Cheylla SILVA, John Paul Jebian, Plaintiffs-Appellants, v. BAPTIST HEALTH SOUTH FLORIDA, INC., Baptist Hospital of Miami, Inc., South Miami Hospital, Inc., Defendants-Appellees.
No. 16-10094
United States Court of Appeals, Eleventh Circuit.
May 8, 2017
856 F.3d 824
AFFIRMED.
Eric David Isicoff, Teresa Ragatz, Christopher Michael Yannuzzi, Isicoff Ragatz & Koenigsberg, PA, Miami, FL, for Defendants-Appellees.
Thomas E. Chandler, Dayna Zolle, U.S. Department of Justice, Washington, DC, for Amicus Curiae United States of America.
EBEL, Circuit Judge:
Plaintiffs Cheylla Silva and John Paul Jebian are profoundly deaf. On numerous occasions, they presented at Defendants’ hospitals but allegedly could not communicate effectively with hospital staff because of the absence of certain auxiliary aids or services. Federal law requires, however, that healthcare providers offer appropriate auxiliary aids to hearing-impaired patients where necessary to ensure effective communication. Failure to do so constitutes discrimination against disabled persons. Plaintiffs bring this lawsuit under Title III of the Americans with Disability Act (ADA),
The district court awarded summary judgment to Defendants. It held that Plaintiffs lacked Article III standing to seek prospective injunctive relief because they did not show that they were likely to return to the hospitals in the future. In addition, the district court denied damages on the grounds that Plaintiffs failed to show any instances where communication difficulties resulted in any actual adverse medical consequences to them, and otherwise failed to articulate what they did not understand during their hospital visits. The court concluded that records showed that Plaintiffs communicated their chief medical complaints and understood the treatment plan and discharge instructions, which foreclosed an ineffective-communication claim.
We reverse the district court on these issues. Not only do we conclude that Plaintiffs have standing to seek injunctive relief, we also reject the district court‘s substantive standard for liability. For an effective-communication claim brought under the ADA and RA, we do not require a plaintiff to show actual deficient treatment or to recount exactly what the plaintiff did not understand. Nor is it a sufficient defense for a defendant merely to show that a plaintiff could participate in the most basic elements of a doctor-patient exchange. Rather, the relevant inquiry is whether the hospitals’ failure to offer an appropriate auxiliary aid impaired the patient‘s ability to exchange medically relevant information with hospital staff.
We conclude that Plaintiffs have offered sufficient evidence to survive summary judgment. The record is rife with evidence that, on particular occasions, Plaintiffs’ ability tо exchange medically relevant information was impaired. Ultimately, however, to win monetary damages—which Plaintiffs seek in addition to equitable relief—Plaintiffs still must show that Defendants were deliberately indifferent in failing to ensure effective communication. The district court did not address this question. Thus, we REVERSE the district court‘s order granting summary judgment to Defendants, and REMAND for further proceedings, including consideration of the deliberate-indifference issue.
BACKGROUND
Plaintiffs Silva and Jebian are deaf and communicate primarily in American Sign Language (ASL). Both of them can read and write in simple English—Jebian com-
Plaintiffs separately visited Defendants’ facilities numerous times. They allege that, on many of those occasions, Defendants failed to provide appropriate auxiliary aids necessary to ensure effective communication.2 While Plaintiffs requested live on-site ASL interpreters for most visits, Defendants relied primarily on an alternative communication method called Video Remote Interpreting (VRI). With this internet-connected machine, a live ASL interpreter is located remotely and communicates with the doctor and patient through a portable screen located in the hospital.
