Analyn Rivera v. Jersey City Medical Center

NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION This opinion shall not "constitute precedent or be binding upon any court ." Although it is posted on the internet, this opinion is binding only on the parties in the case and its use in other cases is limited . R. 1:36-3. SUPERIOR COURT OF NEW JERSEY APPELLATE DIVISION DOCKET NO. A-3099-23 ANALYN RIVERA, Individually and as Administratrix Ad Prosequendum for the ESTATE OF ROMEO RIVERA, JO-ANNE CABRERA RIVERA, a minor, ETHAN CABRERA RIVERA, a minor, and CHRISTIAN CABRERA RIVERA, a minor, Plaintiffs-Appellants, v. JERSEY CITY MEDICAL CENTER, RWJ BARNABAS HEALTH, EMERGENCY MEDICAL ASSOCIATES, ADEFRIS ADAL, M.D., LEISTER TALIN, R.N., DIANA CAPRA, R.N., DANA AMORINO, R.N., CECILIA WILSON, R.N., and ZACHARY BAKHTIN, CIM, Defendants-Respondents. __________________________ Argued March 3, 2026 – Decided September 15, 2026 Before Judges Gooden Brown and DeAlmeida. On appeal from the Superior Court of New Jersey, Law Division, Hudson County, Docket No. L-2382-17. Francis X. Dorrity argued the cause for appellant (Dorrity Law Office, attorneys; Francis X. Dorrity and Tracey A. Dorrity, of counsel and on the briefs). Jason M. Altschul argued the cause for respondents Jersey City Medical Center, RWJBarnabas Health, Leister Talin, R.N., Diana Capra, R.N., Dana Amorino, R.N., and Cecilia Wilson, R.N. (Dughi Hewit Domalewski PC, attorneys; Janet Glore, on the brief). Russell J. Malta argued the cause for respondent Emergency Medical Associates (Orlovsky Moody Schaaff Conlon & Gabrysiak, attorneys; Russell J. Malta, of counsel and on the brief). Walter F. Kawalec, III argued the cause for respondents Adefris Adal, M.D. and Zachary Bakhtin, CIM (Marshall Dennehey, PC, attorneys; Walter F. Kawalec, III, on the brief). PER CURIAM In this medical negligence action, plaintiff Analyn Rivera appeals from the dismissal of various claims against defendant medical entities and professionals stemming from the death of her husband, Romeo Rivera. Romeo 1 1 We use first names because of the common surname and intend no disrespect. A-3099-23 2 presented to Jersey City Medical Center, operated by RWJ Barnabas Health (JCMC/RWJ), complaining of back pain, chills, and numbness in his lower limbs. After several emergency department (ED) nurses evaluated him, he was seen by an ED doctor, Adefris Adal, who diagnosed him with sciatica. He received one shot of pain relief medication and was sent home. When he returned home, he collapsed on the floor of his bedroom and was pronounced dead by responding emergency medical services (EMS) shortly thereafter. His autopsy revealed he died of a cardiac tamponade. Plaintiff brought suit on behalf of herself and Romeo's estate against defendants JCMC/RWJ; Emergency Medical Associates, LLC (EMA), that had contracted with JCMC/RWJ to run the ED; JCMC/RWJ ED nurses; and Adal. She alleged claims of "direct and vicarious administrative, medical, and nursing neglect." The trial judge dismissed each of plaintiff's direct claims against JCMC/RWJ, EMA, and the nurses on summary judgment and dismissed plaintiff's remaining claims on a directed verdict. Based on our review of the record and the applicable legal principles, we affirm. I. On January 14, 2017, Romeo, then forty-three years old, sought treatment at JCMC/RWJ's ED. He complained of back pain and numbness in his lower A-3099-23 3 left extremity. Upon arrival at approximately 10:13 p.m., JCMC/RWJ nurse Dana Amorino, R.N., assessed him and noted his main complaint of "left leg numbness." At approximately 10:47 p.m., JCMC/RWJ nurse Talin Leister, R.N., evaluated Romeo. She noted Romeo had developed a sudden onset of lower back "discomfort" in addition to a "brief episode of chills to both hands" as well as the left leg numbness he had reported earlier. She assessed his acuity at level 3, which was considered urgent. Leister testified she believed Romeo had a possible life-threatening condition based on her assessment and believed he needed further intervention and an additional assessment. At approximately 11:24 p.m., JCMC/RWJ nurse Diana Capra, R.N., made note of Romeo's most recent complaint of "bilateral flank pain." Adal saw Romeo the following day, January 15, 2017. Adal's clinical impression was that Romeo had sciatica. He ordered one 60 mg. shot of Toradol (ketorolac), a muscle relaxant. He also prescribed Tylenol for pain and Zantac for heartburn. Adal discharged Romeo at approximately 12:16 a.m. on January 15. At 12:34 a.m., JCMC/RWJ nurse Cecilia Wilson, R.N., administered the Toradol to Romeo; she also noted his pain level was six out of ten on the pain scale. At 12:42 a.m., Capra signed off on Romeo's chart for discharge. A-3099-23 4 At 1:00 p.m. on January 15, after