Barbara T. Collins v. HCA Health Services Of Tennessee, Inc.

IN THE COURT OF APPEALS OF TENNESSEE
AT NASHVILLE
September 21, 2016 Session
BARBARA T. COLLINS v. HCA HEALTH SERVICES OF TENNESSEE,
INC., ET AL.
Appeal from the Circuit Court for Davidson County
No. 14C-339 Hamilton V. Gayden, Jr., Judge
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No. M2016-00524-COA-R3-CV – Filed October 28, 2016
___________________________________
Appellant was injured while attempting to leave the defendant hospital against
medical advice. Appellant appeals the trial court‘s decision to grant summary judgment
in favor of the defendant hospital, concluding that the hospital owed no duty to prevent
Appellant from leaving the hospital. Discerning no error, we affirm.
Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Circuit Court Affirmed
J. STEVEN STAFFORD, P.J.,W.S., delivered the opinion of the court, in which ARNOLD B.
GOLDIN and KENNY ARMSTRONG, JJ., joined.
Timothy R. Holton and Carroll C. Johnson, III, Memphis, Tennessee, for the appellant,
Barbara T. Collins.
Dixie W. Cooper and Kim J. Kinsler, Nashville, Tennessee, for the appellees, HCA
Health Services of Tennessee, Inc. d/b/a Tristar Summit Medical Center.
OPINION
BACKGROUND
Because this case involves the trial court‘s grant of summary judgment, the facts
are largely undisputed. On October 15, 2012, Plaintiff/Appellant Barbara Collins
(―Appellant‖) was transported by ambulance to Defendant/Appellee HCA Health
Services of Tennessee, Inc., d/b/a/ Tristar Summit Medical Center (―the Hospital‖),
located in Hermitage, Tennessee, complaining of dizziness, nausea, chest pain, and
headache. After her arrival at the Hospital, Appellant was evaluated and her medical
records indicate that she was ―alert‖ and that her speech was ―not slurred.‖ According to
Appellant‘s medical records, Appellant had previously been diagnosed with bipolar
disorder and obsessive compulsive disorder, and she was taking psychiatric medication at
the time.
Appellant was admitted to the Hospital under Dr. Ronald Rentuza‘s (―Dr.
Rentuza‖) care.1 Dr. Rentuza ordered a work-up and neurology consult to determine the
cause of her diplopia,2 dizziness, and hypertension. Based on his examination of
Appellant, Dr. Rentuza noted that Appellant was ―awake, oriented, and in no distress at
rest.‖ As part of the work-up, Dr. Rentuza ordered an MRI of Appellant‘s head and neck.
Dr. Rentuza ordered an increased dosage of Appellant‘s psychiatric medication as well as
other additional medication; however, he limited Appellant‘s pain medication so the
medication would not interfere with Appellant‘s neurology assessment. Nurses Maranda
Coggins (―Nurse Coggins‖) and Ann Stenson (―Nurse Stenson‖) assessed Appellant
frequently during her stay on October 15 and noted that Appellant was responsive and
coherent in response to their questions. Appellant stated she did not have any thoughts of
harming herself or others, which Nurse Coggins documented in the medical record. Later
that day, Appellant told Nurse Stenson that she was ―afraid she was dying and had so
much she still want[ed] to do with her life.‖ However, based on Nurse Stenson‘s
assessment, Appellant was aware, responsive, and coherent at all times that they
interacted.
The next day, on October 16, 2012, at 7:47 A.M., Nurse British Sullivan (―Nurse
Sullivan‖) assessed Appellant and noted that she was ―Awake/Alert‖ and oriented to
person, place, time, and stimuli. Nurse Sullivan described Appellant‘s mood as
―agitated,‖ ―anxious,‖ ―fearful,‖ ―irritable,‖ and ―tearful.‖ Appellant again reported that
she ―fe[lt] like she [was] dying‖ and that her ―head belong[ed] to someone else and [wa]s
running off without her.‖ At 8:00 A.M., Appellant was still anxious and tearful and
stated that she wanted to go home. Dr. Rentuza evaluated Appellant again at 10:32 A.M.
and noted that Appellant was awake, alert, oriented, and aware of her surroundings.
According to Dr. Rentuza‘s notes in the medical record, Appellant responded
appropriately to questions. At around noon, Appellant communicated that she wished to
leave. Nurse Sullivan found Appellant in her room dressed, pulling out her IV, and
preparing to leave the Hospital. Appellant was upset that she still had a headache and
had been waiting a long time for a neurologist. Appellant stated that she was not ―getting
any help and c[ould] have a [headache] at home.‖ Nurse Sullivan responded she would
page Dr. Rentuza to see if Appellant could be given additional pain medication to address
her headache. In response, Dr. Rentuza stated that ―we are doing all that we can‖ and
1
Dr. Rentuza works as a hospitalist at the Hospital. A ―hospitalist‖ is ―a physician specializing
in hospital inpatient care.‖ Mosby’s Dictionary of Medicine, Nursing & Health Professions 856 (9th ed.
