Batista-Acevedo et al v. Presbyterian Community Hospital, Inc et al

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
AISLYN BATISTA ACEVEDO, et al.,
Plaintiffs,
v.
PRESBYTERIAN COMMUNITY
HOSPITAL INC., et al.,
Defendants.
Civ. No. 22-01468 (MAJ)
OPINION AND ORDER
I. Introduction and Background
On September 27, 2022, Plaintiffs Aislyn Batista Acevedo, Ina Ruth Kessler
Krugman, and minor A.D.S.B. (“Plaintiffs”) filed the instant suit on behalf of the late
David Suárez (“Suárez”) against nurse practitioner Luis Roa Cordero (“Roa”) and various
physicians, hospitals, service providers, and their insurers (collectively, “Defendants”).
(ECF No. 1). From September 29, 2021, until his death on October 23, 2021, Suárez was
hospitalized at Ashford Presbyterian Hospital (“Presby”) and Doctors’ Center Hospital
Bayamón (“Doctors’”). Plaintiffs allege that, during the time that Suárez was hospitalized,
Defendants failed to properly screen and treat Suárez in violation of the Emergency
Medical Treatment and Labor Act (“EMTALA”). See 42 U.S.C. § 1395. Plaintiffs also allege
that all Defendants are liable under Puerto Rico law for negligence and medical
malpractice. (ECF No. 288).
Before the Court is a Motion in Limine filed by Roa, Suzette Betancourt-Reyes, and
their conjugal partnership, who request that the Court prohibit Plaintiffs from
introducing expert witness testimony regarding the alleged negligence of Roa from
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Plaintiffs’ experts Dr. Michael Quinn (“Dr. Quinn”), Dr. Elliot Goodman (“Dr.
Goodman”), and Dr. Dainius A. Drukteinis (“Dr. Drukteinis”) (collectively, “Plaintiffs’
Experts”). (ECF No. 742). For the reasons that follow, the motion is GRANTED.
II. Factual Background
According to the operative complaint,1 Suárez was admitted to the emergency
room at Presby on September 29, 2021. (ECF No. 288 at 16 ¶ 107). At that time, Suárez
was complaining of acute abdominal pain. Id. Medical staff at the hospital ordered “an
abdominal sonogram, some laboratory tests, pain medications and hydration[,]” as well
as “a consultation with internal medicine and surgery services.” (ECF No. 288 at 16 ¶
110).
Early the next day, Suárez was evaluated by Dr. Cuff, a physician specializing in
general surgery. (ECF No. 288 at 5 ¶ 21, 16 ¶ 112). Dr. Cuff determined that Suárez
would need to undergo surgery, yet he decided that Suárez would first have to submit to
an “MRCP” evaluation before surgery would be possible. (ECF No. 288 at 17 ¶ 113). By
disputed means, medical staff at the hospital allegedly determined that Suárez was too
obese to fit in the MRI machine used to conduct MRCP evaluations at Presby. (ECF No.
288 at 17 ¶ 115). Accordingly, on September 30, 2021, the physicians treating Suárez
decided to transfer him to another hospital facility. (ECF No. 288 at 18 ¶ 120).
On October 1, 2021, Suárez was transferred to Doctors’. By the next day, medical
staff at that facility allegedly determined that they also would not be able to perform the
necessary procedures on Suárez because their facilities could not accommodate his size.
1 The Court recites the following facts from the Complaint for the sole purpose of providing
background on the controversy between the parties; the Court does not accept the allegations in the
Complaint as true.
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(ECF No. 288 at 23–24 ¶¶ 155–156). Medical staff at Doctors’ thus decided to transfer
Suárez back to Presby. (ECF No. 288 at 24 ¶ 161).
Over the course of the next two days, Suárez deteriorated. (ECF No. 288 at 25–
27 ¶¶ 163–176). On October 4, 2021, Suárez was intubated. (ECF No. 288 at 27 ¶ 176).
Several weeks later, on October 23, 2021, Suárez died. (ECF No. 288 at 29–30 ¶ 191).