arriving home, Romeo collapsed on the floor of his bedroom. EMS arrived at 1:13 p.m. but were unsuccessful in resuscitating him. He was pronounced dead at 1:36 p.m. Romeo's autopsy "revealed a right coronary artery aneurysm and an aortic dissection to the renal arteries with hemopericardium." His cause of death was "cardiac tamponade secondary to bleeding from the small ruptured aneurysm of right coronary artery with blood infiltration of sub-adventitia of the tunica externa, of the aortic arch, mediastinal and abdominal aorta and branching vessels." Analyn filed suit on June 7, 2017, on behalf of herself and Romeo's estate, against various defendants including JCMC/RWJ, several of the JCMC/RWJ ED nurses, EMA, and Adal. Following a case management conference, the judge ordered plaintiff to serve an affidavit of merit (AOM) by September 29, 2017. The initial discovery end date was October 11, 2018. Plaintiff served an AOM on each defendant before the deadline. Plaintiff moved to compel EMA, Adal, and Clinical Information Manager (CIM) Zachary Bakhtin to produce discovery in compliance with the case management order. All three parties cross-moved for a protective order. The judge entered an order on January 25, 2018, compelling discovery. The new discovery end date was extended to November 25, 2018. A-3099-23 5 Plaintiff had also moved to compel the production of Romeo's electronic medical record (EMR), but the proposed order included a mistaken request to "photograph and video tape a live view of the audit reports associated with Mr. Rivera's Electronic Medical Records." The judge ordered EMA to produce the EMR audit trail to plaintiff and removed the portion requesting the live view of the reports. Plaintiff retained cardiologist Jeffrey Breall, M.D., Ph.D., who produced a report opining on Romeo's cause of death. Breall opined Romeo's death was "the result of hemopericardium and cardiac tamponade." Further, he opined Romeo's death was "caused by ascribing a wrong diagnosis of sciatica and ignoring signs and symptoms of aortic dissection and evolving tamponade ." Plaintiff also retained Kathleen C. Ashton, Ph.D., R.N., to address JCMC/RWJ nurses' standard of care. Ashton opined as to the nurses' deviation from the standard of care, which she believed led to the wrong diagnosis of sciatica and Romeo's death. Among the deviations cited were the nurses' failure to assess Romeo for cardiac tamponade when he first presented with chest pain, failure to provide a head-to-toe assessment, failure "to properly communicate during the hand off process," and failure "to obtain [Romeo's] complete medical history of hypertension and smoking." A-3099-23 6 Ashton also pointed to various failures by the nurses, including failing to adequately distinguish between Romeo's complaints and their own assumptions that he had "heartburn," and failing to recognize and appropriately respond to Romeo's changing pain levels. Ashton opined the nurses' deviations "fell below both the [JCMC/RWJ] policies and procedures and the standards of nursing care." In addition, plaintiff produced Dr. Michael D'Ambrosio as an expert in emergency medicine and the emergency medicine standard of care. D'Ambrosio's August 20, 2018 report explained that Adal failed to "[o]rder basic lab work and a urinalysis" and "[o]rder a stat CTA scan with IV contrast of the abdomen and pelvis." According to D'Ambrosio, these tests would have made it "apparent that Mr. Rivera had an acute dissection of the entire visualized aorta seen on an abdominal/pelvic CTA scan." He opined Romeo's death was a result of Adal's incorrect diagnosis due to his failure to obtain the CTA scan and "rule - out an acute symptomatic dissection of Mr. Rivera's abdominal." Plaintiff also retained Timothy Hawkins, an expert in hospital administration with over thirty years of experience in the field. In his report, Hawkins gave three distinct opinions regarding JCMC/RWJ's and EMA's negligence. His first opinion was that EMA was responsible for Adal's A-3099-23 7 negligence per Ambrosio's documentation. Second, he opined that JCMC/RWJ and EMA were responsible for the nursing staff's negligence based on Ashton's expert report, specifically, their failure to "perform a complete head-to-toe assessment" and continued reassessments, as well as failure to communicate Romeo's increase in pain level prior to his discharge. Finally, he claimed JCMC/RWJ and EMA "fell below the standard of care and were negligent in their administrative responsibility to the patients of the Jersey City Medical Center Emergency Department in their failure to educate and train the nursing staff on all of the policies and procedures in the [ED]." JCMC/RWJ asserted they were unaware of the claim contained in Hawkins's report alleging negligent