During many of Plaintiffs’ hospital visits, Defendants attempted to use this device. However, the VRI machines routinely suffered from technical difficulties that either prevented the device from being turned on, or otherwise resulted in unclear image quality, thereby disrupting the message being communicated visually on the screen. When the VRI machine was unavailable or malfunctioned, hospital staff would often rely on family-member companions for interpretive assistance, or would exchange hand-written notes with Plaintiffs themselves. On some occasions, after a VRI breakdown, an on-site ASL interpreter would be called to assist with communication. These instances occurred both when Plaintiffs presented as patients, and when Jebian accompanied his father to Defendants’ facilities for treatment.3
Plaintiffs brought this lawsuit under the ADA and RA for unlawful discrimination. They alleged that Baptist‘s facilities failed to provide appropriate auxiliary aids to ensure effective communication with hospital staff. They sought injunctive relief and monetary damages. The district court awarded summary judgment in Defendants’ favor. It held that Plaintiffs lacked Article III standing for injunctive relief and, further, that they had not shown a “genuine dispute as to any material fact” regarding a violation of the ADA and RA.
DISCUSSION
ADA and RA claims are governed by the same substantive standard of liability. See, e.g., Cash v. Smith, 231 F.3d 1301, 1305 (11th Cir. 2000).
But proving the failure to provide a means of effective communication, on its own, permits only injunctive relief. See, e.g., McCullum v. Orlando Reg‘l Healthcare Sys., Inc., 768 F.3d 1135, 1147 n.8 (11th Cir. 2014). To recover monetary damages, a disabled person must further show that the hospital was deliberately indifferent to her federally protected rights. See, e.g., Liese v. Indian River Cty. Hosp. Dist., 701 F.3d 334, 344, 345 (11th Cir. 2012) (stating that, to recover compensatory damages, a disabled plaintiff must show “that the [h]ospital‘s failure to provide appropriate auxiliary aids was the result of intentional discrimination” and “deliberate indifference is the appropriate standard for defining discriminatory intent“) (internal quotation marks omitted). Resolving the case solely on the ineffective-communication issue, the district court declined to consider deliberate indifference.
After reviewing the record evidence in the light most favorable to the Plaintiffs, we hold that summary judgment4 was improper. First, the district court erroneously denied prospective injunctive relief on the basis of Article III standing, concluding in error that Plaintiffs did not show they were likely enough to return to the hospitals in the future or otherwise to suffer discrimination again at those facilities. Second, the district court improperly rejected all relief based on its conclusions that Plaintiffs did not identify any actual adverse medical consequences resulting from ineffective communication, and did not specify what they were unable to understand or convey during their visits, such as the inability to comprehend their treatment plan and discharge instructions or to communicate their principal symptoms.
The district court‘s legal standard was flawed. Instead, the correct standard examines whether a hospital‘s failure to offer an appropriate auxiliary aid impaired a deaf patient‘s аbility to exchange medically relevant information with hospital staff. Applying that standard to this record, construing all facts in Plaintiffs’ favor, we conclude that their claims are suitable for a finder of fact. We therefore reverse the district court‘s order awarding summary judgment to Defendants and remand. Because Plaintiffs also must prove deliberate indifference to win monetary relief—an issue the district court did not decide—we remand for consideration of that question as well.
I. Plaintiffs Have Standing for Injunctive Relief
In this lawsuit, Plaintiffs seek both injunctive relief and compensatory damages. Their request for a permanent
On this ground, the district court held that Plaintiffs lacked Article III standing, reasoning that “it is merely speculative that Plaintiffs will return to Defendants’ hospitals and there is no reliable indication that the VRI technology will malfunction in the future.” Doc. 133 at 34. We disagree.
In the ADA context, our standing inquiry has focused on the frequency of the plaintiff‘s visits to the defendant‘s business and the definitiveness of the plaintiff‘s plan to return. See Houston, 733 F.3d at 1337 n.6. Here, it is evident that Plaintiffs have offered evidence sufficient to support a finding that (1) they will return to Defendants’ facilities; and (2) they “will likely experience a denial of benefits or discrimination” upon their return. See McCullum, 768 F.3d at 1145-46.
