`
`IN THE UNITED STATES DISTRICT COURT
`FOR THE DISTRICT OF PUERTO RICO
`
`MILAGROS DEL PILAR LÓPEZ-VARGAS,
`JOSÉ RAFAEL LÓPEZ-VARGAS and
`MIGUEL ANGEL LÓPEZ-VARGAS AS
`REPRESENTATIVES OF THE ESTATE
`OF JUANITA VARGAS-RIVERA AND IN
`THEIR PERSONAL CAPACITIES,
`
`
`
`
`Civil No. 21-1284
`
`
`
`
`
`Re.: EMTALA; TORT; MEDICAL
`MALPRACTICE; HOSPITAL
`LIABILITY
`
`
`
`JURY TRIAL REQUESTED
`
`Plaintiffs,
`
`v.
`
`HOSPITAL
`CENTER
`DOCTORS’
`GRUPO
`DE
`INC.;
`BAYAMÓN,
`EMERGENICAS VRC, CSP; DR. ANDRÉS
`ÁVILA-GONZÁLEZ, HIS SPOUSE AND THE
`CONJUGAL
`LEGAL
`PARTNERSHIP
`CONSTITUTED BY THEM; PUERTO RICO
`MEDICAL
`DEFENSE
`INSURANCE
`COMPANY;
`SINDICATO
`DE
`ASEGURADORES PARA LA SUSCRIPCIÓN
`CONJUNTA
`DE
`SEGURO
`DE
`RESPONSABILIDAD
`PROFESIONAL
`MÉDICO-HOSPITALARIA; CONTINENTAL
`INSURANCE
`COMPANY;
`DALE
`UNDERWRITING PARTNERS NATIONAL &
`FIRE
`MARINE;
`UNKOWN
`CORPORATIONS X, Y & Z; and UNKOWN
`INSURANCE COMPANIES A, B, & C,
`
`
`Defendants,
`
`The MEMBERS OF THE ESTATE OF
`JESÚS LÓPEZ-VARGAS,
`
`
`Indispensable Party with Interest.
`
`
`
`
`
`
`
`COMPLAINT
`
`TO THE HONORABLE COURT:
`
`COME NOW plaintiffs Milagros Del Pilar López-Vargas (“Milagros”), José
`
`Rafael López-Vargas (“José”) and Miguel Angel López-Vargas (“Miguel”), and
`
`
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 2 of 30
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`together referred to hereinafter as the “López-Vargas Family” or the “Plaintiffs”,
`
`through the undersigned attorney, and respectfully state and pray as follows:
`
`
`1. In this suit, the López-Vargas Family seek redress for all the damages
`
`I.
`
`INTRODUCTION
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`caused by those who negligently let their matriarch die, Mrs. Juanita Vargas
`
`Rivera (“Juanita” or “Mrs. Vargas-Rivera”).
`
`2. The legal predicates for the suit are the Emergency Medical Treatment and
`
`Labor Act (“EMTALA”) as well as Puerto Rico’s general tort statute.
`
`3. The EMTALA violations set forth in the Complaint are based on failure to
`
`screen, as required by the statute.
`
`4. The general tort claims arise from a myriad of negligent deviations from
`
`the applicable standard of medical care in the emergency room setting.
`
`II.
`
`JURISDICTION AND VENUE
`
`5. The jurisdiction of the Court is predicated on the existence of a federal
`
`question jurisdiction pursuant to the provisions of 28 U.S.C. § 1331, as there
`
`are claims and allegations predicated on EMTALA, 42 U.S.C. §1395dd.
`
`6. The Honorable Court also has supplemental jurisdiction over the general
`
`tort claims filed against the co-defendants pursuant to the provisions of 28
`
`U.S.C. § 1367.
`
`7. Pursuant to 28 U.S.C. § 1391 (b)(2) and 42 U.S.C. §1395dd, venue is
`
`proper in this Honorable Court, as the covered hospital for EMTALA purposes is
`
`located within this District.
`
`
`
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`2
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`8. Mrs. Vargas-Rivera was the single mother of Milagros, José and Miguel
`
`III. THE PARTIES
`
`López-Vargas.
`
`9. Mr. Vargas-Rivera’s husband and father to Milagros, José and Miguel, died
`
`seven years ago.
`
`10. Mrs. Vargas-Rivera also had a fourth child, Jesús López-Vargas (“Jesús”),
`
`who died on February 6th, 2017.