Roa was the nurse practitioner who performed the initial emergency room
assessment of Suárez at Doctors’ on October 1, 2021. (ECF No. 288 at 21 ¶ 144).
Plaintiffs allege that, in his evaluation of Suárez, Roa noted “fatigue, malaise, jaundice,
abdominal pain, nausea, vomiting, gallbladder disease, hematuria, headache, anxiety,
acutely ill, and positive Murphy’s sign.” (ECF No. 288 at 22 ¶ 147). His clinical
impression was that Suárez had pancreatitis due to common bile duct stone. (ECF No.
288 at 22 ¶ 147). Roa stated that he would start treatment for Suárez and order
consultations with the emergency room physician. (ECF No. 288 at 22 ¶ 146). He also
suggested a consultation with surgery, ordered laboratory tests on Suárez, and handed off
care of the patient to Dr. Rivera. (ECF No. 288 at 22 ¶¶ 146; 150). Plaintiffs allege that
no surgery, gastroenterology, or internal medicine services were consulted despite Roa’s
request. (ECF No. 288 at 24 ¶ 158).
III. Legal Standard
The admission of expert testimony is governed by Federal Rule of Evidence 702,
which provides that:
A witness who is qualified as an expert by knowledge, skill, experience, training, or
education may testify in the form of an opinion or otherwise if:
(a) the expert’s scientific, technical, or other specialized knowledge will help the
trier of fact to understand the evidence or determine a fact in issue;
(b) the testimony is based on sufficient facts or data;
(c) the testimony is the product of reliable principles and methods; and
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(d) the expert has reliably applied the principles and methods to the facts of the
case.
FED. R. EVID. 702. Rule 702 directs the court to consider the admissibility of expert
testimony by determining whether “an expert’s proffered testimony ‘both rests on a
reliable foundation and is relevant to the task at hand.’” Carrozza v. CVS Pharmacy, Inc.,
992 F.3d 44, 55–56 (1st Cir. 2021) (quoting Daubert, 509 U.S. at 597).
Before a party may admit testimony from an expert witness, Rule 26 of the Federal
Rules of Civil Procedure requires that the party submit a written report containing, in
relevant part, “a complete statement of all opinions the witness will express and the basis
and reasons for them[,]” as well as “the facts or data considered by the witness in forming
them[.]” FED. R. CIV. P. 26(a)(2)(B). An expert witness may reasonably supplement,
explain, or elaborate on the material set forth in their Rule 26 report. Gay v. Stonebridge
Life Ins. Co., 660 F.3d 58, 64 (1st Cir. 2011). However, where a party fails to comply with
the mandatory disclosure requirements of Rule 26(a) and their failure was not
“substantially justified or . . . harmless[,]” that “party is not allowed to use that
information or witness to supply evidence . . . at a trial[.]” FED. R. CIV. P. 37(c)(1). The
admissibility of expert witness testimony is thus contingent upon whether the parties
“make explicit and detailed expert disclosures” that demonstrate the reliability and rigor
of the proffered opinion. Santiago-Díaz v. Laboratorio Clínico y de Referencia del Este,
456 F.3d 272, 276 (1st Cir. 2006); see also Clemente-Vizcarrondo v. United States, Civ.
No. 17-1144, 2020 WL 748840, at *2 (D.P.R. Feb. 14, 2020); Rivera-Marrero v.
Presbyterian Cmty. Hosp., 255 F. Supp. 3d 290, 296 (D.P.R. 2017) (“[E]xpert-related
disclosures are insufficient when they consist of sketchy and vague descriptions of
anticipated opinions or areas of anticipated testimony.”) (quotations omitted).