supervision and training by JCMC/RWJ and EMA and that plaintiff did not provide them with an AOM. Plaintiff moved to amend her complaint to assert additional claims against JCMC/RWJ and EMA, but the judge denied plaintiff's motion on January 18, 2019. At the close of discovery, in November 2019, the judge granted partial summary judgment to JCMC/RWJ dismissing all direct claims against the parties. Later, in January 2020, the judge granted summary judgment to EMA and the nurses, also dismissing all direct claims against the parties. In a written opinion, the judge stated although plaintiff had retained the appropriate experts A-3099-23 8 with regard to EMA's and the nurses' deviation from the standard of care, neither expert, Hawkins nor Ashton, was qualified to opine as to how the negligence of EMA and the nurses was a substantial contributing factor or proximate cause of Romeo's death. The judge further explained that Breall did not opine, as plaintiff asserted, that the nurses' negligence increased the risk of harm to Romeo "and was a substantial factor in causing Mr. Rivera's death." Further, the judge reasoned that plaintiff's own experts opined that Adal's misdiagnosis was the only factor that increased Romeo's risk of death due to his pre-existing condition and that plaintiff's experts did not opine that Adal's misdiagnosis was due to the nurses' failure to record any relevant information. Therefore, the judge found plaintiff failed to meet her burden to demonstrate that EMA and the nurses substantially contributed to Romeo's misdiagnosis and thus plaintiff "failed to establish the requisite causation." A jury trial began on April 15, 2024, on the remaining claims against Adal, JCMC/RWJ, and EMA. Each defendant moved for a directed verdict at the close of plaintiff's case. See R. 4:37-2(b). The judge granted defendants' motions, dismissing all of plaintiff's remaining claims with prejudice. In an oral opinion, referring to the model jury charge, the judge explained plaintiff first had to prove "a deviation from the acceptable standards of medical practice," and second that A-3099-23 9 the "deviation increased the risk of harm posed by the preexisting condition ." However, according to the judge, plaintiff had not offered any expert testimony that would have enabled a jury to understand the extent of the increased risk of harm had it found such risk. Thus, the judge concluded plaintiff failed to satisfy the second prong of its burden. This appeal followed. On appeal, plaintiff raises the following points for our consideration: 2 POINT I: THE COURT ERRED BY DENYING DIRECT CLAIMS AGAINST JCMC WHERE PLAINTIFF'S AOM SUBSTANTIALLY COMPLIED WITH THE AOM STATUTE AND THERE WAS NO REASON TO DENY AN AMENDED COMPLAINT. POINT II: THE COURT ERRED BY DISMISSING DIRECT CLAIMS AGAINST EMA WHEN THE EVIDENCE SHOWED THAT EMA-MANAGED NURSES LACKED TRAINING AND SUPERVISION THAT CONTRIBUTED TO ROMEO RIVERA'S DEATH. POINT III: THE COURT ERRED BY DISMISSING ALL CLAIMS AGAINST THE NURSES. POINT IV: THE COURT ERRED BY DIRECTING A VERDICT IN FAVOR OF DR. ADAL, JCMC/RWJ AND EMA, FINDING THAT PLAINTIFF HAD FAILED TO COME FORWARD WITH SUFFICIENT EVIDENCE OF PROXIMATE CAUSE. POINT V: THE COURT ABUSED ITS DISCRETION BY NOT ALLOWING PLAINTIFF TO 2 We have removed subpoints for conciseness. A-3099-23 10 INVESTIGATE DECEDENT'S EMR AND BY GRANTING PROTECTIVE ORDERS THAT SEVERELY RESTRICTED DISCOVERY OF ROMEO RIVERA'S EMR/AUDIT TRAIL. II. Our analysis begins with some established legal principles. "[W]e review the trial court's grant of summary judgment de novo under the same standard as the trial court." Templo Fuente De Vida Corp. v. Nat'l Union Fire Ins. Co. of Pittsburgh, 224 N.J. 189, 199 (2016). That standard is well-settled. [I]f the evidence of record—the pleadings, depositions, answers to interrogatories, and affidavits—"together with all legitimate inferences therefrom favoring the non-moving party, would require submission of the issue to the trier of fact," then the trial court must deny the motion. R. 4:46-2(c); see Brill v. Guardian Life Ins. Co. of Am., 142 N.J. 520, 540 (1995). On the other hand, when no genuine issue of material fact is at issue and the moving party is entitled to a judgment as a matter of law, summary judgment must be granted. R. 4:46-2(c); see Brill, 142 N.J. at 540 . [Steinberg v. Sahara Sam's Oasis, LLC, 226 N.J. 344, 366 (2016) (citations reformatted).] "An issue of material fact is 'genuine only if, considering the burden of persuasion at trial, the evidence submitted by the parties on the motion, together with all legitimate inferences therefrom favoring the non-moving party, would require submission of the issue to the trier of fact.'" Grande v. Saint Clare's A-3099-23 11 Health Sys., 230 N.J. 1, 24 (2017) (quoting Bhagat v. Bhagat, 217 N.J. 22, 38 (2014)). Where there is no material fact in dispute, "we must then 'decide whether the trial court correctly interpreted the law.'" DepoLink Ct. Reporting & Litig. Support Servs. v. Rochman, 430 N.J. Super. 