For example, Silva testified in a declaration: “Due to many factors, including the location of my doctors, the fact that Defendants have all of my medical records and history, the proximity to my home, and history of prior care/treatment, it is likely I will visit and receive treatment at Defendants’ hospitals.” Doc. 61-13, ¶ 22. Jebian asserted the same in his declaration, and added that he would also go to that same hospital “as a companion of my father in the near future, due to his ongoing health concerns and required follow-up,” Doc. 61-14 ¶ 17. See Houston, 733 F.3d at 1337 (concluding that because the plaintiff had been to the defendant‘s store in the past, wanted to return, and took frequent trips past the store, it was “likely” she would return to the store, and therefore the threat of future injury was not merely conjectural or hypothetical).
What is more, Plaintiffs collectively have attended Defendants’ facilities dozens of times in the years preceding this lawsuit, and Silva has attested that she has recurring health issues. Further, Plaintiffs routinely experienced problems with the VRI devices not working at all or failing to transmit a clear screen image, so there is good reason to believe that will continue to happen at Defendants’ facilities when Plaintiffs do return.5
McCullum v. Orlando Regional Healthcare System, Inc., 768 F.3d 1135 (11th Cir. 2014) does not compel a different conclusion. In that case, there was no evidence that the deaf patient would return to the hospital after a successful surgery re-
Accordingly, given Plaintiffs’ numerous visits to Defendants’ facilities and the wealth of evidence showing repeated VRI malfunctiоns, we conclude that Plaintiffs have Article III standing to proceed with their claims for injunctive relief.6
II. Plaintiffs Have Offered Evidence Sufficient to Defeat Summary Judgment
The district court awarded Defendants summary judgment because it found no triable issue of fact regarding the ineffectiveness of the communication aids offered at Defendants’ hospitals. We first analyze the proper standard for evaluating effective-communication claims under the ADA and RA, and then we examine the evidence offered to overcome summary judgment.
A. The Standard for Effective Communication
The district court faulted Plaintiffs for failing to show two things. First, Plaintiffs could not identify any instances where the means of communication resulted in actual misdiagnosis, incorrect treatment, or adverse medical consequences. Second, Plaintiffs could not articulate what information they were unable to understand or convey during their hospital visits. More specifically, there was no evidence Plaintiffs could not communiсate their chief medical complaint or understand a treatment plan and discharge instructions. We address these requirements in turn, ultimately concluding that they are not the appropriate tests for evaluating effective-communication claims. Instead, the correct standard examines whether the deaf patient experienced an impairment in his or her ability to communicate medically relevant information with hospital staff. The focus is on the effectiveness of the communication, not on the medical success of the outcome.
1. Plaintiffs’ Failure to Show Adverse Medical Consequences
The district court relied, in part, on Plaintiffs’ failure to prove that any communication difficulties resulted in a misdiagnosis, incorrect treatment, or other adverse medical consequences. Doc. 133 at 4 (“There is no specific fact ... demonstrating that either Plaintiff was misdiagnosed, was given the wrong treatment, [or] was impeded in complying with medical instructions for follow-up carе....“); id. at 5 (“Plaintiffs are unable to point to any specific fact, incident, course of treatment, or diagnosis supporting the conclusion that communication at Defendants’ hospitals
The ADA and RA focus not on quality of medical care or the ultimate treatment outcomes, but on the equal opportunity to participate in obtaining and utilizing services.
There can be no question that the exchange of information between doctor and patient is part-and-parcel оf healthcare services. Thus, regardless of whether a patient ultimately receives the correct diagnosis or medically acceptable treatment, that patient has been denied the equal opportunity to participate in healthcare services whenever he or she cannot communicate medically relevant information effectively with medical staff. It is not dispositive that the patient got the same ultimate treatment that would have been obtained even if the patient were not deaf. See
Instead, what matters is whether the handicapped patient was afforded auxiliary aids sufficient to ensure a level of communication about medically relevant information substantially equal to that afforded to non-disabled patients. In other words, the ADA and RA focus on the communication itself, not on the downstream consequences of communication difficulties, which could be remote, attenuated, ambiguous, or fortuitous. For this reason, claims for ineffective communication are not equivalent to claims for medical malpractice.