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IV. Analysis
Roa challenges the admissibility of Plaintiffs’ Experts’ testimony as to Roa on the
grounds that all of Plaintiffs’ Experts fail the Daubert-Kumho standard, as none establish
(i) the applicable standard of care to Roa as a nurse practitioner in an Emergency Room,
[(ii)] any deviation by Roa, specifically, of said standard, or (iii) the causal nexus between
Roa’s actions or omissions and the damages suffered.” (ECF No. 742 at 12).2 Because
the Court finds that Plaintiffs’ Experts’ reports do not discuss any standard of care
applicable to Roa, the Court concludes that Plaintiffs’ Experts may not testify as to the
standard of care applicable to Roa or his deviations from such standard.
While all three expert opinions speak to the standard of care faced by physicians
and/or medical institutions, nurses are subject to a distinct standard of care under Puerto
Rico law in light of their distinct roles and responsibilities. “As to the standard of care
owed specifically by nurses, the Puerto Rico Supreme Court has held that ‘[a] nurse
should exercise a certain standard of reasonable care to see that no unnecessary harm
comes to the patient, and said standard of care must be the same as the standard of care
exercised by other nurses in the locality or similar localities.’” Morales v. Monagas, 723
F.Supp.2d 416, 422 (D.P.R. 2010) (quoting Blas Toledo v. Hospital Nuestra Señora de la
Guadalupe, 146 D.P.R. 267, 207, slip op. at 21 (1998)); see also Castro v. Municipio de
Guánica, 87 D.P.R. 725, 728–29 (1963). Additionally, “[n]urses have the unavoidable
2 Roa challenges the admissibility of Plaintiffs’ Experts’ testimony as to Roa on several additional grounds,
including that they lack accepted methodologies, offer factual conclusions, offer legal conclusions, and
opine on ultimate issues of liability. (ECF No. 742). Because the Court finds that Plaintiffs expert witnesses
have failed to identify a reliable standard of care, none of the expert witnesses will be permitted to present
testimony regarding the alleged negligence of Roa. See Daubert, 509 U.S. at 597 (requiring that, as a
precondition for admissibility, expert witness testimony “both rests on a reliable foundation and is relevant
to the task at hand.”) Accordingly, these additional grounds for excluding the expert witness testimony are
moot and will not be addressed by the Court.
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duty to fulfill medical orders with the required urgency and in accordance with each
patient’s particular circumstances.” Morales, 723 F.Supp.2d at 422.
Plaintiffs argue that “Dr. Drukteinis, Dr. Goodman, and Dr. Quinn each address
specific departures from accepted emergency and hospital-based care that fall squarely
within the scope of a nurse practioner functioning in the emergency department.” (ECF
No. 782 at 31). After a careful review of the expert reports, the Court finds that they
provide no commentary whatsoever as to the proper function of a nurse practitioner in
an emergency department and no basis to properly assist the jury in determining whether
Roa deviated from a standard of care applicable to him.
With respect to Dr. Goodman, Plaintiffs highlight testimony that “it is vital that a
patient who presents with a clinical and biochemical picture of biliary obstruction and
acute pancreatitis has his common bile duct fully evaluated with MRCP and/or ERCP . . .
that is the standard of care.” (ECF No. 782 at 32). No portion of Dr. Goodman’s report,
however, gives any indication that, according to the prevailing “standard of care exercised
by other nurses in the locality or similar localities[,]’” it is incumbent upon the nurse
practitioner to possess this medical knowledge, much less that the prevailing standard of
care requires nurse practitioners to ultimately ensure that the procedures take place
notwithstanding the decisions of their physician supervisors. Monagas, 723 F.Supp.2d at
422. The report does not indicate what, if any, responsibility a nurse has to ensure this
course of treatment is followed. Other points in Goodman’s report identified by Plaintiffs
as establishing a standard of care as to Roa concern issues in which Roa is not alleged to
have had any role. (ECF No. 782 at 33).
With respect to Dr. Quinn, the expert report similarly is silent as to the role of the
nurse practitioner. (ECF No. 742-1). For example, Dr. Quinn states that “[t]he fact that
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David had not had a formal consultation with a gastroenterologist at Ashford or Doctors
by 10/1/21 despite Dr. Morales being notified of David’s case by Dr. Ramos, is a deviation
from the standard of care. Furthermore, the fact that an ERCP could have been performed
at Ashford or Doctors, but was not, was a deviation from the standard of care.” (ECF No.
