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Crawford v. Kaiser Foundation Healthplan

United States District Court, N.D. California, San Francisco Division

July 19, 2019





         Plaintiff Muneerah Crawford brings this action against defendants Kaiser Foundation Health Plan and Kaiser Foundation Hospitals for allegedly violating the Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C. § 1395dd.

         EMTALA prohibits hospital emergency rooms from refusing to treat indigent or uninsured patients or discharging patients without first stabilizing their condition. Ms. Crawford alleges that on March 25, 2017, she went to the emergency room at the Kaiser Permanente hospital in Redwood City (the “Hospital”) with respiratory distress. She was screened in the emergency room and admitted overnight. She alleges that in the morning, she could not breathe or physically walk out of the Hospital, but the Hospital told her that it was discharging her and that if she did not leave, it would call the police. After the Hospital discharged her in the morning, she continued to deteriorate, suffered from septic shock and tachycardia, nearly died, and had to be taken in an ambulance on life support to another hospital that afternoon.

         Ms. Crawford brings an EMTALA failure-to-stabilize claim against defendants Kaiser Foundation Health Plan (“Kaiser Health Plan”) and Kaiser Foundation Hospitals (“Kaiser Hospitals”). The defendants move to dismiss, arguing that (among other things) the Hospital admitted Ms. Crawford as an inpatient and that EMTALA's stabilization requirement ends when a patient is admitted for inpatient care.[1] The defendants also move to strike portions of Ms. Crawford's complaint. Ms. Crawford responds that (1) the Hospital admitted her only as an “observation patient” - as opposed to admitting her for inpatient care - and thus EMTALA's stabilization requirement continued after her admission, and (2) the Hospital failed to stabilize her before discharging her.

         The court held a hearing and now rules as follows. The court grants the defendants' motion to dismiss with respect to Kaiser Health Plan because a plaintiff can bring an EMTALA claim only against a hospital, and Kaiser Health Plan is not a hospital. The court denies the defendants' motion to dismiss with respect to Ms. Crawford's EMTALA failure-to-stabilize claims against Kaiser Hospitals because Ms. Crawford has cognizably pleaded in a non-conclusory manner that the Hospital did not admit her for inpatient care and did not stabilize her before discharging her. To the extent that Ms. Crawford is bringing any other claims, the court grants the defendants' motion to dismiss those claims because Ms. Crawford has not clearly and cognizably pleaded them. The court denies the defendants' motion to strike.


         1. March 24, 2017

         On March 24, 2017 at 9:17 p.m., plaintiff Muneerah Crawford was seen by a Dr. Ruiz at the Kaiser Permanente hospital in Redwood City.[3] Dr. Ruiz diagnosed her with pneumonia and reactive-airway disease and treated her with antibiotics and breathing treatments.[4] On March 25, 2017 at 12:22 a.m., the Hospital discharged Ms. Crawford and sent her home with prescriptions.[5]Ms. Crawford expressly alleges that she was “in stable condition” when she was discharged.[6] Dr. Ruiz told her to come back if her condition deteriorated.[7]

         2. March 25, 2017 - Screening

         On March 25, 2017, at 7:10 p.m., Ms. Crawford returned to the Hospital emergency room.[8]She told Dr. Ruiz that she could not breathe out and that she had a fever, headache, and chest pain.[9] Dr. Ruiz ordered blood tests and heart tests and gave Ms. Crawford breathing treatments in the emergency room.[10] Among other tests, Dr. Ruiz ordered lactic-acid blood tests, which showed that Ms. Crawford's lactic-acid level rose to 1.8 that evening.[11]

         At 7:36 p.m., Ms. Crawford's blood pressure was at 177/87, her pulse was 99, and her blood-oxygen level was at 91 percent.[12] After being treated with oxygen and breathing treatments, at 9:00 p.m., her blood pressure was 164/83, her pulse was 70, and she remained short of breath.[13]Dr. Ruiz told her that she should stay in the Hospital for two or three days to get her breathing under control and so that the Hospital could treat her for pneumonia and stabilize her condition.[14]Ms. Crawford expressly alleges that she “was given an adequate screening in the Emergency Room[.]”[15]

         3. March 25, 2017 - Admission

         When Ms. Crawford was taken from the emergency room to be admitted, a Hospital employee confronted her about her medical insurance.[16] The Hospital employee told her that she should go to the county hospital.[17] Ms. Crawford responded that she could go to any hospital with Medicare and that she had been to the Hospital emergency room the previous night (March 24) and that the ER doctor (Dr. Ruiz) had told her to come back if her condition deteriorated.[18]

         Ms. Crawford asserts that the Hospital then admitted her, but only as an “observation patient, ” as opposed to admitting her as a full inpatient.[19] She supports her assertion with the following factual allegations and documents.