2013).
2
―Diplopia‖ means ―double vision caused by defective function of the extraocular muscles or a
disorder of the nerves that innervate the muscles.‖ Id. at 541.
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that Appellant ―could sign [an against medical advice] form (―AMA form‖) if [she]
wanted [because Dr. Rentuza] did not want to give [Appellant] anything else for [her
headache].‖ Nurse Sullivan ―tried to get [Appellant] to stay at least until [the
neurologist] came.‖ Appellant, however, ―kept repeating over and over that she [wa]s
leaving and [that[ no one care[d] about her and no one [wa]s doing anything for her.‖
Despite Nurse Sullivan‘s pleas, Appellant was ―adamant‖ about walking down the street
to her daughter‘s office. Appellant eventually refused to remain in the hospital or sign an
AMA form. Although Nurse Sullivan encouraged Appellant to use the elevator,
Appellant insisted on taking the emergency exit stairway from the fourth floor to the
Hospital‘s exit.
At some point, Appellant found her way to the second floor and either fell or
dropped herself to the ground. At her later deposition, Appellant admitted that she had
no recollection of her fall or the events leading thereto and did not believe that she was
―incompetent‖ while she was a patient at the Hospital. Appellant‘s medical record from
her later hospitalization at Vanderbilt Medical Center (―Vanderbilt‖) indicated, however,
that Appellant had informed her daughter that the fall occurred when Appellant was
accidently locked onto a balcony at the hospital. Apparently believing that she could
make the fifteen-foot drop to the ground, Appellant indicated that she ―sat down on her
bottom to scoot off the ledge because she thought she could make it [fifteen feet].‖ After
she fell, Appellant was transported to Vanderbilt where she was treated for thoracic and
lumbar burst fractures she sustained from the fall. Psychiatry consultation at Vanderbilt
ruled out a potential suicide attempt.
On January 27, 2014, Appellant filed a complaint against Dr. Rentuza, Summit
Medical Associates, P.C., and the Hospital in Davidson County Circuit Court alleging
―negligence and malpractice‖ and seeking damages of $10,000,000.00. On October 7,
2015, the Hospital moved for summary judgment pursuant to Tennessee Rule of Civil
Procedure 56.02, arguing that only a physician may order a patient to be detained at a
hospital against her will and that the nurses employed by the hospital did not have
statutory grounds to detain or involuntarily commit Appellant under Tennessee Code
Annotated Section 33-6-401 et seq. Alternatively, the Hospital argued that it was entitled
to absolute immunity under Tennessee Code Annotated Section 33-6-407(e).3 In support
of the Hospital‘s motion, it relied on the statement of undisputed material facts filed
simultaneously with the motion, memorandum of law with attached exhibits of portions
of Appellant‘s certified medical records, and portions of various depositions and
3
Tennessee Code Annotated Section 33-6-407(e) provides:
A hospital, treatment resource, or health care provider shall be immune from
any civil liability and shall have an affirmative defense to any criminal
liability arising either from a determination relative to admission of a person
to a facility or treatment resource or from the transportation of a person to and
from the hospital or treatment resource.
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affidavits from Dr. Rentuza and the nurses who cared for Appellant during her stay at the
Hospital. On December 1, 2015, Appellant filed a response to the Hospital‘s statement of
undisputed facts and filed a statement of additional undisputed facts, relying on
psychiatrist Dr. John Griffin‘s affidavit. Dr. Griffin, who reviewed Appellant‘s medical
records, formed the opinion that Appellant was not competent at the time of her
admission to the Hospital and met the criteria for emergency involuntary detention
pursuant to Tennessee Code Annotated Section 33-6-401 et seq. On December 9, 2015,
the Hospital filed a reply memorandum and response to Appellant‘s statement of
additional undisputed facts, attaching Dr. Rentuza‘s affidavit which clarified a statement
in his deposition regarding his intention to visit Appellant again before her departure
from the hospital.
Following a hearing, the trial court entered a memorandum on February 3, 2016,
concluding that the Hospital ―did not have a duty to detain [Appellant] absent a directive
from a physician.‖ On February 12, 2016, the trial court entered an order incorporating
the memorandum by reference, granting the Hospital‘s motion for summary judgment
and dismissing the claims against the Hospital with prejudice. The trial court also
certified the order as final under Rule 54.02 of the Tennessee Rules of Civil Procedure.
ISSUE
Appellant filed a timely appeal, raising one issue for review: Whether the trial
court properly granted summary judgment to the Hospital.