325, 333 (App. Div. 2013) (quoting Massachi v. AHL Servs., Inc., 396 N.J. Super. 486, 494 (App. Div. 2007)). "We review issues of law de novo and accord no deference to the trial judge's [legal] conclusions . . . ." MTK Food Servs., Inc. v. Sirius Am. Ins. Co., 455 N.J. Super. 307, 312 (App. Div. 2018). A motion for a directed verdict pursuant to Rule 4:37-2(b) "should be granted where no rational juror could conclude that the plaintiff marshaled sufficient evidence to satisfy each prima facie element of a cause of action." Prager v. Joyce Honda, Inc., 447 N.J. Super. 124, 134 (App. Div. 2016) (quoting Godfrey v. Princeton Theological Seminary, 196 N.J. 178, 197 (2008)). We apply the same standard as the trial court in reviewing the trial court's determination on a Rule 4:37-2(b) motion. Ibid. (quoting Smith v. Millville Rescue Squad, 225 N.J. 373, 397 (2016)). Turning to the essential elements of the cause of action at issue in this appeal, in a medical malpractice case, a claimant must demonstrate negligence by presenting expert testimony that establishes (1) a standard of care applicable A-3099-23 12 to the circumstances; (2) a deviation from that standard of care; and (3) that this specific deviation proximately caused the injury. Gardner v. Pawliw, 150 N.J. 359, 375 (1997). Ordinarily, proximate cause is a jury issue. Scafidi v. Seiler, 119 N.J. 93, 101 (1990). "Proximate cause as an issue, however, may be removed from the factfinder in the highly extraordinary case in which reasonable minds could not differ on whether that issue has been established." Fleuhr v. City of Cape May, 159 N.J. 532, 543 (1999) (citing Vega by Muniz v. Piedilato, 154 N.J. 496, 509 (1998)). In Scafidi, the Court reduced the traditional burden of proof required to establish proximate cause when a plaintiff in a medical malpractice case has a pre-existing condition. Id. at 108-09. A plaintiff suffering from a pre-existing condition must show that the defendant's negligence increased the risk of harm and that the increased risk of harm was a substantial factor in plaintiff's injury. Gardner, 150 N.J. at 379 . "To satisfy the threshold of the first prong of the Scafidi test, a plaintiff must prove to a reasonable degree of medical probability that a physician's deviation from the standard of care increased the risk of harm from the preexistent condition." Gardner, 150 N.J. at 379 (citing Scafidi, 119 N.J. at A-3099-23 13 109). "A plaintiff may present proof of 'not only what did occur, but what might have occurred.'" Ibid. (emphasis omitted) (citing Evers v. Dollinger, 95 N.J. 399, 415 (1984)). Moreover, "[a] plaintiff will typically use expert medical testimony." Ibid. (citing Rosenberg by Rosenberg v. Cahill, 99 N.J. 318, 325 (1985)). Most importantly, "[a] plaintiff necessarily must establish that a chance of avoiding the harm existed." Ibid. (citing Olah v. Slobodian, 119 N.J. 119, 133 (1990)). Amendment of pleadings in the trial court "is allowed only 'by leave of court which shall be freely given in the interest of justice.'" Notte v. Merchs. Mut. Ins. Co., 185 N.J. 490, 500-01 (2006) (quoting R. 4:9-1). The decision to grant "a motion to file an amended complaint always rests in the court's sound discretion." Id. at 501 (quoting Kernan v. One Wash. Park Urb. Renewal Assocs., 154 N.J. 437, 456-57 (1998)). The trial court's "exercise of discretion will not be disturbed on appeal, unless it constitutes a 'clear abuse of discretion.'" Franklin Med. Assocs. v. Newark Pub. Schs., 362 N.J. Super. 494, 506 (App. Div. 2003) (quoting Salitan v. Magnus, 28 N.J. 20, 26 (1958)). An abuse of discretion will be found where a court's decision was "made without a rational explanation, inexplicably departed from established policies, or rested on an impermissible basis." State v. Chavies, 247 N.J. 245 , 257 (2021) A-3099-23 14 (quoting State v. R.Y., 242 N.J. 48 , 65 (2020)). We will reverse a trial court's decision when its "exercise of discretion was 'manifestly unjust' under the circumstances." Newark Morning Ledger Co. v. N.J. Sports & Exposition Auth., 423 N.J. Super. 140, 174 (App. Div. 2011) (quoting Union Cnty. Improvement Auth. v. Artaki, LLC, 392 N.J. Super. 141, 149 (App. Div. 2007)). "[A] functional approach to abuse of discretion examines whether there are good reasons for an appellate court to defer to the particular decision at issue." R.Y., 242 N.J. at 65 (alteration in original) (quoting Flagg v. Essex Cnty. Prosecutor, 171 N.J. 561, 571 (2002)). Discovery requests "are to be liberally construed and accorded the broadest possible latitude to ensure that the ultimate outcome of litigation will depend on the merits in light of the available facts." Piniero v. N.J. Div. of State Police, 404 N.J. Super. 