Prieto v. Total Renal Care, Inc.

CourtUnited States Courts of Appeals. United States Court of Appeals (11th Circuit)
PartiesBLANCA PRIETO, Plaintiff-Appellant, v. TOTAL RENAL CARE, INC., Defendant-Appellee.
Docket NumberNo. 19-13575,19-13575
Decision Date12 February 2021

BLANCA PRIETO, Plaintiff-Appellant,
TOTAL RENAL CARE, INC., Defendant-Appellee.

No. 19-13575


February 12, 2021


D.C. Docket No. 1:18-cv-21085-MGC

Appeal from the United States District Court for the Southern District of Florida

Before WILSON, LAGOA, and BRASHER, Circuit Judges.


Plaintiff Blanca Prieto ("Prieto"), as personal representative of the Estate of Rodolfo Prieto, appeals from the district court's order granting defendant Total Renal Care, Inc., d/b/a Davita Dialysis Centers d/b/a Florida Renal Care's ("TRC"),

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motion for judgment as a matter of law under Federal Rule of Civil Procedure 50(a) on the issue of proximate causation. Specifically, the district court found that Prieto failed to introduce evidence which afforded a reasonable basis for the conclusion that TRC's negligence more likely than not was a substantial factor in causing Mr. Prieto's injuries. Because Prieto failed to present any evidence that could support a jury's finding that TRC's alleged negligence in failing to send Mr. Prieto home on a stretcher more likely than not caused his injuries—an essential element of Prieto's medical malpractice claim—we conclude that the district court did not err in entering judgment as a matter of law in TRC's favor and affirm.


On January 2, 2016, Rodolfo Prieto ("Mr. Prieto"), a seventy-six-year-old man, was injured when he fell from a wheelchair while being driven in a medical transportation van from his dialysis appointment at one of TRC's dialysis centers back to the University Plaza Rehabilitation Center ("University Plaza") where he was living.

On March 21, 2018, Prieto, as the personal representative of Mr. Prieto's estate, filed this lawsuit against TRC,1 alleging a claim for nursing negligence under Florida Statute § 766.102 ("Count I") and a claim for healthcare center liability

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under Florida Statute § 766.106 ("Count II").2 In her complaint, Prieto alleged the following facts. On January 2, 2016, Mr. Prieto was leaving TRC's dialysis center "by medical transport van, as he had done on countless prior occasions, and being taken back to University Plaza." During the drive back to University Plaza, "the van's brakes were suddenly applied which caused [Mr. Prieto] to fly forward, out of his wheel chair, and sustain various injuries, to wit, a severely fractured right leg, head lacerations, and hospitalization." (emphasis in original omitted). Prieto alleged that TRC

negligently allowed [Mr. Prieto] to exit its facilities by wheelchair when his medical condition, as known by the Defendant, and as dictated and established by the Defendant, whose principal owner was [Mr. Prieto's] actual treating nephrologist, required his daily, ongoing, and consistent transport to be by way of stretcher due to serious medical limitation/restrictions that made it unsafe for him to be transported in any other manner.

(emphasis in original omitted). Prieto also alleged that TRC's "failure to render the nursing care that would have consisted of making sure [Mr. Prieto's] medical transportation home was by stretcher . . . was a deviation from the standard of nursing care, and was a breach in the nursing standard of care that fell below the

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industry standard, and as such was the causation, proximate, and legal cause, and/or the concurring cause, of [Mr. Prieto's] injuries." (emphasis in original omitted). Prieto further alleged that she had complied with all pre-suit notice statutory requirements for medical negligence causes of action, and she attached to the complaint a November 10, 2017, affidavit of Nurse Erika Hall, an adult nurse practitioner.3

As to Count I, Prieto alleged that TRC's nursing staff's failure to send Mr. Prieto home on a stretcher

was a breach of the prevailing standard of care, and the subsequent driving incident that took place during his transport from the Defendant's facility back to his assisted living facility was the concurrent condition caused by the Defendant so that it can be said that a sudden vehicular stop by the transport vehicle alone would not have [led] to [Mr. Prieto's] injury, but could only have occurred due to the Defendant's failure to make sure that he was leaving their facility in a secure position via stretcher, and therefore the negligence condition created by the Defendant was the legal and proximate cause, and/or the concurring cause which caused [Mr. Prieto's] injuries.

(emphasis in original omitted). As to Count II, Prieto alleged that TRC's staff breach of the standard of care owed to Mr. Prieto by sending him home on a stretcher "was

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the legal and proximate cause, and/or a concurring event that caused [Mr. Prieto's] right leg fracture."