STANDARD OF REVIEW
In this case, only the Hospital moved for and was granted summary judgment by
the trial court. Summary judgment is appropriate where: (1) there is no genuine issue
with regard to the material facts relevant to the claim or defense contained in the motion
and (2) the moving party is entitled to judgment as a matter of law on the undisputed
facts. Tenn. R. Civ. P. 56.04. Our Supreme Court in Rye v. Women’s Care Center of
Memphis, MPLLC recently explained the burden-shifting analysis to be employed by
courts tasked with deciding a motion for summary judgment:
[I]n Tennessee, as in the federal system, when the moving party does
not bear the burden of proof at trial, the moving party may satisfy its
burden of production either (1) by affirmatively negating an essential
element of the nonmoving party‘s claim or (2) by demonstrating that the
nonmoving party‘s evidence at the summary judgment stage is insufficient
to establish the nonmoving party‘s claim or defense. We reiterate that a
moving party seeking summary judgment by attacking the nonmoving
party‘s evidence must do more than make a conclusory assertion that
summary judgment is appropriate on this basis. Rather, Tennessee Rule
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56.03 requires the moving party to support its motion with ―a separate
concise statement of material facts as to which the moving party contends
there is no genuine issue for trial.‖ Tenn. R. Civ. P. 56.03. ―Each fact is to
be set forth in a separate, numbered paragraph and supported by a specific
citation to the record.‖ Id. When such a motion is made, any party opposing
summary judgment must file a response to each fact set forth by the movant
in the manner provided in Tennessee Rule 56.03. ―[W]hen a motion for
summary judgment is made [and] ... supported as provided in [Tennessee
Rule 56],‖ to survive summary judgment, the nonmoving party ―may not
rest upon the mere allegations or denials of [its] pleading,‖ but must
respond, and by affidavits or one of the other means provided in Tennessee
Rule 56, ―set forth specific facts‖ at the summary judgment stage ―showing
that there is a genuine issue for trial.‖ Tenn. R. Civ. P. 56.06.
Rye v. Women’s Care Ctr. of Memphis, MPLLC, 477 S.W.3d 235, 264–65 (Tenn. 2015)
(judicially adopting a summary judgment parallel to the statutory version contained in
Tenn. Code Ann. § 20-16-101); see also Tenn. Code Ann. § 20-16-101 (applying to cases
filed after July 1, 2011).
On appeal, this Court reviews a trial court‘s grant of summary judgment de novo
with no presumption of correctness. See City of Tullahoma v. Bedford Cnty., 938
S.W.2d 408, 412 (Tenn. 1997). In reviewing the trial court‘s decision, we must view all
of the evidence in the light most favorable to the nonmoving party and resolve all factual
inferences in the nonmoving party‘s favor. Luther v. Compton, 5 S.W.3d 635, 639 (Tenn.
1999); Muhlheim v. Knox. Cnty. Bd. of Educ., 2 S.W.3d 927, 929 (Tenn. 1999). If the
undisputed facts support only one conclusion, then the court‘s summary judgment will be
upheld because the moving party was entitled to judgment as a matter of law. See White
v. Lawrence, 975 S.W.2d 525, 529 (Tenn.1998); McCall v. Wilder, 913 S.W.2d 150, 153
(Tenn.1995).
This case presents an issue of statutory construction, which is a question of law,
and questions of law are amenable to disposition by summary judgment. Metro. Dev. &
Housing Agency v. Trinity Marine Nashville, Inc., 40 S.W.3d 73, 76 (Tenn. Ct. App.
2000). Questions of law are reviewed de novo, affording no presumption of correctness
to the trial court‘s determination. Maggart v. Almany Realtors, Inc., 259 S.W.3d 700,
703 (Tenn. 2008).
DISCUSSION
As we perceive it, the dispositive issue is whether the Hospital had a duty to
involuntarily detain Appellant based upon the undisputed facts in the record. Generally, a
claim of simple negligence requires the following elements: ―1) a duty of care owed by
the defendant to the plaintiff; 2) conduct falling below the applicable standard of care
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amounting to a breach of that duty; 3) an injury or loss; 4) causation in fact; and 5)
proximate, or legal, cause.‖ King v. Anderson Cnty., 419 S.W.3d 232, 246 (Tenn. 2013)
(citing Giggers v. Memphis Hous. Auth., 277 S.W.3d 359, 364 (Tenn. 2009)). In her
complaint, however, Appellant alleged both ―negligence and malpractice‖ and neither
party to this appeal makes any distinction between a claim of simple negligence and a
claim of medical malpractice or health care liability.4 Indeed, for purposes of this appeal,
we are not required to decide which type of action governs Appellant‘s claim against the
Hospital because the existence of a duty is an essential element to either claim. See
Draper v. Westerfield, 181 S.W.3d 283, 290 (Tenn. 2005) (―[Health care liability actions]
. . .incorporate[] the common law elements of negligence.‖). As such, if the undisputed
facts establish that the Hospital did not owe a duty of care to Appellant to prevent her
injury by involuntarily detaining her, she cannot prevail in her claim against the Hospital
and the trial court correctly granted summary judgment.