`
`11. Upon information and belief, at the time Jesús died, he was married and
`
`had two children, whose identity and whereabouts are unknown to plaintiffs for
`
`which reason they are included as nominal parties.
`
`12. Milagros and José López-Vargas are citizens of Bayamón, Puerto Rico.
`
`13. Miguel López-Vargas is a citizen of the State of New York.
`
`14. Due to financial constraints, when the events alleged in the Complaint
`
`happened, Mrs. Vargas-Rivera was a beneficiary of “La Reforma”, Puerto Rico’s
`
`public health insurance.
`
`15. Co-defendant Doctor’s Center Hospital Bayamón, Inc. (“the Hospital”) is
`
`a for profit corporation organized under the laws of the Commonwealth of Puerto
`
`Rico. According to information available at the Puerto Rico State Department
`
`website, the Hospital’s principal place of business and headquarters are located
`
`at the following address: Calle J#9, Urb. Hermanas Dávila, Bayamón, Puerto
`
`Rico, 00960.
`
`16. Doctor’s Center Hospital Bayamón, Inc. is part of a conglomerate of for-
`
`profit private hospitals and health care institutions with facilities in Puerto Rico.
`
`
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`3
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 4 of 30
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`17. On June 18, 2020, the Hospital was a covered entity under the provisions
`
`of the EMTALA.
`
`18. On June 18, 2020, nurse Brenda P. Contreras-Irizarry (“Ms. Contreras-
`
`Irizarry”) was an employee of the Hospital.
`
`19. In June 2020, the provisions of the Puerto Rico Health Department
`
`Regulation Number 117 (“Reglamento del Secretario de Salud Núm. 117 para
`
`Reglamentar el Licenciamiento, Operación y Mantenimiento de los Hospitales en
`
`el Estado Libre Asociado de Puerto Rico”) promulgated on December 21, 2004
`
`(“Regulation No. 117”) applied to the Hospital, as more fully alleged hereinafter.
`
`20. Co-defendant Grupo de Emergencias VRC, CSP (“GEVRC”) is a for profit
`
`corporation organized under the laws of the Commonwealth of Puerto Rico.
`
`According to information available at the Puerto Rico State Department website,
`
`the Hospital’s principal place of business and headquarters are located at the
`
`following address: Calle Amatista # 5, Bucare, Guaynabo, PR, 00969.
`
`21. At all times alleged herein, GEVRC was the corporate entity in charge of
`
`the administration and operation of the Hospital’s Emergency Room.
`
`22. GEVRC’s duties for the administration and operation of the Emergency
`
`Room on June 18, 2020, were assigned by the Hospital.
`
`23. In June 2020, Regulation No. 117 applied to GEVRC, as more fully alleged
`
`hereinafter.
`
`24. On June 18, 2020, Dr. Victor J. Rivera Cruz was the owner, President and
`
`Director of GEVRC.
`
`25. On June 18, 2020, Dr. Victor J. Rivera Cruz was also the Hospital’s
`
`Emergency Department Director.
`
`
`
`4
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 5 of 30
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`26. Co-defendant Dr. Andrés Ávila-González (“Dr. Ávila”) is a general
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`medicine physician who was on duty at the Hospital on June 18, 2020, and the
`
`healthcare professional in charge of Mrs. Vargas-Rivera at the Hospital’s
`
`Emergency Room.
`
`27. When the events that give rise to this suit occurred, Dr. Ávila was an
`
`employee of GEVRC and/or the Hospital, its subcontractor and/or had medical
`
`privileges there.
`
`28. Upon information and belief, Dr. Ávila has settled at least one other
`
`medical malpractice suit filed against him with similarities to the instant action.
`
`29. Dr. Ávila’s conjugal partnership, constituted between Dr. Ávila and his
`
`spouse, is liable for the damages caused by Dr. Ávila while engaging in those
`
`activities which benefited the conjugal partnership.
`
`30. Co-defendant Puerto Rico Medical Defense Insurance Company
`
`(“PRMDIC”) is an insurance company organized pursuant to the laws of the
`
`Commonwealth of Puerto Rico which, who at all material times alleged herein,
`
`was the primary and/or excess liability insurer of GEVRC and had issued and
`
`in force one or more policies insuring the claims referred to herein and is directly
`
`liable to the plaintiffs for the damages claimed.