2. Plaintiffs’ Failure to Articulate What It Was That They Could Not Communicate
The district court also faulted Plaintiffs for failing to articulate, with the
First, limiting the required level of communication to that necessary to convey the primary symptoms, a treatment plan, and discharge instructions may still result in deaf patients receiving an unequal opportunity to participate in healthcare services in comparison to non-disabled patients. When a hearing (i.e., non-disabled) person goes to the hospital, that person is not limited only to describing symptoms and receiving the treatment plan and discharge instructions. The patient‘s conversation with the doctor could, and sometimes should, include а whole host of other topics, such as any prior medical conditions and history, medications the patient is taking, lifestyle and dietary habits, differential diagnoses, possible follow-up procedures and tests, informed-consent issues, and side effects and costs of potential courses of treatment. Because a non-disabled person has the benefit of this expansive informational exchange, it is error to conclude on summary judgment that the mere successful communication of the primary symptoms, treatment plan, and discharge instructions is enough, as a matter of law, to preclude liability under the ADA and RA.
Second, the district court‘s requirement that Plaintiffs articulate exactly what they failed to understand is overly burdensome. It would be exceedingly difficult for a deaf patient to recount a conversation he or she could not hear—just as it would be hard for blind patients to describe the contents of materials they could not read. Thus, we reject a requirement that a disabled patient explain exactly what was poorly communicated when that patient could not know that information precisely because of the disability.
3. The Correct Standard—Impairing the Exchange of Medically Relevant Information
The proper inquiry under the ADA and RA is simply to examine whether the hospital provided the kind of auxiliary aid necessary to ensure that a deaf patient was not impaired in exchanging medically relevant information with hospital staff. To be ineffective communication, it is sufficient if the patient experiences a real hindrance, because of her disability, which affects her ability to exchange material medical information with her health care providers. This standard is consistent with the requirement that hospitals afford a level of communication to a deaf patient about medically relevant information that is substantially equal to that affоrded to non-disabled patients.7
That does not mean that deaf patients are entitled to an on-site interpreter every time they ask for it. See McCullum,
It is precisely because of this fact-intensive inquiry that an effective-communication claim often presents questions of fact precluding summary judgment. See Liese v. Indian River Cty. Hosp. Dist., 701 F.3d 334, 342-43 (11th Cir. 2012) (citing cases that conclude the effectiveness of the auxiliary aids is a “question of fact” inappropriate for summary judgment). “Nonetheless, this does not mean that every request for an auxiliary aid that is not granted precludes summary judgment or creates liability[.]” Id. at 343.
With this in mind, we proceed to evaluate the record evidence pertaining to whether there are disputed issues of material fact regarding Plaintiffs’ claimed impairments in their ability to exchange medically relevant information with Defendants’ hospital staff.
B. The Evidence Is Sufficient to Overcome Summary Judgment
Examining the facts in the light most favorable to Plaintiffs, we conсlude that Plaintiffs have offered sufficient evidence to defeat summary judgment.
1. Silva‘s Claims Survive Summary Judgment
Silva has offered sufficient evidence for a rational jury to find that Defendants’ failure to offer appropriate auxiliary communication aids impaired her ability to exchange medically relevant information with hospital staff. In her sworn declaration, she addressed communication difficulties that arose from her visits to Baptist‘s facilities:
At each such hospitalization or visit, hospital staff would conduct tests, perform procedures, prescribe medication, and attempt to communicate with me regarding my condition and treatment options through my friends and family (none of who [sic] are fluent in ASL), written notes and gestures[;] [h]owever, I was unable to understand most of what they attempted to communicate through these means.