Appellant argues that ―hospitals [owe] a duty to protect patients, who, because of
physical or mental conditions, lack the capacity to recognize and avoid dangerous
situations.‖ In support, she cites three cases in which she asserts Tennessee courts have
placed such a duty on hospitals. See Keeton v. Maury Cnty. Hosp., 713 S.W.2d 314, 316
(Tenn. Ct. App. 1986); Rural Ed. Ass’n v. Anderson, 261 S.W.2d 151 (Tenn. Ct. App.
1953); v. St. Thomas Hosp., 211 S.W.2d 450 (Tenn. Ct. App. 1947). We will proceed to
discuss each of these cases in turn.
In Keeton, plaintiff was not provided with a urinal and felt the urge to urinate after
his catheter was removed subsequent to a prostate surgery. 713 S.W.2d at 315. Although
the hospital staff was aware of plaintiff‘s vertigo condition and of his need for assistance
in getting out of bed, help was not provided when plaintiff sought assistance on several
occasions. Id. at 315–16. After a while, plaintiff got out of bed himself and fell on his
way back to bed. Id. at 316. The evidence showed that plaintiff‘s physicians did not
leave orders restricting plaintiff from getting out of bed. Id. The trial court ruled that
plaintiff was required to show that the hospital staff violated orders left by the doctor in
order for the hospital to be liable for negligence; because the plaintiff‘s physicians did not
leave such orders, the trial court dismissed the plaintiff‘s claim. Id. This Court reversed,
holding that it was foreseeable that plaintiff might fall if he went to the bathroom
unassisted and that ―it is not necessary to prove that hospital personnel violated an order
left by plaintiff‘s physician‖ in order to find the hospital liable. Id. at 317.
In Anderson, the decedent was admitted to defendant mental institution
(―institution‖) that held itself out as equipped to care for mental patients. 261 S.W.2d at
4
We are now required to use the term ―health care liability‖ because in 2012, statutes authorizing
suit against health care providers were amended to replace ―medical malpractice‖ with ―health care
liability.‖ Act of Apr. 23, 2012, ch. 798, §§ 7–15, 2012–2 Tenn. Code Ann. Adv. Legis. Serv. 274, 274–
75 (codified at Tenn. Code Ann. §§ 29-26-115 to -122, -202 (2012)).
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212. Decedent‘s doctor informed the institution that plaintiff ―was deranged and there
was danger that he might harm himself if not put on the ground floor and properly
watched.‖ Id. at 213. However, decedent was put in a bed near a window on the second
floor. Id. at 214. While at the hospital, decedent ―suffer[ed] from fears and delusions‖
and ―was getting out of bed, walking around, going into rooms of other patients,
wandering about—‘out in the halls and making a nuisance of himself.‘‖ Id. After a few
hours, he either fell or jumped out the window and died. Id. at 215. This Court held that
the circumstances of the case ―were sufficient to raise a duty upon [the institution] to use
reasonable care to protect [decedent] against the danger of his getting out of bed and
harming himself, and to make it a question for the jury whether [the institution] breached
this duty.‖ Id. at 216.
Similarly, in Spivey, decedent was admitted to defendant hospital for pneumonia
and high fever and was put in a bed close to an unfastened and unguarded third floor
window. 211 S.W.2d at 452–53. During his stay, he was delirious and attempted to get
out of bed multiple times. Id. at 452. Decedent‘s family wanted to stay with him to make
sure that he stayed in bed; however, a nurse sent the family away and at the same time
assured the family that hospital staff would ―tie [decedent] in bed if he tries to get up,‖
and restraints were in fact used. Id. at 453–54. Later that night, hospital staff noticed that
decedent freed himself of the restraints and was out of bed but did nothing further to
restrain him. Id. at 454. Decedent thereafter jumped out of the window to his death. Id.
Though the hospital argued that decedent‘s injury was unforeseeable, this Court held that
knowledge that the decedent was suffering from a high fever and delirium was sufficient
to create a duty on defendant to protect him against the risk of getting out of bed and
harming himself. Id. at 455.
As the preceding cases demonstrate, ―[i]n Tennessee, the common-law standard of
conduct to which a person must conform to avoid being negligent is the familiar
‗reasonable person under similar circumstances‘ standard.‖ Blasingame v. Church Joint
Venture, L.P., No. 15-1038, 2015 WL 4758933, at *7 (W.D. Tenn. Aug. 12, 2015)
(quoting Rains v. Bend of the River, 124 S.W.3d 580, 588 (Tenn. Ct. App. 2003)). ―As a
general matter, this standard requires a person to exercise reasonable care under the
circumstances to refrain from conduct that could foreseeably injure others.‖ Rains, 124
S.W.3d at 588 (citing Bradshaw v. Daniel, 854 S.W.2d 865, 871 (Tenn. 1993)). Whether
a particular conduct conforms to the standard of care is determined based on the
particular facts of a case. Id. Typically, a ―hospital owes a duty to give its patient such
reasonable care and attention for his safety as his physical and mental condition may
require; and it must use reasonable care to safeguard him against any known or
reasonably apprehended danger to himself due to his mental derangement.‖ Anderson,
261 S.W.2d at 154 (emphasis added). Generally, a ―patient‖ is a ―person under medical or
psychiatric care.‖ Black’s Law Dictionary (10th ed. 2014) see also Shockley v. Mental
Health Coop., Inc., 429 S.W.3d 582, 591 (Tenn. Ct. App. 2013) (holding that it ―is well
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settled that in interpreting the meaning of a word or phrase in a rule . . ., the court may
use dictionary definitions‖).