`
`31. Co-defendant Sindicato de Aseguradores Para la Suscripción Conjunta
`
`de Seguro de Responsabilidad Profesional Médico-Hospitalaria (“SIMED”) is
`
`an insurance company organized pursuant to the laws of the Commonwealth of
`
`Puerto Rico which, who at all material times alleged herein, was the primary
`
`and/or excess liability insurer of Dr. Ávila and/or some of the other defendants
`
`
`
`5
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 6 of 30
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`and had issued and in force one or more policies insuring the claims referred to
`
`herein and is directly liable to the plaintiffs for the damages claimed.
`
`32. Co-defendant Continental Casualty Company (“Continental”) is an
`
`insurance company organized pursuant to the laws of the Commonwealth of
`
`Puerto Rico who at all material times alleged herein, was the primary and/or
`
`excess liability insurer of the Hospital, had issued and in force one or more
`
`policies insuring the claims referred to herein and is directly liable to the
`
`plaintiffs for the damages claimed.
`
`33. Co-defendant Dale Underwriting Partners National & Fire Marine
`
`(“Dale”) is an insurance company organized pursuant to the laws of the
`
`Commonwealth of Puerto Rico which, at all material times alleged herein, was
`
`the excess liability insurer of the Hospital, had issued and in force one or more
`
`policies insuring the claims referred to herein and is directly liable to the
`
`plaintiffs for the damages claimed and is directly liable to the plaintiffs for the
`
`damages claimed.
`
`34. The Estate of Jesús López-Vargas is made up by Mr. Jesús López-Vargas’
`
`heirs following his passing on February 6th, 2017 and who, upon information
`
`and belief, at the time was married and had two children, whose identities and
`
`whereabouts are unknown to plaintiffs.
`
`35. Unknown Corporations X, Y & Z (“Corporations X, Y & Z”), whose names
`
`are currently unknown to the López-Vargas Family, are legal entities organized
`
`under the laws of the Commonwealth of Puerto Rico that employed the
`
`employees, agents, administrators, owners, directors and/or subcontractors
`
`who negligently provided the subpar medical treatment that caused Mrs. Vargas-
`
`
`
`6
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 7 of 30
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`Rivera’s death, and who are directly liable to plaintiffs for their negligent acts
`
`and/or omissions and/or who are vicariously liable to Plaintiffs for the negligent
`
`act and/or omissions of the co-defendants and/or third parties who have yet to
`
`be identified.
`
`36. Unknown Insurance Companies A, B, & C (“Insurance Companies A, B
`
`& C”), whose names are currently unknown to the Plaintiff, is/are insurers
`
`organized pursuant to the laws of the Commonwealth of Puerto Rico, which at
`
`all material times alleged herein, were the primary and/or excess liability
`
`insurers, respectively, of the any/all of the above co-defendants, including the
`
`Hospital and GEVRC, and had issued and in force one or more policies insuring
`
`some or all of the defendants for the claims referred to herein. Those insurance
`
`policies provide coverage for the damages claimed in this suit.
`
`37.
`
`All of the named defendants are jointly and severally liable to the
`
`Plaintiffs for the damages claim in this case.
`
`
`A. MRS. VARGAS-RIVERA GOES TO THE HOSPITAL’S EMERGENCY ROOM
`
`IV. THE FACTS
`
`
`
`38.
`
`Late in the evening of June 17, 2020, after spending a regular family
`
`day, Mrs. Vargas-Rivera called Milagros - her daughter – complaining and
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`afflicted with chest pain.
`
`39.
`
`40.
`
`Shortly after 11:30 p.m. on even date, Milagros called an ambulance.
`
`Mr. Vargas-Rivera was transported to the Hospital’s emergency
`
`room by ambulance, arriving approximately at 12:34 a.m. on June 18, 2020.
`
`41.
`
`Mr. Vargas-Rivera was accompanied by Milagros.
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`7
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`42.
`
`Mrs. Vargas-Rivera was triaged by a nurse at 1:04 a.m. on June 18,
`
`2020.
`
`43.
`
`The Hospital’s nurse that triaged Mrs. Vargas-Rivera was Ms.
`
`Contreras-Irizarry.
`
`44.
`
`The triage sheet in the medical record shows that Mrs. Vargas-
`
`Rivera personally provided all information required from her on arrival at the
`
`Hospital’s Emergency Room.