TRC filed an answer denying all allegations of negligence, causation, and damages and alleging numerous affirmative defenses, including that the entities and individuals responsible for transporting Mr. Prieto from TRC's facility on January 2, 2016, were responsible for an intervening and superseding negligent act not subject to TRC's control.

Pursuant to a pretrial stipulation, damages were limited to Mr. Prieto's pain and suffering from the date of his injury until the time of his death. The matter then proceeded to a three-day trial where Prieto presented the testimony of Dr. Hassan Ali, Head Nurse Sergio Alfonso, and patient care technician Yureiesky Ventura Valdez, as well as the testimony of Nurse Hall as an expert witness.4

Dr. Ali was Mr. Prieto's nephrologist and the medical director of Florida DaVita Renal Center, which is a subsidiary of TRC. During trial, in portions of deposition testimony read to the jury, Dr. Ali testified that Mr. Prieto's health at the time of the accident included "complications of diabetes," such as diabetic nephropathy, eye problems, heart disease, a below-the-knee left leg amputation, and

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amputation of several toes from his right foot. Mr. Prieto also suffered from "end-stage renal disease." The jury further heard from Dr. Ali's deposition testimony that, from November 2, 2015, through December 31, 2015, Dr. Ali had recommended that Prieto be transported to and from dialysis by stretcher, and that a summary treatment sheet showed that Prieto presented for his dialysis care on a stretcher and, after treatment, was placed back on a stretcher eighteen times from November 2, 2015, through December 31, 2015. In his deposition testimony, Dr. Ali further agreed that on January 2, 2016, Mr. Prieto should have been transported back home by stretcher, and that TRC was responsible for Mr. Prieto "until he hits the door."

Dr. Ali also testified in person at trial. Dr. Ali testified that the medical facility was not involved in "the mode of transportation" and that transportation of a patient was arranged by the patient or the patient's representative. Dr. Ali testified that Mr. Prieto's nursing home was the patient representative who arranged the transportation. Relevant here, Dr. Ali did not offer an opinion as to whether Mr. Prieto would have suffered injury had he returned on a stretcher that was bolted to the van's floor. Dr. Ali testified that he did not agree that on January 2, 2016, Mr. Prieto should have been transported home on a stretcher, and Prieto impeached Dr. Ali with his deposition testimony on this issue. On redirect, Dr. Ali testified that every one of his patients is a fall risk.

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Prieto then presented the testimony of Nurse Alfonso and read portions of his deposition to the jury. In his deposition, Nurse Alfonso agreed that Mr. Prieto was the kind of patient who needed to be transferred by stretcher. During his trial testimony, Nurse Alfonso clarified that the level of transportation for Mr. Prieto was determined by his place of transportation. Nurse Alfonso testified that on the day of his treatment, Mr. Prieto finished his dialysis in a "stable manner" and left in a wheelchair. When asked by Prieto's attorney whether it would have been better to send Mr. Prieto out of the facility secured and strapped down on a stretcher, Nurse Alfonso stated that his training was not in transportation.

Prieto also called Nurse Hall, an adult nurse practitioner, to testify as an expert in the field of nursing. Nurse Hall explained that she works for a company that provides health care to inmates at the Hillsborough County Jail, and at any given time, two to three of her patients at the jail are on dialysis. However, she testified that she is not the person who initiates dialysis or monitors a patient while on dialysis. Additionally, Nurse Hall acknowledged on cross-examination that her patients are not transported outside the jail and that, while the jail uses stretchers and wheelchairs, it has no vehicles. Therefore, she is not involved with transport vehicles.

Nurse Hall testified that Mr. Prieto was a fall risk. His chart from University Plaza stated that for transfer, he has "total dependence" and needed three people to

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help him do things like getting into the shower or into bed. The chart also reflected that Mr. Prieto had a severe medical condition that placed him at a high risk of falling. Other documents showed that Mr. Prieto could not brace himself for a fall and had impaired sitting balance. Nurse Hall also testified that a document entitled "Side Rail Screen," that was apparently from University Plaza, indicated that Mr. Prieto needed to be in a stretcher that had side rails.

Nurse Hall opined that everyone involved in Mr. Prieto's care and treatment knew he was a fall risk, and therefore, every person who came into contact with him should have made sure he was safe and not going to fall. Nurse Hall also opined that "every licensed person should have known through their nursing clinical judgment, should have stopped and questioned the fact that this gentleman was not in a stretcher when he was released from that [TRC] facility."...

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