Doc. 61-13 at ¶ 8 (emphasis added). She further explained that “[h]ospital staff would also make me sign forms without explaining what I was signing, including signing forms consеnting to treatment and medications that I did not fully understand or even have the opportunity to ask questions about.” Id. ¶ 9 (emphasis added). And addressing the tendency of the VRI devices to malfunction, Silva explained that “[o]n some occasions ... the machine was inoperable or unusable” and “it appeared that hospital staff could not figure out how to operate the machine[;] [o]ther times, the
Silva also highlighted specific instances of ineffective communication. For example, on January 4, 2011, Silva went to Baptist Hospital for stomach pain. She “requested an interpreter many times” and “wait[ed] for so long” before the interpreter arrived. Doc. 78-5 at 16-17. While waiting for the live interpreter, Silva communicated back and forth with handwritten notes—“an extremely frustrating experience” given “the type of terminology that doctors use.” Id. at 17. On that occasion, until the delayed arrival of the live interpreter, Silva stated she “was not аble to communicate at all.” Id. This evidence of an impaired informational exchange is difficult to ignore.8
Further, on March 9, 2015, Silva went to Baptist Hospital for chest pains. The nurse turned on the VRI device but could not get it to function. As a result of the VRI machine‘s malfunction, Silva recounted:
During this time, I could not communicate with the hospital staff. The nurses kept coming in and out of the room, they communicated with my dad and I had no idea what they were saying. I wanted to know what they were saying, I couldn‘t explain how I felt and I saw the nurses talking and I didn‘t know if they were talking about me and it was something bad.
Doc. 78-9 ¶ 16 (emphasis added). After more than an hour, the VRI did eventually become operational, and Silva used it to communicate until her live interpreter arrived. Nonetheless, a rational jury could find, after hearing about this incident, that Silva‘s ability to exchange medically relevant information with hospital staff was impaired.9
In addition to specific instances where Silva was unable to communicate effectively, there are other occasions where the malfunctioning of Defendants’ VRI machines could generate a reasonable inference of an impaired informational exchange. For instance, on April 29, 2014, Silva went to SMH because of pregnancy complications—she was unable to detect fetal movement during her pregnancy. The staff attempted to set up the VRI, “[b]ut it wasn‘t working at all.”10 Doc. 78-5 at 32. More generally, Silva explained her frequent experience that “the [VRI] connection is not smooth[,] [i]t‘s not strong enough.” Doc. 78-4 at 44. In a supplemental declaration, she stated:
[E]ach time that I would go to both hospitals, the hospitals may bring in a VRI, but it would rarely work, and it
would fail. Even some times when it would work at Baptist Hospital, it would freeze on me and there would be a huge lag time where it would seem like the interpreter was in slow motion.
Doc. 78-9 ¶ 38.
This is just one example and there are others: On May 9, 2011, Silva had an appendectomy at Baptist Hospital, but there is a fact issue as to whether the VRI worked then or worked only for 46 minutes for post-operation teaching and discharge. On May 20, 2011, Silva was admitted to Baptist Hospital for abdominal pain. Although the hospital‘s notes state that it fixed a “[n]etwork glitch” with the VRI and the machine was then “in working order,” Doc. 59-1 at 232, Silva stated in her deposition that her boyfriend assisted her in communicating with staff and, further, the hospital‘s records of VRI usage do not show any usage by Silva on this date. On December 6, 2012, Silva went to Baptist Hospital for chest pains and testified that staff used the VRI “briefly,” but VRI records again do not show any usage by Silva on this date. On March 4, 2013, Silva went to Baptist Hospital for shoulder pain, and she claims that the VRI worked for only a portion of that visit. On June 11-12, 2013, Silva went to Baptist Hospital for nausea and abdominal pain, but she claims that hospital staff only used the VRI machine for 10 minutes across a two-day visit. And in a July 2014 visit to SMH fоr abdominal pain and contractions, Silva stated in a declaration that she was provided with a VRI machine and “the VRI would not work.” Doc. 61-13 ¶¶ 17-18.
A deaf person must rely on the slight and sophisticated hand movements of the interpreter depicted on the screen, so when the screen image is unclear or becomes choppy, the message is disrupted.11 Thus, we view the instances of technological failures as corroborative evidence of Silva‘s assertions that she could not communicate effectively with hospital staff.12
In light of the above evidence, Silva‘s effective communication claims survive summary judgment.