194, 204 (App. Div. 2008) (citing Shanley & Fisher, PC v. Sissleman, 215 N.J. Super. 200, 216 (App. Div. 1987)). However, a party does not have unfettered rights to discovery. Ibid. Rule 4:10-2 allows the discovery of materials "relevant to the subject matter involved in the pending action . . . including the existence, description, nature, custody, condition and location of any . . . electronically stored information." Although the discovery rules do not expressly define "relevant A-3099-23 15 evidence," it "is defined elsewhere as 'evidence having a tendency in reason to prove or disprove any fact of consequence to the determination of the action.'" Payton v. N.J. Tpk. Auth., 148 N.J. 524, 535 (1997) (quoting N.J.R.E. 401). "All relevant evidence is admissible" except where a rule provides otherwise. N.J.R.E. 402. We generally review a trial court's decision on discovery matters for an abuse of discretion. See State v. Brown, 236 N.J. 497, 521 (2019) (quoting Pomerantz Paper Corp. v. New Cmty. Corp., 207 N.J. 344, 371 (2011)). Similarly, we afford trial judges substantial deference in issuing protective orders under the same abuse of discretion standard. Grande v. DiBenedetto, 366 N.J. Super. 597, 610 (App. Div. 2004) (quoting Payton, 148 N.J. at 559 ). III. In Point I, plaintiff argues the judge erred in denying her direct claims against JCMC/RWJ because she substantially complied with the AOM statute, N.J.S.A. 2A:53A-26 to -29. Plaintiff further contends the judge incorrectly denied her leave to amend her complaint. The AOM statute provides: In any action for damages for personal injuries, wrongful death or property damage resulting from an alleged act of malpractice or negligence by a licensed person in his profession or occupation, the plaintiff A-3099-23 16 shall, within 60 days following the date of filing of the answer to the complaint by the defendant, provide each defendant with an affidavit of an appropriate licensed person that there exists a reasonable probability that the care, skill or knowledge exercised or exhibited in the treatment, practice or work that is the subject of the complaint, fell outside acceptable professional or occupational standards or treatment practices. . . . In the case of an action for medical malpractice, the person executing the affidavit shall meet the requirements of a person who provides expert testimony or executes an affidavit as set forth in [N.J.S.A. 2A:53A-41]. [N.J.S.A. 2A:53A-27.] "The stated purpose of the AOM statute, N.J.S.A. 2A:53A-26 to -29, is laudatory—to weed out frivolous claims against licensed professionals early in the litigation process." Meehan v. Antonellis, 226 N.J. 216, 228 (2016). "The submission of an appropriate affidavit of merit is considered an element of the claim." Ibid.; see also Alan J. Cornblatt, PA v. Barow, 153 N.J. 218, 244 (1998) (holding that failure to submit an AOM "goes to the heart of the cause of action as defined by the Legislature"). To that end, "[f]ailure to submit an appropriate affidavit ordinarily requires dismissal of the complaint with prejudice." Meehan, 226 N.J. at 228 . However, "[c]onsistent with the dual purposes of the statute to identify and eliminate unmeritorious claims against licensed professionals and to permit A-3099-23 17 meritorious claims to proceed efficiently through the litigation process," the Court has "fashioned two equitable remedies 'that temper the draconian results of an inflexible application of the statute.'" Id. at 229 (quoting Ferreira v. Rancocas Orthopedic Assocs., 178 N.J. 144, 151 (2003)). "Thus, a complaint will not be dismissed if the plaintiff substantially complied with the affidavit of merit obligations," and "a complaint will be dismissed without prejudice if the plaintiff can demonstrate extraordinary circumstances that prevented compliance." Ibid. Here, the judge denied plaintiff's motion to amend her complaint to add direct claims against JCMC/RWJ and EMA, explaining: The first reason is as plaintiff's counsel admitted at the time they filed the initial [AOM] against EMA, September of 2017, there was an indication, some type of belief, that there was a direct claim also against JCMC. Plaintiff's counsel has emphasized a number of times today, and the last time we argued this that they thought that that initial [AOM] sufficiently put JCMC on notice that they might be a target in this case, because they were thinking about that even though they needed more information. Well, that's not true. That's not the way that I read that [AOM]. That is not substantial compliance to say that the treatment