From our review, the cases cited above do not support Appellant‘s position under
the unique facts of this case. In the three cases discussed above, all of the injured persons
were admitted to their respective hospitals as patients and sustained foreseeable injuries
while they were under active treatment and care of the physicians and hospital staff.
Hospital staff therefore had a duty to act with reasonable care to protect those patients
against foreseeable injuries with respect to each patient during their stay at the hospitals.
In the instant case, however, Appellant terminated medical treatment and voluntarily
decided to leave the hospital. This is not a case where Appellant sustained her injuries
during her stay at the Hospital. On the contrary, it is undisputed that Appellant received
her injuries as she was leaving the Hospital after having refused treatment and against
medical advice. Once she terminated treatment and decided to leave against medical
advice, however, her status as a patient of the Hospital ceased as well as the Hospital‘s
general duty of care to her as a patient. Cf. Church v. Perales, 39 S.W.3d 149, 164
(Tenn. Ct. App. 2000) (citing Glenn v. Carlstrom, 556 N.W.2d 800, 802 (Iowa 1996);
Weiss v. Rojanasathit, 975 S.W.2d 113, 119–20 (Mo. 1998)) (stating that ―[a]
physician‘s duty to attend a patient continues as long as required unless the physician-
patient relationship is ended by . . . the dismissal of the physician by the patient‖ and
noting other instances where the duty ceases).
Appellant argues, however, that she should not have been permitted to refuse
medical treatment and leave the hospital because she was not competent at the time of her
decision. In general, all competent patients have the right to refuse medical care. As we
have explained in Church v. Perales, 39 S.W.3d 149 (Tenn. Ct. App. 2000):
All competent adults have a fundamental right to bodily integrity. See
Washington v. Glucksberg, 521 U.S. 702, 720, 117 S. Ct. 2258, 2267, 138
L. Ed. 2d 772 (1997); Hezeau v. Pendleton Methodist Mem. Hosp., 715 So.
2d 756, 760 (La. Ct. App. 1998); Mahan v. Bethesda Hosp., Inc., 84 Ohio
App. 3d 520, 617 N.E.2d 714, 718 (1992); Shellenbarger v. Brigman, 3
P.3d 211, 216 (Wash. Ct. App. 2000). This right is rooted in the Anglo-
American tradition of personal autonomy and the right of self-
determination. See Thor v. Superior Court, 5 Cal. 4th 725, 21 Cal. Rptr. 2d
357, 855 P.2d 375, 380 (1993); In re Gardner, 534 A.2d 947, 950 (Me.
1987); Brophy v. New England Sinai Hosp., Inc., 398 Mass. 417, 497
N.E.2d 626, 633 (1986). Included in this right is the right of competent
adult patients to accept or reject medical treatment. See Cruzan v. Director,
Missouri Dep’t of Health, 497 U.S. 261, 278–79, 110 S. Ct. 2841, 2851–
52, 111 L. Ed. 2d 224 (1990).
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Church, 39 S.W.3d at 158. The issue in this case, however, does not solely concern
Appellant‘s decision to decline further diagnosis and treatment, but rather her decision to
terminate her status as a patient and leave the hospital against medical advice.
Specifically, Appellant argues that because she was suffering from a psychiatric disorder,
the Hospital had a duty to ―take reasonable steps to prevent [Appellant] from injuring
herself.‖ Because there is no dispute that Appellant clearly and unequivocally expressed
her intention to leave the hospital, Appellant is essentially arguing that in order to protect
Appellant, the Hospital had a duty to prevent Appellant from leaving the Hospital despite
her unequivocal desire to do so. The answer to this question, however, cannot be
determined based upon mere incompetency, but must be answered in light of Tennessee‘s
involuntary commitment statutory scheme.
In 2000, the Tennessee General Assembly enacted the current version of the
involuntary commitment statutes, which limit a hospitals‘ ability to detain patients
without their consent. See 2000 Tenn. Pub. Acts, c. 947, § 1, eff. March 1, 2001
(codified in Tenn. Code Ann. §§ 33-6-401 et seq.). The statutory guidelines for
emergency involuntary admission to inpatient treatment are provided in Tennessee Code
Annotated Section 33-6-401 et seq. The guidelines are specific and narrow.