2. Jebian‘s Claims Survive Summary Judgment
Jebian submitted a sworn declaration stating that, during his hospital visits, he was “unable to understand most of what [medical staff] attempted to communicate” based on the failure to provide an in-person interpreter. Doc. 61-14 ¶ 8. Jebian also similarly recounted, in general terms, the unavailability of the VRI machines, either becаuse the “hospital staff could not figure out how to operate the machine” or because the “video picture would freeze or break down.” Id. ¶ 10. However, in addition to claiming that he was denied needed auxiliary aids as a patient, Jebian also alleged that Defendants denied him required auxiliary aids while accompanying his father to Baptist Hospital for treatment. See
Most of Jebian‘s problematic hospital visits occurred in his capacity as a patient. On July 11, 2012, Jebian presented at Baptist Hospital for pain in his chest. That visit generated a clinical report which contains a notation that Jebian‘s deafness “limited” the medical evaluation. Doc. 59-3 at 11. The district court dismissed this indicator of ineffective communication because the doctors were still able to document the “chief complaint,” “onset of symptoms,” “severity of condition,” and other “information available in the outpatient context only through patient reporting” (such as insomnia and urinary output). Doc. 133 at 16-17. Moreover, Jebian “verbalized understanding” of his discharge instructions. Id. at 17 (internal quotation marks omitted). That, however, at most shows that Jebian‘s contention of ineffective communication is disputed by Defendants—but a disputed material fact goes to a jury. Further, as we have explained, evidence that the medical staff could ascertain a patient‘s basic symptoms and convey treatment instructions is not enough for us to conclude, as a matter of law, that a disabled patient‘s level of informational exchange was equal to that of non-disabled patients as required by the ADA and RA.
On July 15, 2012, Jebian presented at Baptist Hospital reporting symptoms of kidney stones. The pain was “excruciating.” Doc. 78-7 at 25. The hospital staff attempted to set up the VRI device, but could not figure it out—they could not even figure out “how to plug it in.”13 Id. at 26. When that did not work, the hospital relied on Jebian‘s father, who had accompanied him to the hospital, for interpretive assistance. But as we have already stated, absent certain narrow exceptions not applicable here, reliance on companions for communication assistance is not an “appropriate” auxiliary aid.
Similar problems occurred during Jebian‘s visit to one of Baptist‘s outpatient centers on March 11, 2014. On that occasion, Jebian arrived reporting sports-related injuries. Because Baptist does not have VRI machines at its outpatient facilities, the medical team there relied on Jebian‘s accompanying wife for interpretive assistance. (Again, ordinarily, reliance on a companion is improper under ADA regulations). When they discovered Jebian had a broken rib, they transferred him to Baptist Hospital for emergency treatment where a VRI was used. But, yet again, the VRI malfunctioned. Jebian testified that the image quality was unclear, and “[t]he screen would black out.” Doc. 78-7 at 35. Like with Silva, a jury could rationally infer that a deaf person—who must discern slight and sophisticated hand movements in order to understand a message on the screen—would be hindered in comprehending the message when the screen image is corrupted or unclear.
