tried to encourage plaintiff to allow herself to be evaluated in
the ER, but plaintiff refused. (See Smith Dep. at 29:9-13.)
When Smith then stated, "just let me take you in and try to clean
you up a little bit," plaintiff agreed and allowed Smith to take
her into the building by wheelchair. (See id. at 37:2-5,
39:13-21.) After plaintiff was inside, Pamela Canfield, an ER
registration clerk, asked plaintiff to sign a form giving
defendant permission to treat her; plaintiff refused. (See
Canfield Dep. at 9:14-15.)*fn8 Further, once Smith had
obtained wet cloths to attempt to remove "a little bit of blood"
on plaintiff's forehead, plaintiff would not allow Smith to clean
her, and began yelling, "No, I'm not staying"; "You are just
trying to get me to stay here"; "I want to go"; "Get me outside";
and "If you don't take me outside, I will go out myself." (See
Smith Dep. at 35:15-19, 37:6-25.) When Smith advised plaintiff
that she needed to stay and be evaluated by a physician and that
plaintiff had previously been admitted to the hospital for a
reason, plaintiff stated she did not want to stay and there was
no reason for her to stay. (See id. at 35:24-36:5, 46:4-10.)
Smith did not conduct a "triage assessment," as she "was not able
to get [plaintiff's] vital signs," nor was she able "to take a
stethoscope and listen to her lungs" or "to take a pen light and
evaluate her pupils." (See id. at 42:21-43:5.) Smith did
conduct, however, a mental orientation test, by propounding to
plaintiff a series of questions, asking her if she knew what year
it was, what her name was, where she was, who the president was,
and who her primary care physician was, all of which questions
plaintiff answered correctly; based on this assessment, Smith
formed the opinion that plaintiff was mentally competent. (See
id. at 41:18-25, 42:4-6.)
Plaintiff got up from the wheelchair, as though she was going
to attempt to walk out of the ER, and stated to Smith, "If you
don't take me outside, I will walk out." (See id. at 44:19;
45:6-14.) Smith, having been informed by someone in the ER that
plaintiff's family was coming to the hospital, then took
plaintiff outside in the wheelchair and waited beside her. (See
id. at 45:13-14, 54:8-25.) When Roderick and Robert arrived,
they saw plaintiff seated in a wheelchair, with a security guard, Smith, and
defendant's head nurse, Alden Rabb, R.N. ("Rabb") standing around
plaintiff. (See Roderick Decl. ¶ 5.) Both Roderick and Robert
made comments to indicate they wanted defendant to keep
plaintiff, and Rabb and Smith stated that they could not keep
plaintiff.*fn9 (See id. ¶¶ 6-7; Robert Decl. ¶
4;*fn10 Smith Dep. at 55:8-16, 55:24-56:4, 57:13-16.) After
a heated discussion about whether defendant would or could keep
plaintiff, Smith helped plaintiff to Robert's car, and Roderick
and Robert took plaintiff home. (See Roderick Decl. ¶¶ 7-8.)
At some point during the above-described incident in the ER on
August 1, 2005, plaintiff was presented with a form titled
"Leaving Hospital Against Medical Advice," indicating that
plaintiff was voluntarily leaving the hospital against the advice
of Dr. Andrus; the form bears the signatures of Smith and Raab as
witnesses to plaintiff's refusal to sign the form. (See Lovejoy
Decl. Ex. B.) Thereafter, Dr. Andrus wrote a report titled
"Discharge Summary," in which he noted: "Patient left hospital
against medical advice 8/1/03." (See id. Ex. A, 14th
Late in the evening of August 2, 2003, while plaintiff was at
home, plaintiff's daughter called Roderick to advise him that
"something else had happened" to plaintiff. (See Roderick Decl.
¶ 6.) At 1:30 a.m. on August 3, 2003, plaintiff was readmitted to
defendant hospital, where it was determined plaintiff had
suffered a second stroke. (See id.)
Rule 56 provides that a court may grant summary judgment "if
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.
The Supreme Court's 1986 "trilogy" of Celotex Corp. v.
Catrett, 477 U.S. 317 (1986), Anderson v. Liberty Lobby, Inc.,
477 U.S. 242 (1986), and Matsushita Electric Industrial Co. v.
Zenith Radio Corp., 475 U.S. 574 (1986), requires that a party
seeking summary judgment show the absence of a genuine issue of
material fact. Once the moving party has done so, the nonmoving
party must "go beyond the pleadings and by her own affidavits, or
by the `depositions, answers to interrogatories, and admissions
on file,' designate `specific facts showing that there is a
genuine issue for trial.'" See Celotex, 477 U.S. at 324
(quoting Rule 56(c)). "When the moving party has carried its
burden under Rule 56(c), its opponent must do more than simply
show that there is some metaphysical doubt as to the material
facts." Matsushita, 475 U.S. at 586. "If the evidence is merely
colorable, or is not significantly probative, summary judgment
may be granted." Liberty Lobby, 477 U.S. at 249-50 (citations
omitted). When determining whether there is a genuine issue for
trial, "`inferences to be drawn from the underlying facts . . .
must be viewed in the light most favorable to the party opposing
the motion.'" See Matsushita, 475 U.S. at 587 (quoting
United States v. Diebold, Inc., 369 U.S. 654, 655 (1962)).