Under Tennessee Code Annotated Section 33-6-401, a prospective detainee may
be detained by statutorily authorized persons:
IF AND ONLY IF
(1) [the prospective detainee] has a mental illness or serious emotional
disturbance, AND
(2) [the prospective detainee] poses an immediate substantial likelihood of
serious harm under § 33-6-501 because of the mental illness or serious
emotional disturbance[.]
Section 33-6-402 defines the individuals with authority to make involuntary detentions in
Tennessee as: (1) an officer authorized to make arrests in the state; (2) a licensed
physician; (3) a statutorily authorized psychologist; and (4) a professional designated by
the commissioner under the statute. These authorized persons must have ―reason to
believe‖ that the prospective detainee meets the criteria under Section 33-6-401 before
they may detain the individual. Thereafter, the detainee must immediately be examined
by ―a licensed physician, psychologist, or designated professional‖ to determine whether
the individual should be admitted to the hospital. Tenn. Code Ann. § 33-6-404 (outlining
the procedure for admission).5
5
Section 33-6-404 provides:
IF
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If the authorized person determines that the detainee is subject to admission to a
hospital under the statute, then the authorized person ―shall complete a certificate of need
for such emergency diagnosis, evaluation, and treatment showing the factual foundation
for the conclusions.‖ Under Tennessee Code Annotated Section 33-6-403, a detainee
―may be admitted and detained by a hospital . . . for emergency diagnosis, evaluation, and
treatment‖ in very limited circumstances:
IF AND ONLY IF
(1) a person has a mental illness or serious emotional disturbance, AND
(2) the person poses an immediate substantial likelihood of serious harm,. .
. , because of the mental illness or serious emotional disturbance,6 AND
(1)(A) a licensed physician, psychologist, or designated professional takes a person into
custody under § 33-6-402, OR
(B) a person is brought to the physician, psychologist, or designated professional for
examination under this section,
THEN
(2) the physician, psychologist, or designated professional shall immediately examine the
person and decide whether the person is subject to admission to a hospital or treatment
resource under § 33-6-403, AND
(3)(A) IF
(i) the person is not subject to admission, THEN
(ii) the physician, psychologist, or designated professional shall release the person, AND
(B) IF (I) the person is subject to admission, THEN (ii) the physician, psychologist, or designated
professional shall complete a certificate of need for such emergency diagnosis, evaluation, and
treatment showing the factual foundation for the conclusions on each item of Section 33-6-403,
AND (iii) the physician, psychologist, or designated professional shall assess the person‘s clinical
needs and need for physical restraint or vehicle security and determine the mode of transportation
to the hospital in consultation with the mandatory pre-screening agent, other mental health
professional familiar with the person, or a knowledgeable family member.
6
―Substantial likelihood of serious harm,‖ as defined under Tennessee Code Annotated Section
33-6-501, occurs in only four situations:
IF AND ONLY IF
(1)(A) a person has threatened or attempted suicide or to inflict serious bodily harm on
the person, OR
(B) the person has threatened or attempted homicide or other violent behavior, OR
(C) the person has placed others in reasonable fear of violent behavior and serious
physical harm to them, OR
(D) the person is unable to avoid severe impairment or injury from specific risks, AND
(2) there is a substantial likelihood that the harm will occur unless the person is placed
under involuntary treatment[.]
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(3) the person needs care, training, or treatment because of the mental
illness or serious emotional disturbance, AND
(4) all available less drastic alternatives to placement in a hospital or
treatment resource are unsuitable to meet the needs of the person[.]
In this case, Appellant does not dispute that the Hospital‘s duty was bounded by
Tennessee‘s involuntary commitment statutes. Indeed, this Court has previously indicated
that ―the common law is not the only source of legal duties . . . in negligence cases.‖
Rains v. Bend of the River, 124 S.W.3d 580, 588 (Tenn. Ct. App. 2003)). ―In addition to
the general duty to act reasonably to avoid harming others, more specific duties
governing particular situations and relationships may be imposed by the [Tennessee]
General Assembly.‖ Id. at 588–89 (citing Cook v. Spinnaker’s of Rivergate, Inc., 878
S.W.2d 934, 937 (Tenn. 1994)). Much like the Tennessee General Assembly can create
additional duties that may not have arisen under the common law, the Tennessee General
Assembly can limit those situations wherein a duty to use reasonable care arises. See
Lindsey v. Miami Dev. Corp., 689 S.W.2d 856, 860 (Tenn. 1985) (examining the
limitation on duty of care evident in Tennessee‘s Good Samaritan law).