rendered at Jersey City Medical Center by EMA was negligent. It would be the same as saying the treatment rendered by the . . . emergency technicians who arrived on the scene at Dunkin' Donuts . . . was negligent. That doesn't mean Dunkin' Donuts A-3099-23 18 is a target of an [AOM] phrase[d] like that. I don't blame the plaintiff for that. I don't think there's anything wrong with . . . phrasing it that way. But by the same token under the [AOM] statute, since the plaintiff admits they were thinking about it at the time they had an obligation to go out . . . to submit the form and say we need further information to look into any possible direct claims against JCMC. None of that happened. That's one of the reasons why I'm denying the motion to amend the complaint, because the initial [AOM] was not adequate. It did not . . . provide substantial notice to JCMC that they were a target, even though it was contemplated by the plaintiff at the time. Second reason, and probably the more important reason, is the extensive discovery that this will require .... . . . What was deficient about the training would have to be specified by Mr. Hawkins. He doesn't do that in his report. The defendant will need to retain a new expert. .... I'm finding that if I permit this amendment there will be extensive and undue delay in trial of this matter when . . . all of this information . . . was probably available in the first few months of 2018, a year ago. Plaintiff argues the judge erred in concluding her "initial AOM did not identify a direct claim against JCMC." Plaintiff asserts the AOM that she served on all defendants was timely and sufficient. Specifically, plaintiff contends A-3099-23 19 Hawkins, "an expert in hospital administration and healthcare safety," made reference to "Hospital Administration standards of emergency medicine," and since defendant JCMC/RWJ was the hospital involved, JCMC/RWJ had to know there was a claim against it for failure to satisfy the aforementioned standard. Additionally, plaintiff asserts the AOM referenced the nursing staff, which she believes clearly suggests a claim against JCMC/RWJ as they were JCMC/RWJ employees. She argues although EMA managed and supervised the nurses, this was a concurrent responsibility, not one that took the place of JCMC/RWJ's role in managing and supervising the nurses. Plaintiff also takes issue with the fact that defendant JCMC/RWJ waited three months after Hawkins served his report in August of 2018 to raise an issue about "the scope of Mr. Hawkins' opinions and conclusions." Plaintiff maintains the only evidence available for review when Hawkins served the AOM was JCMC/RWJ's emergency department records. Hawkins submitted a supplemental AOM that was based on his review of additional information plaintiff received during discovery. Within the amended affidavit, Hawkins clarified that both JCMC/RWJ and EMA had rendered care to decedent that "fell outside acceptable Hospital Administration Standards," thereby ascribing responsibility to each of these defendants. Thus, plaintiff asserts there was A-3099-23 20 substantial compliance with the AOM statute given defendants' belated contention that the AOM was deficient and plaintiff's prompt exercise "to cure any perceived defect" with a supplemental AOM. Plaintiff argues there was no prejudice in submitting the supplemental AOM or her motion for leave to amend. She claims any error in the AOM was corrected less than thirty days after defendants raised the issue and the motion to amend was made well within the discovery period, which wound up being extended even further after the motion was denied. We discern no abuse of discretion in the judge's decision. The judge correctly decided plaintiff failed to present sufficient evidence linking JCMC/RWJ's alleged negligence to the decedent's ultimate demise and plaintiff failed to comply with the requirements of the AOM statute as to JCMC/RWJ. The judge's decision was supported by a rational explanation that was consistent with established AOM principles and did not result in a manifest injustice. See Chavies, 247 N.J. at 257 (quoting R.Y., 242 N.J. at 65); Newark Morning Ledger Co., 423 N.J. Super. at 174 (quoting Union Cnty. Improvement Auth., 392 N.J. Super. at 149 ). Plaintiff initially submitted an AOM prepared by Hawkins stating, "There exists a reasonable probability that the care to Romeo Rivera rendered at the A-3099-23 21 Jersey City Medical Center by Emergency Medical Associates, LLC, fell outside the acceptable Hospital Administration standards of emergency medicine." In a supplemental AOM, Hawkins repeated the aforementioned allegation and added, "There exists a reasonable probability that the care to Romeo Rivera rendered by the Jersey City Medical Center to Romeo Rivera fell