In addition, Jebian also offered at least one occasion where he could not communicate effectively as a companion to his father who was suffering a heart attack. On November 5, 2010, the medical staff performed a surgical heart procedure on Jebian‘s father. Despite the complexity and emotionality of those circumstances, hospital staff relied on Jebian‘s niece to communicate with Jebian. Putting aside the fact that reliance on companions for interpretive assistance (absent some narrow exceptions) violates the command of ADA regulations,
The district court correctly noted that Jebian was more consistent than Silva in refusing to accept the VRI even before hospital staff attempted to set up the device. But he refused the VRI only after experiencing difficulties with the machine in the past. As he recounts in his deposition: “It was all day long I had a bad experience with that VRI[;] [e]very staff member tried to get it going and nobody could.” Doc. 59-2 at 86. For that reason, Jebian thereafter declined the VRI because he did not “even want to waste all that time” with a device that could—and as we know from others’ testimony—often did malfunction. Id. We are thus unwilling to hold against Jebiаn his tendency to decline the VRI because a jury could conclude he acted reasonably in anticipating that the VRI would not facilitate effective communication.14
In sum, both Silva and Jebian have demonstrated a genuine dispute of material fact on whether they could communicate effectively with medical staff at Defendants’ facilities. Summary judgment was thus improper.15
Defendants offer several alternative grounds to affirm the award of summary judgment. First, Defendants ask us to affirm summary judgment as to the claims for compensatory damages on the ground that Plaintiffs failed to offer evidence of deliberate indifference. To win monetary relief, Plaintiffs must prove that Defendants exhibited deliberate indifference. See Liese, 701 F.3d at 345. Under that standard, “a plaintiff must show that the defendant ‘knew that harm to a federally protected right was substantially likely’ and ‘failed to act on that likelihood.‘” McCullum, 768 F.3d at 1147 (emphasis omitted) (quoting Liese, 701 F.3d at 344).
The district court did not address deliberate indifference—it resolvеd the case solely on the question whether the hospitals’ auxiliary aids precluded effective communication. While we have the power to affirm a judgment on any basis supported by the record, the absence of any analysis by the district court on this issue makes it particularly difficult to make an informed decision on review. We therefore remand to the district court for an independent consideration of whether there exists a triable issue of fact on the deliberate-indifference issue.
Second, Defendants contend that some of Plaintiffs’ hospital visits are time-barred because they occurred outside the limitations period for this lawsuit. Neither the ADA nor RA provides a statute of limitations, so we apply the most analogous state statute of limitations. See Everett v. Cobb Cty. Sch. Dist., 138 F.3d 1407, 1409 (11th Cir. 1998). The most analogous state limitations period comes from personal injury actions, id., which in Florida is a four-year period,
In opposing summary judgment below, Plaintiffs acknowledged that they “may not receive damages for [their] claims” arising out of hospital visits preceding the limitations period, but that these earlier visits are “relevant and admissible” to show deliberate indifference. Doc. 79 at 11. We agree. Hospital visits occurring before the limitations period are not to be relied upon themselves as discrete claims of discrimination, but evidence of discrimination during those visits is relevant to whether the hospitals had the requisite knowledge to establish deliberate indifference during Plaintiffs’ subsequent hospital visits, which did occur during the limitations period.16 Thus, on remand, the
Third, Defendants argue that all claims against Baptist Health are improper because it is the pаrent organization to Baptist Hospital and SMH; it is not itself a medical facility at which Plaintiffs presented with medical needs. We reject this contention. There is no rule that a covered entity under the ADA or RA must be the direct service-provider—in fact the ADA addresses itself to those who own, lease, or operate a place of public accommodation.
Fourth, Defendants contend that Silva, in particular, cannot rely on evidence of discrimination during hospital visits when she presented as a companion, rather than a patient. In her complaint, Silva (unlike Jebian) alleged discriminatiоn only in her capacity as a patient, so the district court did not err in declining to consider evidence of discrimination while Silva was accompanying her daughter to the hospital for treatment. On appeal, Defendants ask us to ignore that evidence, and Plaintiffs offer no dispute in their reply brief. For that reason, our analysis has not relied on any hospital visits during which Silva claims she suffered discrimination as a companion.
CONCLUSION
We REVERSE the district court‘s order granting summary judgments to Defendants and REMAND for further proceedings consistent with this opinion. Plaintiffs have Article III standing to proceed with their claims for injunctive relief. Plaintiffs have also offered sufficient evidence for a rational jury to conclude they could not communicate effectively with hospital staff due to their hearing disabilities. So, it was error to grant summary judgment to the hospitals on Plaintiffs’ claims under the ADA and RA. However, because the award of monetary damages requires a finding of deliberate indifference, we REMAND the claims for damages to the district court to consider whether summary judgment is proper in light of that question.