In her complaint, plaintiff brings a federal claim against
defendant under the Emergency Medical Treatment and Active Labor
Act ("EMTALA"), 42 U.S.C. § 13955d, as well as state law claims.
"42 U.S.C. § 1395dd(a) provides that if any individual comes to
the emergency department of a hospital which participates in
Medicare, 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 . . .
to determine whether or not an emergency medical condition . . .
exists.'" Eberhardt v. City of Los Angeles, 62 F. 3d 1253,
1255-56 (9th Cir. 1995) (quoting § 1395dd(a); alterations in
original). "If 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 [§ 1395dd(b)].'" Id.
(quoting § 1395dd(b)).
Here, plaintiff's EMTALA claim is based on the theory that
defendant failed to comply with its duty under § 1395dd(a) to
provide an appropriate medical screening examination at the time
plaintiff, having "eloped"*fn12 from the hospital, was
returned to the hospital in the early hours of August 1,
2003.*fn13 Defendant seeks summary judgment on this claim,
while plaintiff seeks partial judgment, specifically, a finding
that it is undisputed that defendant violated § 1395dd(a) by not
providing a medical screening when so requested by plaintiff's
son Roderick and ex-husband Robert.
Defendant argues that plaintiff cannot establish a violation of
EMTALA because, at the time of the events giving rise to
plaintiff's EMTALA claim, plaintiff was an inpatient, in that
plaintiff had been admitted the previous day. Defendant further
argues that, irrespective of plaintiff's status as a patient,
plaintiff had repeatedly refused to be screened and treated in
the ER, thereby relieving defendant of any duty to provide any
services required under EMTALA.
As the Ninth Circuit has explained, EMTALA "was not enacted to
establish a federal medical malpractice cause of action nor to
establish a national standard of care." See Bryant v.
Adventist Health System/West, 289 F. 3d 1162, 1166 (9th Cir.
2002). Rather, EMTALA was enacted because "Congress was concerned
that hospitals were `dumping' patients who were unable to pay, by
either refusing to provide emergency medical treatment or
transferring patients before their conditions were stabilized."
See id. (internal quotation and citation omitted). Accordingly, "EMTALA's
stabilization requirement ends when an individual is admitted for
inpatient care. . . . After an individual is admitted for
inpatient care, state tort law provides a remedy for negligent
care." See id. at 1169. If this were not so, EMTALA would
become a "federal malpractice statute, something it was never
intended to do." See id. (internal quotation and citation
omitted). Further, if a plaintiff has, in fact, refused to submit
to a medical screening, such party would be estopped from later
seeking relief based on the defendant's failure to perform the
very act the plaintiff had prevented. See, e.g., Steam Press
Holdings, Inc. v. Hawaii Teamsters and Allied Workers Union,
Local 996, 302 F. 3d 998, 1011 (9th Cir. 2002) (holding
plaintiff estopped from alleging claim for breach of contract,
because plaintiff, prior to filing suit, had repudiated
contract). As a consequence, plaintiff, in order to avoid summary
judgment, must submit evidence sufficient to establish that she
was no longer an inpatient when she was returned to defendant's
hospital during the early morning hours of August 1, 2003, and,
further, that defendant was required by EMTALA to perform a
medical screening examination of plaintiff despite her repeated
refusal to consent to such.
Plaintiff's theory is that plaintiff, upon her elopement from
the hospital, was no longer an inpatient, and that thereafter,
when she was returned to the ER following her elopement, she was
not competent to refuse a screening examination, thus obligating
defendant to provide services against plaintiff's will, and, in
particular, at the point when plaintiff's family requested
treatment. For the reasons expressed below, these theories are,
under the rather unusual circumstances presented,*fn14
First, as to the issue of discharge, there is no dispute that
defendant, at all times up to the point plaintiff left the
hospital with her son and ex-husband, considered plaintiff to be an inpatient. Plaintiff asserts that irrespective of defendant's
understanding, when plaintiff eloped from the hospital, she no
longer was an inpatient and, as a consequence, when she was
returned to the ER she was, in effect, a newly-presenting patient
to whom defendant, again, owed the duties set forth in EMTALA.