`
`45.
`
`The only person at the Hospital to have spoken to Mrs. Vargas-
`
`Rivera while she was able to speak, was Ms. Contreras-Irizarry.
`
`46.
`
`Mrs. Vargas-Rivera referred a crushing chest pain located under the
`
`left breast, radiating towards the left flank and back, intensifying to touch.
`
`47.
`
`Mrs. Vargas-Rivera was rather short in stature, 4 ft - 11 inches, and
`
`weighed 115 pounds, as estimated by the Hospital’s staff.
`
`48.
`
`The Emergency Classification assigned by Ms. Contreras-Irizarry
`
`was “Urgent”.
`
`49.
`
`Mrs. Vargas-Rivera’s was left on a stretcher in the hall for
`
`“Observation”.
`
`50.
`
`According to the certified medical record provided by the Hospital,
`
`the Emergency Room physician, Dr. Andrés Ávila, was notified of the patient’s
`
`condition, signs, and symptoms at 1:04 a.m.
`
`51.
`
`Even though Dr. Ávila was at the Hospital at 1:04 a.m., he failed to
`
`evaluate Mrs. Vargas-Rivera.
`
`52.
`
`Upon information and belief, Dr. Ávila was the only physician on
`
`duty at the Hospital’s emergency room at the time of Mrs. Vargas-Rivera’s arrival.
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`8
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 9 of 30
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`53.
`
`In the alternative, upon information and belief, Dr. Doe and Dr. Roe
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`were also on duty at the Hospital’s emergency room at the time of Mrs. Vargas-
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`Rivera’s arrival and/or oversaw the personnel responsible to provide medical
`
`care but failed to evaluate and/or treat her.
`
`54.
`
`Triage evaluation showed that Mr. Vargas-Rivera had a serious life-
`
`threatening condition requiring immediate medical intervention.
`
`55.
`
`Rather than admitting Mr. Vargas-Rivera for inpatient care, treating
`
`her or transferring her to another facility, the Hospital’s personnel left her
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`waiting, in crushing pain, at the emergency room for four (4) hours.
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`56.
`
`During that time, Mr. Vargas-Rivera received no medical evaluation
`
`or treatment.
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`57.
`
`No screening was performed at the Hospital’s emergency room —
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`personnel there did not even bother to administer any medications, ancillary
`
`tests or perform a basic medical screening for Mrs. Vargas-Rivera.
`
`58.
`
`Mr. Vargas-Rivera was left unattended at the Hospital’s Emergency
`
`Room until almost 5:00 a.m.
`
`59.
`
`The medical record contains an entry showing that, when Dr. Ávila
`
`finally examined Mrs. Vargas-Rivera four (4) hours after her arrival, she was
`
`already unresponsive, not breathing and without vital signs.
`
`60.
`
`Mrs. Vargas-Rivera suffered an acute myocardial infarction and was
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`pronounced dead at 5:02 a.m. on June 18, 2020.
`
`61.
`
`Dr. Ávila attempted to justify his reckless medical care, or lack
`
`thereof, by telling Milagros that Juanita “was already pretty old”.
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`9
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 10 of 30
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`62.
`
`Dr. Ávila and Dr. Rivera both refused to certify Mrs. Vargas-Rivera’s
`
`death at the Hospital.
`
`63.
`
`The Hospital had available both the facilities and the medical
`
`personnel to provide the specialized medical intervention needed to save Mr.
`
`Vargas-Rivera’s life. But neither was deployed to do so.
`
`B. THE HOSPITAL’S PERSONNEL IGNORE THE CRIES FOR HELP FROM MRS.
`VARGAS-RIVERA’S FAMILY
`
`During the early hours of June 18, 2020, Milagros sought assistance
`
`64.
`
`from the Hospital’s personnel at the Emergency Room, as she witnessed how her
`
`mother’s health began to rapidly deteriorate.
`
`65.
`
` Among other things, Mrs. Vargas-Rivera’s daughter told the
`
`Hospital’s nurses and doctors that her mother needed medical attention. But
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`no one came to examine Mrs. Vargas-Rivera.
`
`66.
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`At approximately 4:00 a.m., Juanita informed that she needed to
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`urinate and, given her mother’s acute pain, Milagros pleaded for the nurses’
`
`assistance, again to no avail.
