3.1. Precedents Cited

A. Rule 12(b)(6) pleading standards and plausibility

• EEOC v. STME, LLC: Set the de novo review standard for a motion-to-dismiss ruling.
• Campbell v. Air Jam. Ltd.: Pro se pleadings are liberally construed, but courts cannot rewrite deficient complaints—an important limit that the panel invoked when rejecting the original screening claim.
• Olivares v. Martin: Licensed attorneys representing themselves do not receive liberal construction; the court included this as general doctrine though the appellants were treated as pro se.
• Caterpillar Fin. Servs. Corp. v. Venequip Mach. Sales Corp., Bell Atl. Corp. v. Twombly, and Ashcroft v. Iqbal: Provided the two-step plausibility framework and rejected conclusory element recitations. The opinion used these cases to separate malpractice-like allegations (“they should have done X test/treatment”) from EMTALA’s comparative/disparate-treatment screening requirement.
• Young v. Grand Canyon Univ., Inc. and Resnick v. AvMed, Inc.: Reinforced the “reasonable inference” component of plausibility.
• Adinolfe v. United Techs. Corp.: A central influence on the stabilization analysis; the panel analogized that determining whether malnutrition qualifies as an “emergency medical condition” and whether deterioration was “material” are medically complex questions ill-suited for dismissal absent a developed record.

B. EMTALA doctrine: screening, stabilization, and EMTALA’s scope

• Harry v. Marchant (en banc): Anchored the opinion’s insistence that EMTALA is designed to prevent patient dumping and is “not intended to be a federal malpractice statute.” The panel used this to explain why “they failed to do a urinalysis” is not enough unless tied to disparate screening.
• Kizzire v. Baptist Health Sys.: Supplied the familiar formulation that EMTALA is violated when a hospital either fails to screen adequately or discharges/transfers without stabilizing. It also undercut the Hospital’s argument that stabilization obligations disappear upon admission, because discharge can still trigger EMTALA stabilization duties.
• Nolen v. Boca Raton Cmty. Hosp.: The controlling standard for screening claims—no EMTALA liability where the patient is screened consistently with other patients who present similarly. The panel used Nolen to show the original complaint lacked the necessary comparator allegations, while the proposed amended complaint supplied them.
• Holcomb v. Monahan: Provided the stabilization elements (emergency medical condition; hospital knowledge; failure to stabilize before transfer/discharge). The panel mapped the alleged facts—diagnosis of malnutrition, decline during stay, severe abdominal pain, discharge, collapse two hours later—onto the Holcomb framework.
• Vickers v. Nash Gen. Hosp. (4th Cir.): The Hospital relied on this case, but the panel distinguished it, reading Vickers to mean stabilization attaches to the emergency condition detected; here, the condition (malnutrition) was detected but allegedly not stabilized.

C. EMTALA regulation on inpatient admission and “good faith”

• Williams v. Dimensions Health Corp. (4th Cir.): The Eleventh Circuit noted it had not addressed 42 C.F.R. § 489.24 in a published decision, and cited Williams for the principle that inpatient admission can satisfy EMTALA only if done in “good faith,” not as a liability-avoidance pretext. While not ultimately dispositive in this case, its inclusion signals that “admission” is not a categorical shield if the pleadings plausibly suggest a sham admission.