742-1 at 4–5). Dr. Quinn does not, however, indicate to any degree whether a nurse
practitioner is responsible for ensuring that a consultation with a gastroenterologist takes
place or that an ERCP is performed. Indeed, Dr. Quinn explicitly presents himself as being
“familiar with the accepted standard of care for the average qualified gastroenterologist
providing care and treatment to patients in 2021 to the present.” (ECF No. 742-1 at 1)
(emphasis added). Dr. Quinn’s report therefore provides no basis to allow testimony as to
the standard of care of a nurse practitioner in Puerto Rico.
With respect to Dr. Drukteinis, Plaintiffs assert that “[w]hen Dr. Drukteinis
establishes the ‘Standard of Care in the Emergency Department for a Patient with
Suspected Choledocholithiasis’ and the ‘Standard of Care in the Emergency Department
for Patient’s Handoffs’, he includes Roa in those standards.” (ECF No. 782 at 31). To
the contrary, Dr. Drukteinis explicitly qualified his enumeration of the standard of care
as pertaining to physicians: “When a patient presents with suspected choledocholithiasis
to the emergency department, the goal of the emergency medicine physician is to arrange
confirmation of the diagnosis with imaging.” (ECF No. 742-3 at 11) (emphasis added).
Additionally, Dr. Drukteinis’ discussion of deviations from the standard of care with
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respect to patient handoffs are likewise directed at physicians.3 While the report
summarily states that “the physicians and staff at both Ashford Presbyterian Community
Hospital and Doctors’ Center Hospital fell below the standard of care in their
management of Mr. David Suarez Kessler and failed to adhere to EMTALA requirements,”
this conclusory assertion alone does not assist the jury with any standard by which to
evaluate the actions of Roa.
Because Plaintiffs’ Experts’ reports do not speak to the standard of care of a nurse
practitioner, Federal Rule of Civil Procedure 26 dictates that Plaintiffs’ Experts cannot
testify as to the standard of care applicable to Roa or his deviation from that standard.
See Rodríguez Perez v. Abreu Garcia, 2024 WL 808654, at *3 (D.P.R. Feb. 27, 2024)
(“[T]he Court will not permit [Plaintiffs] to circumvent the discovery and disclosure
process by allowing [Plaintiffs’ Experts] to testify beyond the bounds of [their] expert
report[s].”).4
V. Conclusion
After careful consideration, the Court finds that Plaintiffs’ Experts do not provide
a basis to offer any testimony as the alleged negligence of Roa. As such, Roa’s Motion in
Limine is GRANTED.
3 See id. at 14 (“The Doctors’ Hospital physicians also exhibited significant delays in attempting to
perform (or not perform) an ERCP, delays in assessing why the ERCP could not be performed (including
the confirmed weight and habitus of Mr. Suarez Kessler, and the confirmed limitations of the operating
room tables at each hospital), delays due to management from the emergency department director’s home
rather than the hospital, delays in use of proper consult channels to reach the gastroenterologist, delays in
the gastroenterologist returning the consult, and delays in the decision and initiation of Mr. Suarez Kessler’s
ultimate transfer to another hospital. These delays were also due to communication problems between the
emergency department physicians, the medical director, and the gastroenterologist.”) (emphasis added);
id. at 15 (“Each emergency department physician should have been aware of Mr. Suarez Kessler’s presence
in their department and concerned that he was not yet dispositioned by the end of each of their shifts.”)
(emphasis added).
4 The Court notes, however, that with respect to their opinions regarding other defendants in this
case, Plaintiffs’ Experts may discuss the facts of Roa’s involvement in the treatment of Suárez, to the extent
that those facts are relevant.
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It is hereby ORDERED.
In San Juan, Puerto Rico, this 10th day of February, 2026.
/s/ María Antongiorgi-Jordán
MARIA ANTONGIORGI-JORDAN
UNITED STATES DISTRICT JUDGE
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