`
`67.
`
`At approximately 4:15 a.m., Milagros inquired with the nurses
`
`again. She also informed that her mother could not hold it any longer and had
`
`voided herself.
`
`68.
`
`Shortly after 4:15 a.m., Milagros saw Dr. Ávila passing by and
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`questioned him directly about the excessive delay in evaluating her mother. Dr.
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`Ávila stated that he needed to see another patient.
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`69.
`
`When Dr. Ávila finally examined Juanita at almost 5:00 a.m., she
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`was already unresponsive, not breathing and without vital signs.
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`
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`10
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 11 of 30
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`70.
`
` Before or after Dr. Ávila’s intervention at almost 5:00 a.m. on June
`
`18, 2020, the medical record shows that Mrs. Vargas-Rivera received no medical
`
`screening from the Hospital’s physicians in the early hours of that day.
`
`V.
`
`EMTALA CAUSE OF ACTION
`
`A. THE EMTALA STANDARD
`
`All the allegations stated above are incorporated by reference as if
`
`71.
`
`fully set forth and restated herein.
`
`72.
`
`Congress enacted EMTALA intending “that all patients be treated
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`fairly when they arrive in the emergency department of a participating hospital
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`and that all patients who need some treatment will get a first response at
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`minimum and will not simply be turned away.” Reynolds v. Maine General
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`Health, 84 218 F.3d 78 (1st Cir.2000), citing Baber v. Hospital Corp. of America,
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`977 F.2d 872, 880 (4th Cir.1992).
`
`73.
`
`EMTALA provides a private cause of action against a covered
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`hospital to redress all the damages suffered from a violation of its provisions. 42
`
`U.S.C. §1395dd(d)(2)(A).
`
`74.
`
`As pertinent here, EMTALA sets forth core obligations that covered
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`hospitals must satisfy.
`
`75.
`
`One of the EMTALA’s core obligation mandates covered hospitals to
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`provide a “proper screening examination” aimed at determining whether the
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`person who requests emergency medical care presents an “emergency medical
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`condition.” §1395dd(a)
`
`76.
`
`Even though EMTALA does not specify what constitutes a “proper
`
`medical screening”, the First Circuit has interpreted the term as calling for an
`
`
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`11
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 12 of 30
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`examination “reasonably calculated to identify critical medical conditions that
`
`may be afflicting symptomatic patients and [to] provide[] that level of screening
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`uniformly to all those who present substantially similar complaints.” Cruz–
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`Vazquez v. Mennonite Gen. Hosp., Inc., 717 F.3d 63, 69 (1st Cir. 2013). This
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`requirement is in place to ensure “that there be some screening procedure, and
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`that it be administered even-handedly.” Id.
`
`77.
`
`In turn, the term “emergency medical condition,” as pertinent here,
`
`is defined by the statute 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.
`
`§1395dd(e)(1).
`
`As long established by the First Circuit Court of Appeals, to prevail
`
`
`
`
`78.
`
`in an EMTALA claim
`
`a plaintiff must show that (1) the hospital is a participating
`hospital, covered by EMTALA, that operates an emergency
`department (or an equivalent treatment 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. Hosp. San Francisco, 69 F.3d 1184, 1190 (1st Cir.
`1995).
`
`B. THE HOSPITAL VIOLATED EMTALA BY FAILING TO SCREEN MRS.
`VARGAS-RIVERA UPON HER ARRIVAL TO THE EMERGENCY ROOM
`
`
`79.
`
`All the allegations stated above are incorporated by reference as if
`
`fully set forth and restated herein.
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`12
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`80.
`
`On June 18, 2020, Mrs. Vargas-Rivera arrived to the Hospital’s
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`emergency room via ambulance afflicted with and complaining of chest pain.
`
`81.
`
`Thirty (30) minutes after her arrival to the emergency room, Mrs.
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`Vargas-Rivera was triaged by nurse Brenda P. Contreras-Irizarry.
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`82.
`
`At Triage, Mrs. Vargas-Rivera pulse was irregular with a rate of 100,
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`respiratory rate 20 with normal respiratory effort, blood pressure 145/89,
`
`temperature 36.7 degrees centigrade, oxygen saturation 99%, and Glasgow
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`Coma Scale normal at 15.
`
`83.