Here, there is no dispute that Dr. Rentuza, the only licensed physician or other
authorized person to examine Appellant, never completed a certificate of need under
Section 33-6-404 authorizing the Hospital to detain Appellant against her will. Appellant
argues, however, that there is a dispute of material fact as to whether Dr. Rentuza had
actually authorized the detention of Appellant in order that he could examine her,
possibly in order to make a determination as to her competency. Specifically, Appellant
argues that Dr. Rentuza‘s deposition testimony that Appellant ―could leave against
medical advice after I had seen her‖ indicates that Dr. Rentuza intended to examine
Appellant again and that the Hospital, with Nurse Sullivan acting as its agent, had a duty
to detain Appellant until after Dr. Rentuza made that examination. Appellant argues that
Dr. Rentuza cannot later supplement this deposition statement with an affidavit clarifying
the meaning of this statement. We respectfully disagree.
Here, Dr. Rentuza‘s deposition itself clearly establishes that he had already seen
Appellant two hours before she left and that he did not intend to examine her again. In
relevant part, Dr. Rentuza‘s deposition provides:
[Appellant‘s counsel]: [You] agree that you never told the nurse, ―Tell her
hang on a second, I‘ll be right there,‖ did you?
Dr. Rentuza: I don‘t remember our specific conversion, but I don‘t
remember telling her that.
[Appellant‘s counsel]: There‘s nothing in this note to indicate that you
were going to come and see [Appellant], correct?
Dr. Rentuza: No, because I just saw her two hours ago.
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[Appellant‘s counsel]: So you made the decision at that point, even though
you were in the hospital, not to come see [Appellant] and evaluate her
before she left the facility, correct?
Dr. Rentuza: Based on my encounter with her two hours prior to that, yes.
Despite Appellant‘s contention otherwise, Appellant has not shown a genuine dispute of
material fact by taking a fragment of Dr. Rentuza‘s testimony out of context. Taking Dr.
Rentuza‘s deposition as a whole, in addition to his later-filed affidavit, it is clear that Dr.
Rentuza never directed Nurse Sullivan to detain Appellant or otherwise made any
indication that he intended to examine her again. While Dr. Rentuza‘s statement might
have been ill-defined when read on its own,7 doctors are not lawyers and the clear import
from his deposition testimony is that Dr. Rentuza did not intend to detain her or examine
her again prior to her departure. Accordingly, there is no dispute in the record that Dr.
Rentuza never signed, nor intended to sign a certificate of need, that would have
authorized the Hospital to detain Appellant under the involuntary commitment statutes.
Despite the statute‘s clear language of conferring the authority to detain patients
only to specific persons, Appellant next argues that the involuntary commitment statutes
should be interpreted to give nurses and other hospital employees the authority to detain
patients. Appellant cites no binding authority but rather relies on a 2007 Tennessee
Attorney General‘s opinion for the proposition that nurses may initiate involuntary
commitment proceedings. See Detention of Mentally Ill Patients, No. 07-92, Tenn. Op.
Att‘y Gen., 2007 WL 1876294 (2007). ―Our role is to determine legislative intent and to
effectuate legislative purpose.‖ Mills v. Fulmarque, 360 S.W.3d 362, 368 (Tenn. 2012).
―The text of the statute is of primary importance, and the words must be given their
natural and ordinary meaning in the context in which they appear and in light of the
statute‘s general purpose.‖ Id. ―‗When the language of the statute is clear and
unambiguous, courts look no farther to ascertain its meaning.‘‖ Id.
The involuntary commitment statute pursuant to Section 33-6-402 is clear that
only the listed persons are authorized to detain patients against their will. Nurses simply
are not listed as authorized individuals under Section 33-6-402. Expanding the scope of
this section would frustrate both the letter and spirit of Title 33 applicable to protect the
autonomy of mental health patients from unreasonable interference. See Tenn. Code Ann.
§ 33-3-101(a) (―No person shall be deprived of liberty on the grounds that the person has
or is believed to have a mental illness, a serious emotional disturbance, a developmental
disability, or is in need of service for such a condition except in accordance with [Title
33].‖); id. § 33-3-101(b) (―A person with mental illness . . . has the same rights as all
other persons except to the extent that the person‘s rights are curtailed in accordance with
[Title 33] or other law.‖). Thus, the involuntary commitment procedures constitute
7
At oral argument, counsel for the Hospital revealed that English was not Dr. Rentuza‘s
first language.
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exceptions to the general rule that mental health patients‘ rights should not be curtailed,
and ―exceptions to the general statutory provision[s] should be narrowly construed.‖
State v. Sundahl, No. E2006-00569-CCA-R3-CD, 2007 WL 1280724, at *4 (Tenn. Crim.
App. May 2, 2007) (citing United States v. Scharton, 285 U.S.518, 52 S. Ct. 416 (1932)).
Accordingly, we respectfully decline to expand the scope of Section 33-6-402, and to
usurp the Tennessee General Assembly‘s authority, by adding nurses to the list of persons
authorized to detain patients absent properly executed involuntary commitment
proceedings.