D. Amendment standards, pro se protections, and post-judgment practice

• Chang v. JPMorgan Chase Bank, N.A.: Established the abuse-of-discretion standard for denial of leave to amend and de novo review of futility.
• Berry v. Crestwood Healthcare LP: Provided the abuse-of-discretion review standard for denial of Rule 59(e) relief.
• Woldeab v. Dekalb Cnty. Bd. of Educ.: The pivotal pro se rule—district courts must give pro se plaintiffs at least one chance to amend before dismissing with prejudice (or the functional equivalent), unless amendment would be futile or plaintiffs clearly decline to amend. The panel treated the limitations-driven effect as bringing the case squarely within Woldeab.
• Blackburn v. Shire US Inc. and Foman v. Davis: Defined the amendment factors (undue delay, bad faith, repeated failure, prejudice, futility) and the “freely given” baseline.
• L.S. ex rel. Hernandez v. Peterson: Clarified futility—an amendment is futile only if it would still fail at the motion-to-dismiss or summary-judgment stage.
• Tampa Bay Water v. HDR Eng'g, Inc. (and CSX Transp., Inc. v. Gen. Mills, Inc. as overruling on other grounds): Provided the court’s framework for “undue delay” and “prejudice,” emphasizing prejudice is more likely where new theories or additional discovery are required; here, the panel found neither.
• Andrx Pharms., Inc. v. Elan Corp., PLC: Contrasted a scenario supporting undue delay (multi-year delay after notice) with this case’s six-month timeline.
• Mickles v. Country Club Inc.: Supplied the “without prejudice but effectively with prejudice” doctrine when limitations bar refiling—central to the panel’s conclusion that the district court’s no-amendment dismissal was legally consequential.
• Arthur v. King, Gulisano v. Cohen, and United States v. Marion: Defined Rule 59(e) grounds (“manifest error of law or fact” or new evidence), applied a “clear error” lens, and illustrated when misapplication of controlling law constitutes an abuse of discretion. The panel characterized the denial of amendment and post-judgment relief as a “manifest error of law.”

E. Florida § 395.1041 authorities

• Ramsay v. S. Lake Hosp.: Confirmed the statute provides a civil action for persons harmed by violations.
• Porter, Brown, Chitty & Pirkle, M.D.P.A. v. Pearson: Explained that a Chapter 395 “dumping” claim need not comply with Chapter 766 medical malpractice pre-suit requirements.
• Agency for Health Care Admin. v. Baker County Med. Servs.: Summarized the screening/stabilize/transfer duties under Florida law, paralleling EMTALA concepts.
• Cintron v. St. Joseph's Hosp.: Noted uncertainty under Florida law about hospital liability via respondeat superior, but the Eleventh Circuit resolved this case on statutory text: § 395.1041(5)(b) authorizes suits against “staff or personnel,” not hospitals.
• Baker County Med. Servs. v. United States AG: Noted similarities between EMTALA and Florida’s statutory scheme, underscoring why litigants often plead both, though the proper defendants may differ.

3.2. Legal Reasoning

A. Screening vs. malpractice: why the original screening allegations failed

The court treated EMTALA screening as a comparative obligation: the key is whether the hospital provided a screening “consistent with” what it provides to other similarly situated patients. Under Nolen v. Boca Raton Cmty. Hosp., alleging a missing test (urinalysis) is not enough unless tied to disparate treatment. Because the original complaint did not allege that insured patients with similar symptoms would have received a urinalysis (or any differential protocol triggered by insurance status), the allegation read as a quality-of-care dispute—precisely what Harry v. Marchant warns EMTALA is not.

B. Stabilization plausibility: malnutrition, severe pain, rapid deterioration, and limits of judicial inference

The panel reversed on stabilization because the pleadings alleged: (1) the Hospital diagnosed malnutrition (knowledge), (2) Matthews’s condition declined and she experienced “severe abdominal pain” near discharge (acute symptoms), (3) the Hospital discharged her without stabilizing/treating the condition (failure to stabilize before discharge), and (4) she collapsed within two hours (temporal proximity supporting plausibility).

Critically, the district court’s categorical statement that malnutrition is not an EMTALA “emergency medical condition” was treated as an unsupported medical conclusion. Relying on Adinolfe v. United Techs. Corp., the panel reasoned that whether malnutrition—combined with acute symptoms like severe pain—meets EMTALA’s statutory definition (42 U.S.C. § 1395dd(e)(1)(A)) is not a question that can be resolved at the pleading stage simply by “judicial experience and common sense,” particularly when the complaint plausibly alleges imminent deterioration absent immediate attention.