`
`Mrs. Vargas was an 88-year-old female with a past medical history
`
`of hypertension, cardiovascular disease, hypothyroidism and peripheral vascular
`
`disease.
`
`84.
`
`The Hospital had knowledge of Mr. Vargas-Rivera’s past medical
`
`history.
`
`85.
`
`Mr. Vargas-Rivera’s pain was 7-8 on a scale of 10 and was described
`
`as crushing, acute, continuous and associated with anxiety.
`
`86.
`
`At the time, Mrs. Vargas-Rivera was taking a medication called
`
`verapamil.
`
`87.
`
`An 88-year-old patient with the above history, presenting
`
`complaints like Mrs. Vargas-Rivera, taking verapamil and with a heart rate of
`
`100, has high likelihood of having a severe medical condition causing her
`
`complaints.
`
`88.
`
`Ms. Contreras-Irizarry documented that no electrocardiogram (EKG)
`
`was performed on Mrs. Vargas-Rivera.
`
`
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`13
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`89.
`
`Pursuant to the Hospital’s written policies, emergency room patients
`
`must be triaged upon arrival to determine the severity of their conditions and
`
`then be classified in one of three categories: (i) Emergent; (ii) Urgent; or (iii)
`
`Ambulatory.
`
`90.
`
`At the Hospital, “Emergent” Category encompasses the most serious
`
`conditions, including chest pain, abdominal pain, cardiopulmonary arrest,
`
`among others, and the Categories “Urgent” and “Ambulatory” encompass
`
`progressively less serious conditions.
`
`91.
`
`Nurse Brenda P. Contreras-Irizarry failed to follow the Hospital’s
`
`protocol when she placed Mrs. Vargas-Rivera in “Urgent” Category despite her
`
`complaint of chest pain that should have placed her in “Emergent” Category, and
`
`this departure from the Hospital’s protocol violated EMTALA’s appropriate
`
`screening requirement.
`
`92.
`
`On June 18, 2020, the Hospital had emergency room protocols that
`
`described their general procedures for evaluating patients with complaints, signs
`
`or symptoms similar to Mrs. Vargas-Rivera.
`
`93.
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`At all material times alleged herein, the Hospital’s emergency room
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`protocols required that a patient with conditions such as chest pain, high blood
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`pressure, abdominal pain, cardiopulmonary arrest, among others, be considered
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`emergencies and receive immediate medical attention.
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`94.
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`At all material times alleged herein, the Hospital protocols required
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`that a patient presenting to the emergency room with chest pain be placed on a
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`cardiac monitor, an electrocardiogram (EKG) performed, be initiated on an I.V.,
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`receive a physical exam, obtain blood tests and administer a chest x-ray.
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`95.
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`At the Hospital, all patients that present to the Hospital’s emergency
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`room with chest pain are placed on a cardiac monitor, an electrocardiogram
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`(EKG) is performed, are initiated of an I.V., receive a physical exam, obtain blood
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`tests and are administered a chest x-ray.
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`96.
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`Because Mr. Vargas-Rivera received neither, she was provided with
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`disparate treatment in violation of EMTALA’s screening obligations at the
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`Hospital’s emergency room.
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`97.
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`Both the Hospital’s nursing staff and Dr. Ávila had the obligation
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`under the Hospital’s protocols to place Mrs. Vargas-Rivera on a cardiac monitor,
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`perform electrocardiogram (EKG), initiate an I.V., perform a physical exam,
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`obtain blood tests and administer a chest x-ray
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`98.
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`On June 18, 2020, Mrs. Vargas-Rivera was never placed on a
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`cardiac monitor.
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`99.
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`On June 18, 2020, Mrs. Vargas-Rivera was not initiated on an I.V.
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`100.
`
`On June 18, 2020, Mrs. Vargas-Rivera was not administered an
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`EKG.
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`101.
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`On June 18, 2020, Mrs. Vargas-Rivera was not administered a chest
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`x-ray.
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`102.
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`No one at the Hospital performed a physical evaluation for Mrs.
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`Vargas-Rivera before she had already coded.
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`103.
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`No one at the Hospital even attempted to establish a medical
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`diagnosis for Mrs. Vargas-Rivera on June 18, 2020.
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`104.
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`No one at the Hospital ordered any diagnostic test for Mrs. Vargas-
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`Rivera on June 18, 2020.
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`105.