Even considering the Attorney General‘s opinion as persuasive authority in this
case, see Silliman v. City of Memphis, 449 S.W.3d 440, 460 (Tenn. Ct. App. 2014),
appeal denied (Nov. 12, 2014) (quoting State v. Black, 897 S.W.2d 680, 683
(Tenn.1995)) (―Opinions of the Tennessee Attorney General are ‗persuasive‘ . . . and
‗entitled to considerable deference.‘‖), Appellant nevertheless mischaracterized its
application to the facts of this case. According to the Attorney General‘s opinion, nurses
may initiate an emergency response to an emergency situation through the use of force
only after a physician or other authorized persons has determined that the patient is
subject to admission and signs a certificate of need for emergency diagnoses, evaluation,
and treatment. Detention of Mentally Ill Patients, 2007 WL 1876294, at *2–3. The
Attorney General‘s opinion opines that the signing of the certificate of need may create a
―duty on the hospital to detain the person pending transportation to a psychiatric facility,
using force, if necessary, to accomplish the detention.‖ Id. at *3. Thus, rather than
authorizing nurses to initiate involuntary commitment procedures, as Appellant suggests,
the Attorney General‘s opinion clearly affirms the fact that only a physician or other
statutorily authorized persons may initiate the proceedings and that the Hospital‘s duty
does not arise until after a certificate of need has been signed.
Finally, Dr. Griffin, Appellant‘s expert witness, states in his affidavit that
Appellant was subject to involuntary commitment because she was ―suffering from a
psychiatric disorder at the time of her hospitalization.‖ Dr. Griffin therefore opines that it
was a deviation of the standard of care to allow Appellant to leave the Hospital against
medical advice. Even taking Dr. Griffin‘s opinion as correct, however, we conclude that
his statements are insufficient to establish a duty on the Hospital to prevent Appellant
from leaving. As previously, discussed, the involuntary commitment statutes provide the
isolated and narrow circumstances in which a hospital may detain an individual without
his or her consent. Specifically, ―a licensed physician, psychologist, or designated
professional‖ must sign a certificate of need indicating that the requirements of the
involuntary commitment statutes have been met. There is no dispute that even though
Appellant was examined by a licensed physician, no certificate of need was ever signed.
Without a certificate of need, the Hospital and its nurses, had neither the ability nor the
duty to detain Appellant.
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In our view, Appellant and Dr. Griffin appear to argue that Dr. Rentuza breached
the applicable standard of care in failing to properly diagnose Appellant with a
psychiatric disorder and thereafter detain her pursuant to the involuntary commitment
statutes. Appellant‘s claim against Dr. Rentuza remains viable.8 This appeal, however,
involves only the direct liability of the Hospital regarding its failure to detain Appellant. 9
We simply cannot hold that the Hospital had any duty to detain Appellant where no
certificate of need had been properly signed. Without this certificate, the Hospital was
required to acquiesce in Appellant‘s desire to refuse medical treatment and leave the
facility. To hold otherwise would be to place the Hospital between the proverbial Scylla
and Charybdis:10 on the one hand, arguably negligent for failing to detain Appellant; on
the other, arguably having committed an intentional tort for detaining Appellant where no
certificate of need was signed by an authorized individual. See Abeyta v. HCA Health
Servs. of Tenn., Inc., No. M2011-02254-COA-R3-CV, 2012 WL 5266321, at *20–21
(Tenn. Ct. App. Oct. 24, 2012) (holding that plaintiff could maintain a claim against the
hospital for false imprisonment because a question existed as to whether the proper
procedure for involuntary commitment was followed when the hospital detained plaintiff
against her will); see also Vickroy v. Pathways, Inc., No. W2003-02620-COA-R3-CV,
2004 WL 3048972, at *10 (Tenn. Ct. App. Dec. 30, 2004) (holding that the only
authorized persons who personally examined a prospective detainee have the legal
authority to sign the certificate of need committing the prospective detainee to the
hospital under the involuntary commitment statute). Such a rule is simply not
appropriate. Based on these circumstances, the trial court‘s grant of summary judgment to
the Hospital was proper because the Hospital had no duty to, and could not legally, detain
Appellant as a matter of law.
CONCLUSION
The judgment of the Davidson County Circuit Court is affirmed and this cause is
remanded to the trial court for all further proceedings as are necessary and consistent with
this Opinion. Costs of this appeal are taxed to Appellant, Barbra T. Collins, and her
surety, for which execution may issue if necessary.
8
We express no opinion as to the merits of any of the claims remaining in this lawsuit.
9
Appellant did not raise vicarious liability against the Hospital for Dr. Rentuza‘s alleged
negligence in her complaint. Regardless, any question of vicarious liability is not at issue in this
appeal.
10
Scylla is ―a dangerous rock on the Italian side of the Straits of Messina, opposite the
whirlpool of Charybdis,‖ used to symbolize a place ―between two perils, neither of which can be
evaded without risking the other.‖ Webster’s New World College Dictionary 1308 (5th ed. 2014).
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_________________________________
J. STEVEN STAFFORD, JUDGE
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