C. Admission does not necessarily eliminate stabilization duties where discharge occurs

The Hospital argued EMTALA’s stabilization duty ceased upon admission. The panel rejected the argument as inconsistent with Eleventh Circuit formulations that EMTALA can be violated when a hospital “discharges” a patient without stabilizing (Kizzire v. Baptist Health Sys.). The opinion thus frames discharge—whether after admission or not—as a relevant EMTALA endpoint when an emergency medical condition is known and allegedly left unstabilized.

D. Post-judgment timing and the separate-document rule

The panel held the Rule 59(e) motion timely because the district court did not enter judgment in a separate document as required by Rule 58; therefore, judgment was “deemed entered” 150 days after the dismissal order (Rule 58(c)(2)(B)). This portion is a procedural reminder that “finality” for post-judgment deadlines can hinge on compliance with Rule 58’s formality.

E. Mandatory leave to amend for pro se litigants when limitations make dismissal effectively with prejudice

The EMTALA statute of limitations (two years) had expired by the time of dismissal, so a “without prejudice” dismissal was functionally “with prejudice” under Mickles v. Country Club Inc.. Under Woldeab v. Dekalb Cnty. Bd. of Educ., a pro se plaintiff must receive at least one opportunity to amend unless amendment is futile or the plaintiff refuses.

The panel found futility was wrongly decided because the proposed amended complaint added the missing comparator allegation (that similarly symptomatic patients would have received a urinalysis) satisfying Nolen, and continued to allege facts supporting stabilization under Holcomb. The court also rejected “undue delay” and “undue prejudice” rationales under Blackburn v. Shire US Inc. and Tampa Bay Water v. HDR Eng'g, Inc., stressing that plaintiffs are not required to amend merely because a motion to dismiss is filed (Woldeab), and there was no discovery and no new theory.

F. Florida § 395.1041: correct defendant is a statutory gatekeeping issue

The panel affirmed dismissal of the Florida claim on the statute’s text: § 395.1041(5)(b) authorizes recovery against “responsible hospital administrative or medical staff or personnel,” not the hospital. The court acknowledged Cintron v. St. Joseph's Hosp. noted ambiguity about respondeat superior, but the Eleventh Circuit did not resolve that broader question; it treated plaintiffs’ naming of the Hospital as a straightforward pleading defect, mitigated by the dismissal being without prejudice.

3.3. Impact

A. EMTALA stabilization claims at the pleading stage (medical complexity and “emergency medical condition”)

The opinion’s most practically significant move is its insistence that courts should not prematurely foreclose stabilization claims by declaring—without record support—that a diagnosed condition (here, malnutrition) cannot qualify as an “emergency medical condition.” By invoking Adinolfe, the panel signals that when pleadings allege acute symptoms and rapid post-discharge deterioration, debates about the medical character and consequences of the condition generally belong to evidence (expert testimony, medical records, fact development) rather than Rule 12 dismissal.

B. Screening claims: comparator allegations remain essential

The opinion reinforces the Eleventh Circuit’s long-standing line that EMTALA screening is about disparate procedures, not medical negligence. Plaintiffs must plead facts permitting an inference of inconsistency with how similarly situated patients are screened (Nolen), or risk recharacterization as malpractice.

C. Pro se amendment rights when limitations bar refiling

The case is also a strong reminder that a nominally “without prejudice” dismissal can become outcome-determinative when the statute of limitations has run (Mickles). In that posture, Woldeab requires at least one opportunity to amend absent futility or refusal, and courts must assess futility with care—particularly where an amendment supplies a missing comparator allegation or other key factual content.

D. Litigation practice: Rule 58 can control Rule 59(e) deadlines

The Rule 58 holding highlights a frequent trap: absent a separate judgment, the Rule 59(e) clock may not start when parties assume it does. This can materially affect appellate and post-judgment strategy.

E. Florida “patient dumping” claims: defendant selection matters

For Florida Statutes § 395.1041, the opinion underscores that plaintiffs must carefully identify statutorily authorized defendants (“administrative or medical staff or personnel”), and that suing the hospital directly may fail at the threshold even if the alleged conduct resembles EMTALA-type dumping.