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`The Hospital failed to employ ancillary services routinely available
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`to its emergency department in order to identify Mrs. Vargas-Rivera’s emergency
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`medical condition.
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`106.
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`The triage assessment performed at the Hospital’s emergency room
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`failed to result in a patient categorization consistent with the perilous, life-
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`threatening symptoms Mrs. Vargas-Rivera was experiencing in connection with
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`her chest pain.
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`107.
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`With Mrs. Vargas-Rivera’s age, past medical history and presenting
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`complaints that were very concerning for the presence of an emergent medical
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`condition, required Emergent (not Urgent) triage categorization and medical
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`evaluation.
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`108.
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`The Hospital’s nurse noted that Mrs. Vargas-Rivera was suffering
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`from a crushing and intense pain located under her left breast radiating to her
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`left flank and back, intensifying to touch.
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`109.
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`At 1:04 a.m. the Hospital’s nurse also noted that Dr. Ávila was
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`notified about Mrs. Vargas-Rivera condition.
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`110.
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`Even though Mrs. Vargas-Rivera arrived at the Hospital seeking
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`emergency medical care, Hospital personnel at the emergency room refused to
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`provide a proper medical screening, or any other medical care to her in over four
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`(4) hours.
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`111.
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`Mrs. Vargas-Rivera’s arrival time to the Hospital’s emergency room
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`was 12:42 a.m. and no doctor evaluated her in four (4) hours.
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`16
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`112.
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`In other words, from 12:42 a.m. when Mrs. Vargas-Rivera arrived
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`at the Hospital’s Emergency Room, it took the Hospital’s physicians four hours
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`to first examine her.
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`113.
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`It was not until Mrs. Vargas-Rivera had already coded that an initial
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`cursory evaluation by Dr. Ávila was performed at approximately 4:40 a.m.
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`114.
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`In fact, Dr. Ávila’s only medical evaluation assessment documented
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`in the medical record is postmortem, initiated at 6:42 a.m. and signed at 6:46
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`a.m. on June 18, 2020.
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`115.
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`This 4-hour delay in performing a medical screening exam of Mrs.
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`Vargas-Rivera constitutes a violation of EMTALA.
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`116.
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`Put differently, Mrs. Vargas-Rivera never received a medical
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`screening exam reasonably calculated to identify critical medical conditions that
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`were afflicting her.
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`117.
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`On June 18, 2020, the Medicine Department in the Hospital
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`consisted of the department of Internal Medicine and the services of Neurology,
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`Nephrology, Hematology, Endocrinology, Pneumology, Infectious Disease and
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`Cardiovascular Disease; Emergency Room Physicians; Family Medicine
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`Specialists, and Nuclear Medicine, among others.
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`118.
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`On June 18, 2020, the Surgery in the Hospital consisted of the
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`department of General Surgery and the services of Vascular Surgery,
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`Anesthesiology, Pathology, and Radiology, and Radiotherapy, among others.
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`119.
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`EMTALA requires that all patients who arrive at a hospital’s
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`emergency room seeking emergency medical care receive a proper medical
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`
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 18 of 30
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`screening. In failing to screen Mr. Vargas-Rivera, the Hospital’s emergency room
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`personnel fragrantly violated EMTALA.
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`120.
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`In not providing the patient with a proper medical screening for four
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`(4) hours after presenting to the Hospital’s emergency room, the screening
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`provided Mr. Vargas-Rivera differed in significant respects to the screening
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`generally provided to similarly situated patients.
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`121.
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`Absent a proper medical screening, no one at the Hospital
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`determined that Mrs. Vargas-Rivera was suffering from an acute coronary
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`syndrome or acute myocardial infarction.
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`122.
`
`Had an EKG been performed and laboratory testing been obtained
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`shortly after her triage, Mrs. Vargas-Rivera would have been found to have been
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`suffering from acute coronary syndrome or acute myocardial infarction.
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`123.
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`Had a proper medical screening been conducted, emergent therapies
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`would have been initiated, which could have included, but would not be limited
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`to, administration of aspirin, anticoagulation, cardiac monitor, treatment for
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`arrythmia, correction of electrolyte abnormalities, cardiology consult, hospital
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`admission or transfer and further treatment, and Mrs. Vargas-Rivera would have
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`survived.
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`124.
`
`Mrs. Vargas-Rivera was denied access to the services available at
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`the Hospital’s emergency room and she died as a result of such denial.