         First, Ms. Crawford attaches as exhibits to her complaint certain medical records she obtained from the Hospital. On one page, under a heading titled “Service & Length of Stay, ” the records say that her “Patient Class” was “Observation.”[20] On another page, under a heading titled “Code Status, ” the records say, “[p]lan to monitor as observation since patient was discharged from the ED and then came back.”[21] On another page, under a heading titled “Admit to Hospital, ” the records say that her “Type of Admission” was “Observation.”[22] (Five lines up, that third page also calls her an “Inpatient.”[23])

         Second, Ms. Crawford attaches as an exhibit to her complaint her Medicare statement of claims from her time at the Hospital. The statement says that the Hospital submitted claims for payment for “Hospital observation service, per hour.”[24]

         Third, Ms. Crawford alleges that after she was discharged, she asked the Hospital for a copy of her medical records and for a copy of a notice that she says that Medicare rules require the Hospital to give her.[25] The Hospital responded, “You were in Observation, we don't have to give you a Medicare notice!”[26]

         Ms. Crawford was not told at the time that she was being admitted as an observation patient, as opposed to as an inpatient.[27] She claims that under federal and state law, the Hospital was required to give her an “Observation Notice” and did not do so.[28] She claims that if she had received these required notices, she could have appealed her discharge from the Hospital to the Medicare Quality Improvement Organizations.[29]

         4. March 25, 2017 to March 26, 2017 - Post-Admission and Discharge

         Ms. Crawford was taken to a room, and at about 10:30 p.m. that night (March 25), a respiratory therapist came and gave her breathing treatment.[30]

         After the treatment, Ms. Crawford's breathing became worse.[31] Her blood pressure and pulse were not monitored the way that (she alleges) an inpatient's blood pressure and pulse would have been.[32]

         At 12:00 a.m., Ms. Crawford called a nurse and asked the nurse to call a doctor.[33] The nurse recorded Ms. Crawford's pulse as being in the 30s.[34] At 12:15 a.m., a Dr. Abhyanker, the doctor on Ms. Crawford's case, came to see Ms. Crawford, conducted an examination, and told her to breathe with pursed lips.[35]

         Dr. Abhyanker left at 12:30 a.m., after which no other doctors came to see Ms. Crawford that night.[36] At some unspecified point in time, Dr. Abhyanker discontinued the lactic-acid blood tests that Dr. Ruiz previously had ordered.[37]

         On the morning of March 26 at 9:00 a.m., Ms. Crawford's roommate arrived at the Hospital.[38]Ms. Crawford was discussing her condition and the fact that no one had brought her breakfast, when a Hospital custodian arrived and started to mop the floor.[39] The custodian told Ms. Crawford that the Hospital had discharged her.[40]

         Ms. Crawford asked the custodian to get a doctor or a nurse.[41] A nurse arrived and confirmed that Ms. Crawford had been discharged.[42]

         Ms. Crawford demanded to see her doctor.[43] The nurse called someone on a telephone and handed the phone to Ms. Crawford.[44] The person on the other end told Ms. Crawford that she had been discharged and told her that she was fine, that she was just having bronchial spasms, and that she should go home.[45] Ms. Crawford demanded to see a doctor, and the person on the phone hung up.[46]

         Ms. Crawford told the nurse that she could not walk across the street and that she was not okay and again demanded to see a doctor.[47] The nurse responded that if Ms. Crawford did not leave, the Hospital would call the police.[48] Ms. Crawford alleges that she was ill to the point that she could not argue with Hospital about being discharged.[49] She left the Hospital at approximately 10:30 a.m.[50] She was physically unable to walk out of the Hospital and had to be taken to her car.[51] As she left, her condition and breathing got worse, because she was no longer on oxygen.[52]

         5. Subsequent Events

         At approximately 4:30 p.m. that afternoon (March 26), Ms. Crawford's breathing worsened, and she called 911.[53] An ambulance transported her on life support to Stanford Hospital in Palo Alto at approximately 5:15 p.m.[54]

         When she arrived at Stanford Hospital, her lactic-acid level was at 2.17 and continued to rise to 4.16.[55] She discovered for the first time at Stanford that her repeated treatments with bronchodilators had caused her lactic-acid levels to rise.[56] She was in septic shock, suffering from tachycardia, and had deteriorated to the point that she nearly died.[57]


         1. Motion to Dismiss

         A complaint must contain a “short and plain statement of the claim showing that the pleader is entitled to relief to give the defendant “fair notice” of what the claims are and the grounds upon which they rest. Fed.R.Civ.P. 8(a)(2); Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555 (2007). A complaint does not need detailed factual allegations, but “a plaintiffs obligation to provide the ‘grounds' of his ‘entitlement to relief requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do. Factual allegations must be enough to raise a right to relief above the speculative level[.]” Id. (internal citations omitted).