Plaintiff, however, offers no authority for her argument that she
ceased to be an inpatient when she secretly left the hospital. In
the absence of any such authority, defendant is entitled to
summary judgment on plaintiff's EMTALA claim, because a
hospital's failure to treat an inpatient is actionable, if at
all, only under state law. See Bryant, 289 F. 3d at 1169.
Even assuming arguendo, a patient's unilateral act of
elopement can constitute a "discharge" for purposes of EMTALA,
plaintiff's claim nonetheless fails. Plaintiff's entire theory as
to why defendant is liable for any failure to perform an
examination after plaintiff's return in the early hours of August
1, 2003, despite her repeated refusal to submit to such
examination, is that plaintiff was not competent to refuse
treatment. In support thereof, plaintiff relies on plaintiff's
behavior, specifically, that she "walk[ed] away from the hospital
in the dead of the night, without telling anyone or notifying her
family." (See Pl.'s Opp., filed July 12, 2005, at 10:27-11:2.)
Additionally, plaintiff relies on the opinion of her expert, P.
John Simic, M.D. ("Dr. Simic"), who opines that plaintiff, as a
result of a "variety of acute and chronic illnesses," was "not of
sound mind and lacked the mental capacity at the times in
question," as evidenced by plaintiff's having placed herself in
"peril." (See Simic Decl. D.2.)*fn15 Plaintiff offers no
expert or other evidence from which a trier of fact could find
plaintiff's status as to competency at the time of her elopement
differed from her status at the time of her return.*fn16
Consequently, if plaintiff ultimately proves, as she must, that
plaintiff was not competent to refuse treatment at the time of
her return, plaintiff also will have proved that she was not competent to "discharge" herself by
eloping. This, in turn, would require a finding that plaintiff,
at the time she was returned to the ER, remained an
inpatient,*fn17 and, again, defendant would be entitled to
summary judgment on plaintiff's EMTALA claim. See Bryant,
289 F. 3d at 1169. In short, there is no evidence from which a trier
of fact could find plaintiff was "dumped."*fn18 See id.
Accordingly, defendant is entitled to summary judgment on
plaintiff's EMTALA claim, plaintiff having failed to offer
evidence to show the existence of a triable issue of fact as to
whether defendant violated EMTALA.
B. State Law Claims
The Court's jurisdiction over the instant action is based on
the existence of a federal question. Plaintiff's claims other
than her claim under EMTALA arise under state law, and, thus, the
Court's jurisdiction over such claims is supplemental in nature.
See 28 U.S.C. § 1367(a).
A district court may decline to exercise supplemental
jurisdiction where "the district court has dismissed all claims
over which it has original jurisdiction." See
28 U.S.C. § 1367(c)(3). Where a district court has granted summary judgment
on the sole federal claim, the district court, pursuant to §
1367(c)(3), may properly decline to exercise supplemental
jurisdiction over remaining state law claims. See Bryant,
289 F. 3d at 1169.
Additionally, a district court may decline to exercise
supplemental jurisdiction over a claim that "raises a novel or
complex issue of State law." See 28 U.S.C. § 1367(c)(1). Here,
plaintiff alleges that defendant violated a state statute setting
forth a hospital's duties with respect to the provision of
emergency care, specifically, § 1317(a) of the California Health & Safety Code. Neither party, however, addresses, let
alone submits any authority, as to whether a hospital owes the
duties set forth in § 1317(a) once an individual has been
admitted as a patient, and the Court has located no such
authority. Consequently, it would appear that plaintiff's claim
under § 1317(a) may raise a novel issue of California law.
Further, a district court may decline to exercise supplemental
jurisdiction over a claim that "substantially predominates over
the claim or claims over which the district court has original
jurisdiction." See 28 U.S.C. § 1367(c)(2). Here, plaintiff
alleges a claim of negligence, which claim is predicated,
according to plaintiff's motion, on the entire course of
treatment plaintiff received following her July 31, 2003
admission. Plaintiff's EMTALA claim, by contrast, is based
exclusively on events that occurred in the early hours of August
1, 2003. Consequently, it would appear that plaintiff's
negligence claim, being significantly broader in scope than her
EMTALA claim, substantially predominates over plaintiff's EMTALA
Accordingly, the Court will exercise its discretion to decline
to exercise supplemental jurisdiction over plaintiff's state law
For the reasons stated above:
1. Defendant's motion for summary judgment is hereby GRANTED on
plaintiff's EMTALA claim, and is DENIED without prejudice with
respect to plaintiff's state law claims.
2. Plaintiff's motion for partial judgment is hereby DENIED.
3. Plaintiff's state law claims are hereby DISMISSED without
prejudice to refiling in state court.
IT IS SO ORDERED.
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