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`125.
`
`Milagros, José and Miguel López-Vargas also suffered anguish and
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`emotional distress in direct consequence of the Hospital’s EMTALA violation
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`inflicted upon Mrs. Vargas-Rivera.
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`VI. MEDICAL MALPRACTICE AND OTHER CAUSES OF ACTION
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 19 of 30
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`C. FIRST CAUSE OF ACTION: MEDICAL MALPRACTICE UNDER PUERTO RICO
`CIVIL CODE, ARTICLES 1802 AND 1803
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`All the allegations stated above are incorporated by reference as if
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`126.
`
`fully set forth and restated herein.
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`127.
`
`Dr. Ávila, Dr. Doe and Dr. Roe and all Hospital personnel who either
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`negligently provided subpar medical care or negligently failed to provide medical
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`care to Mrs. Vargas-Rivera on June 18, 2020, and are jointly and severally liable
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`for the damages claimed in this case.
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`128.
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`Mrs. Vargas-Rivera’s health deteriorated significantly and
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`irreversibly under co-defendants’ watch because they negligently failed to
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`provide emergency medical care that would comply with the applicable standard
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`of care.
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`129.
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`Under the provisions of Article 1802 of the Puerto Rico Civil Code,
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`applicable in this case pursuant to Erie R. Co. v. Tompkins, 304 U.S. 64 (1938),
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`all co-defendants are jointly and severally liable for the negligent acts and
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`omissions that caused Mrs. Vargas-Rivera’s death.
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`130.
`
`Had co-defendants properly and timely diagnose and treat Mrs.
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`Vargas-Rivera’s emergency condition at the Hospital’s Emergency Room, she
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`would not have died.
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`131.
`
`Co-defendants failed to delineate an emergency care plan to identify
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`and treat the root of Mrs. Vargas-Rivera’s chest pain.
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`132.
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`Instead, co-defendants left her waiting unattended in the hall at the
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`Hospital’s Emergency Room for more than 4 hours.
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`133.
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`Co-defendants negligently failed to promptly place Mrs. Vargas-
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`Rivera in a cardiac monitor, in a room that was appropriate to perform CPR,
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 20 of 30
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`administer an EKG and a chest x-rays, order diagnostic tests, initiate I.V., and
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`physically examine the patient, as required under internal policies and protocols,
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`the applicable regulations and the standard of care.
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`134.
`
`When Mrs. Vargas-Rivera arrived to the Hospital’s emergency room
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`complaining of crushing pain under her left breast radiating to the left flank and
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`back, the Hospital’s personnel and Dr. Ávila knew or should have known that
`
`this placed Mrs. Vargas-Rivera at extreme risk of acute coronary syndrome or
`
`acute myocardial infarction, and the standard of care required an EKG be
`
`obtained, that the patient be placed on a cardiac monitor, lab work ordered
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`STAT, an IV started and the patient be located in a room that would be
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`appropriate to perform CPR . None of this was done for Mrs. Vargas-Rivera and
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`she died as a result.
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`135.
`
`Dr. Ávila and the Hospital’s emergency room personnel negligently
`
`failed to provide Mrs. Vargas-Rivera medical care compliant with the standard of
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`care. Among other things, that personnel failed to (i) provide proper
`
`anticoagulation treatment; (ii) secure timely consultation with the required
`
`specialists; (iii) provide other proper medical treatment needed to stabilize Mrs.
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`Vargas-Rivera’s health condition and/or (iv) procure a timely transfer to another
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`hospital for needed emergency treatment.
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`136.
`
`When Dr. Ávila finally decided to evaluate Mrs. Vargas-Rivera, she
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`was already unresponsive, not breathing and without vital signs.
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`137.
`
`Mrs. Vargas-Rivera’s condition considerably worsened during the 4-
`
`hour period between the time she arrived at the Hospital’s Emergency
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`
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`20
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`Case 3:21-cv-01284 Document 1 Filed 06/15/21 Page 21 of 30
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`Department and when Dr. Ávila finally evaluated her, after she had already
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`coded.
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`138.
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`If Dr. Ávila was busy with the care of other patients in the emergency
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`room on June 18, 2020, then the standard of care required that he emergently
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`arrange for the charge nurse, Emergency Department director, and/or hospital
`
`administrator to assist in this process, but he failed to do so.