         To survive a motion to dismiss, a complaint must contain sufficient factual allegations that, when accepted as true, “‘state a claim to relief that is plausible on its face.'” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting Twombly, 550 U.S. at 570). “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. (citing Twombly, 550 U.S. at 556). “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.” Id. (citing Twombly, 550 U.S. at 556). “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. (internal quotation marks omitted) (quoting Twombly, 550 U.S. at 557).

         “A pro se complaint must be ‘liberally construed,' since ‘a pro se complaint, however inartfully pleaded, must be held to less stringent standards than formal pleadings drafted by lawyers.'” Entler v. Gregoire, 872 F.3d 1031, 1038 (9th Cir. 2017) (quoting Erickson v. Pardus, 551 U.S. 89, 94 (2007)).

         If a court dismisses a complaint, it should give leave to amend unless the “pleading could not possibly be cured by the allegation of other facts.” United States v. United Healthcare Ins. Co., 848 F.3d 1161, 1182 (9th Cir. 2016) (citations and internal quotation marks omitted).

         2. Motion to Strike

         A “court may strike from a pleading an insufficient defense or any redundant, immaterial, impertinent, or scandalous matter.” Fed.R.Civ.P. 12(f). “Motions to strike are regarded with disfavor, as they are often used as delaying tactics, and should not be granted ‘unless it is clear that the matter to be stricken could have no possible bearing on the subject matter of the litigation.'” Brown v. Hain Celestial Grp., Inc., 913 F.Supp.2d 881, 888 (N.D. Cal. 2012) (quoting Colaprico v. Sun Microsystems, Inc., 758 F.Supp. 1335, 1339 (N.D. Cal. 1991)). “In the Ninth Circuit, motions to strike are proper, even if the material is not prejudicial to the moving party, if granting the motion would make trial less complicated or otherwise streamline the ultimate resolution of the action.” Id. (citing Fantasy, Inc. v. Fogerty, 984 F.2d 1524, 1527 (9th Cir.1993), rev'd on other grounds, 510 U.S. 517 (1994)). “When considering a motion to strike, a court must view the pleadings in a light most favorable to the non-moving party.” Id. (citing California ex rel. State Lands Comm'n v. United States, 512 F.Supp. 36, 39 (N.D. Cal. 1981)). The ultimate decision under Rule 12(f) lies within the sound discretion of the court. See Davidson v. Kimberly-Clark Corp., 889 F.3d 956, 963 (9th Cir. 2018).


         1. Motion to Dismiss

         1.1 Governing Law

         “EMTALA imposes two duties on hospital emergency rooms: a duty to screen a patient for an emergency medical condition, and, once an emergency condition is found, a duty to stabilize the patient before transferring or discharging him.” Baker v. Adventist Health, Inc., 260 F.3d 987, 992 (9th Cir. 2001) (citing 42 U.S.C. § 1395dd; Jackson v. E. Bay Hosp., 246 F.3d 1248, 1254-55 (9th Cir. 2001)). Ms. Crawford expressly disclaims bringing a claim based on EMTALA's screening requirement.[58] The issue here thus is only whether the defendants complied with EMTALA's stabilization requirement.

         EMTALA defines an “emergency medical condition” in relevant part 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 -
(i) placing the health of the individual . . . 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). Under EMTALA,

If any individual . . . comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either -
(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.

42 U.S.C. § 1395dd(b)(1). EMTALA defines “to stabilize” in relevant part 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 individual from a facility[.]” 42 U.S.C. § 1395dd(e)(3)(A).

         EMTALA further provides that “[i]f an individual at a hospital has an emergency medical condition which has not been stabilized (within the meaning of subsection (e)(3)(B) of this section), [59] the hospital may not transfer the individual, ” absent certain exceptions not at issue here. 42 U.S.C. § 1395dd(c)(1). The term “transfer” includes discharging a patient from a hospital. 42 U.S.C. § 1395dd(e)(4).

         The Centers for Medicare & Medicaid Services, an agency within the Department of Health and Human Services, promulgated regulations interpreting key EMTALA provisions. See 42 C.F.R. § 489.24. The regulations provide that EMTALA's stabilization requirement does not apply to patients who have been admitted as an inpatient for further treatment:

If an emergency medical condition is determined to exist, [the hospital must] provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's ...

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