News: A woman brought to the emergency department (ED) died due to a stroke suffered while under the facility’s care. The patient’s estate sued the hospital for violating the Emergency Medical Treatment and Labor Act (EMTALA) by failing to provide her with adequate care or transfer her to another hospital.

The hospital argued it satisfied its obligations under EMTALA. The court agreed, and dismissed the case against the hospital. Although the plaintiff appealed, the determination was upheld by the appellate court, which confirmed the hospital met its obligation under EMTALA by admitting the patient to the ICU after the initial ED screening.

Background: On Aug. 3, 2016, a female patient with elevated blood pressure and weakness was transported to an ED. Upon initial screening, the hospital admitted her to the ICU for overnight care based on a concern for her cardiac condition and the potential for a stroke. The medical providers in charge were concerned the patient was “trending toward a stroke” based on neurological exams and informed the patient she could not be discharged until further tests were completed.

The patient’s family inquired about transferring her to a different medical facility after an MRI showed signs of a severe ischemic stroke. A representative of the hospital had informed the patient’s family that a transfer was unlikely based on the patient’s care plan. Nevertheless, the patient’s family provided paperwork requesting a transfer to multiple other hospitals, but those requests were denied by those other hospitals for financial and insurance reasons.

On Aug. 17, an apnea test (which was delayed following a request from the patient’s family to be present when the result was received) revealed the patient to be clinically brain dead. The hospital ceased treatment and canceled the outstanding transfer request. The patient’s family presented a written request to the hospital and received the patient’s medical records.

In July 2019, the patient’s estate filed suit against the hospital, expressing dissatisfaction in the quality of treatment. The complaint contained two overarching claims. First, the patient’s estate alleged the hospital violated EMTALA by failing to provide adequate care to the patient or transfer the patient to another hospital. Second, the plaintiffs alleged the records the hospital provided concealed information and test results that prevented the plaintiffs from filing a timely medical malpractice action.

For the allegation of inadequate care, the patient’s estate claimed the hospital violated its duties under EMTALA to screen, treat, stabilize, and transfer the patient by failing to comply with national and community standards of care. EMTALA’s purpose is to prevent denial of emergency treatment — and, in fact, discourages transfers instead of providing treatment. The court determined an emergency condition existed; thus, the patient could not be transferred to another hospital or discharged until she received stabilizing treatment. The appellate court confirmed the hospital’s conduct did not violate EMTALA.

As the plaintiff acknowledged in the complaint, the hospital met the screening requirement by examining the patient and determining the emergency condition. Furthermore, the hospital met the duty imposed by EMTALA to either provide further treatment or to transfer the patient (in accordance with certain parameters) by admitting the patient into its ICU. In summary, the court confirmed the hospital met its EMTALA obligations to the patient; thus, the hospital bore no liability.

For the allegation of concealment, the patient’s estate claimed certain information, paperwork, and test results were missing from the records the hospital provided. The court stated the allegations were viable only if the hospital had intentionally concealed material facts that the patient’s estate could not have discovered through a reasonable inquiry or inspection.

According to the court, the patient’s estate knew generally about the existence of the test results because the doctors who performed the tests told the patient or her family about them. The court determined if the patient’s estate had conducted a reasonable inquiry, they could have discovered the information.

Furthermore, the court ruled the claim of fraudulent concealment rooted itself in an allegation of malpractice. In the state where these events occurred, a claim of medical malpractice is required to be accompanied by an affidavit affirming consultation with a medical expert. The patient’s estate failed to provide any such documentation. The lower court and appellate court both agreed the hospital bore no liability under these circumstances.

What this means to you: This case highlights important provisions of EMTALA, which is a less common basis for allegations of improper medical care when compared to standard allegations of medical malpractice. EMTALA was enacted to prevent denial of emergency treatment regardless of ability to pay, citizenship, or legal status. It imposes obligations on medical facilities with EDs. The substantive requirements do not extend beyond the initial screening. This means EMTALA does not apply to any treatment the patient had undergone after the point of admittance or transfer, nor to the national or communal standard of care by which the patients should be treated, as EMTALA also does not specify such substantive standards.

In this case, the hospital relied on this lack of substantive provisions within EMTALA to defend against the allegations of inadequate care. The hospital appropriately provided the necessary medical screening examination to the patient when she was admitted, and actually provided treatment for the patient. The hospital did not refuse to admit or treat the patient. Its recommendation that transfer was unlikely due to the patient’s status similarly did not violate EMTALA.

Since the basis of the plaintiff’s allegations were not based in medical malpractice, the hospital’s standard of care was not at issue in this case and was not evaluated by the court. The plaintiff claimed the hospital’s failure to provide the adequate and complete records prevented a timely medical malpractice action, but the court disagreed.

Hospitals and care providers are obligated to provide a patient’s medical records in a timely manner following an appropriate request. In this case, there is no indication the hospital deliberately concealed or refused to provide requested records. Such a failure would not arise to the level of medical malpractice since the provision of records is separate from the provision of medical services. It is important to provide requested records, not only because patients are entitled to such records, but also to prevent the types of allegations raised in this case where a patient attempts to circumvent an untimely claim by alleging improper concealment by the care provider.

This case also is an important reminder about how courts evaluate allegations of fraudulent concealment. Generally, a party making such allegations must assert a concealment of material information intended to induce a party into acting or refusing to act, and that party could not have discovered the information otherwise. Allegations of fraud often hold higher standards for the amount of specificity required for the initial claims to prevent parties from always claiming that the other side engaged in “fraud.” It might be easier for hospitals and care providers to challenge such vague allegations of fraud early by requiring the party asserting the allegations to add specificity or concrete facts to their claims. Hospitals and care providers can eliminate frivolous fraud claims early in the litigation process to save time and effort later.

REFERENCE

  • Decided June 28, 2021, in the United States Court of Appeals for the Seventh Circuit, Case Number 1:18-cv-5327.