outside acceptable Hospital Administration Standards." Although plaintiff served the AOM within the sixty-day time period prescribed by the AOM statute, the affidavit failed to identify any direct negligence claim against JCMC/RWJ. Plaintiff's initial AOM did not specify what conduct by JCMC/RWJ fell outside the acceptable standards, nor did it identify the connection between JCMC/RWJ's conduct and Romeo's death. Plaintiff's supplemental affidavit likewise failed to cure the deficiencies of the initial AOM and did not identify any specific conduct that deviated from the acceptable standards or contributed to Romeo's death. Plaintiff argues both JCMC/RWJ and the nurses were on notice because the affidavit referenced JCMC/RWJ, the facility where the nurses were employed and the location of the incident. However, plaintiff's argument is unavailing. The AOM statute requires notice of a direct claim against each defendant, not notice based on association alone. Accepting plaintiff's argument A-3099-23 22 would undermine the statute's purpose in "weed[ing] out frivolous claims against licensed professionals early in the litigation process." Meehan, 226 N.J. at 228 . Likewise, plaintiff's later-filed supplemental affidavit did not cure the original AOM's failure to assert a direct claim against JCMC/RWJ because the AOM statute does not allow a claimant to assert a new claim after the deadline by supplementing it. IV. In Point II, plaintiff argues the judge improperly dismissed her direct claims against EMA on summary judgment. Specifically, plaintiff argues the evidence showed the nurses "lacked training and supervision," which eventually led to decedent's death. After reviewing medical records, the nurses' deposition testimony, and Ashton's expert opinion, Hawkins, plaintiff's expert in hospital administration, opined that EMA was responsible for the clinical negligence of Adal as D'Ambrosio had documented. Hawkins opined that based on Ashton's report, JCMC/RWJ's nursing staff had failed in their responsibility to perform a complete head-to-toe assessment per hospital policy, failed to perform re-assessments of patient Rivera every [thirty] minutes during his stay in the [ER], failed to notify [ER] physician Adal that patient Rivera's pain scale had increased to 6/10 immediately prior to discharge A-3099-23 23 following the administration of pain medication, and failed to re-assess patient Rivera [thirty] minutes after administering an IM injection of Toradol as required under policy. In granting summary judgment to EMA and the nurses, the judge determined: [A]s presented by [p]laintiff's experts, Dr. Adal's misdiagnosis was the factor – and the only factor – which increased [p]laintiff's risk from his alleged pre- existing illness. Plaintiff offers no qualified expert opinion that the nurse's failures – due to EMA's negligence or otherwise – played a part – in any way – with Dr. Adal's misdiagnosis. The judge also considered the fact that D'Ambrosio did not attribute Adal's negligence in diagnosing Romeo to a lack of "appropriate history, physical examination and adjunctive testing." The judge explained: Dr. D'Ambrosio, to the contrary, opines that ". . . consequently, the autopsy findings . . . support the conclusion that if a CT Scan of the abdomen and pelvis with IV contrast had been done in the Emergency Dept. of JCMC, that scan would have been abnormal and demonstrated an acute dissection of the distal thoracic and abdominal aorta visualized on the scan. Dr. Adal's failure to suspect and rule out an acute symptomatic dissection of Mr. Rivera's abdominal aorta resulted in his incorrect diagnosis and fell below the standard of care expected for an emergency medicine physician." Again, . . . as Dr. D'Ambrosio does not infer, imply or opine that the nurse's negligence—due to EMA's failure to properly train or otherwise—in any way contributed A-3099-23 24 to Dr. Adal's failure to rule out acute symptomatic dissection of Mr. Rivera's aorta. The [c]ourt agrees with the [d]efendants: Dr. D'Ambrosio does not infer or opine that Dr. Adal did not have necessary history or other information from the nurses which prevented him from correctly diagnosing Mr. Rivera's illness. [Citations omitted.] The judge added that because plaintiff "failed to present the necessary expert testimony connecting the nurses' negligence with Dr. Adal's misdiagnosis, . . . there can be no causal relationship between EMA's failure to properly train those nurses and Dr. Adal's misdiagnosis." The judge acknowledged "plaintiff's burden [was] not to establish that EMA and the four nurse[s'] negligence were the proximate cause of Mr. Rivera's death." Instead, "[i]t suffices if [p]laintiff can present qualified expert testimony that their individual negligence were substantial contributing factors to Mr. Rivera's death." (citing Perez v. Wyeth Lab. Inc., 161 N.J. 1, 27 (1999)). In other words, according to the judge, plaintiff was required to present qualified expert testimony "to establish a prima facie case" that the nurses' negligence, whether due to EMA's negligence or otherwise, "increased the risk" of decedent's death. The judge concluded plaintiff failed to do so. Instead, plaintiff presented expert testimony that Adal's misdiagnosis had increased the risk of A-3099-23 25 decedent's death, but, as far as causation, plaintiff had not presented expert testimony as to how the nurses' negligence lead to the misdiagnosis. We affirm the judge's decision granting summary judgment in favor of EMA on plaintiff's direct claims of negligence for the reasons stated by the judge. Plaintiff contends the judge erred because the evidence showed the EMA-managed nurses lacked training and supervision, which ultimately led to Romeo's death. Plaintiff maintains "EMA's failure to supervise, to oversee and to train Emergency Department staff within [JCMC/RWJ] Emergency Department was a contributing cause of Romeo Rivera's death," and proximate cause was a factual issue for the jury. Plaintiff concedes Hawkins did not provide an opinion on medical negligence and admits Hawkins's opinion dealt only with EMA's negligence in "supervision, oversight, training and enforcement of the [JCMC/RWJ] Emergency Department policies and procedures." Nonetheless, plaintiff asserts Hawkins was "permitted to rely on the medical liability and causation medical experts' opinions when formulating his own conclusions because a medical clinician's deviation is necessary to show that policies and procedures were not applied, taught or enforced by EMA." At his deposition, Hawkins testified about "the administrative standard of care," and provided "opinions regarding the contractual obligations and the A-3099-23 26 regulatory obligations of physicians, hospitals, and contracted services on a national basis." Hawkins did not provide an opinion on the nurses' or doctors' clinical standard of care because he maintained he was not a doctor or a nurse. His testimony on proximate causation relied on the conclusions of experts on the clinical standard of care. Plaintiff emphasizes EMA's role in providing training to hospital personnel and maintains that, combined with the testimony of EMA and ED staff, such testimony could permit a reasonable jury to find proximate cause. We reject plaintiff's contentions. Plaintiff failed to demonstrate how EMA's negligence or deviation from the standard of care led to the decedent's demise and failed to present any witnesses who could address whether EMA's negligence was actually a contributing cause in decedent's death. Plaintiff only provided Hawkins's testimony that the nurses deviated from the nursing standard of care. However, under Scafidi, plaintiff was required to present expert testimony that defendants' deviation from the standard of care increased the risk of Romeo's death with his pre-existing condition. See Gardner, 150 N.J. at 379 (citing Scafidi, 119 N.J. at 109 ). For example, plaintiff failed to present any evidence that had the specific medical tests been performed before decedent left the hospital, JCMC/RWJ doctors would have been able to perform life -saving A-3099-23 27 surgery which would have prevented decedent's demise. Plaintiff merely states that the diagnostic tests were not completed but fails to establish the causal link between the lack of diagnostic testing and decedent's eventual death. V. In Point III, plaintiff similarly argues the judge erred in dismissing her claims against the nurses on summary judgment. Plaintiff asserts the ED staff's deviation from the standard of acceptable nursing care was a "substantial" factor in increasing the risk that decedent died from a ruptured aortic aneurysm. Plaintiff argues the JCMC/RWJ nurses were required to perform necessary diagnostic testing, but their failure to perform those tests amounted to negligence that increased the risk of decedent's death. We affirm the judge's decision granting summary judgment in favor of the nurses for the same reasons the judge granted summary judgment in favor of EMA on plaintiff's direct claims. VI. In Point IV, plaintiff argues the judge erred in entering a directed verdict in favor of defendants Adal, JCMC/RWJ, and EMA after determining plaintiff had not provided enough evidence of proximate cause. Plaintiff asserts, "[i]n granting defendants' request for a directed verdict, the trial court held that A-3099-23 28 plaintiffs had failed to produce any evidence from which a jury could find that defendants' deviation increased the risk of harm to Mr. Rivera from his pre - existing condition." She contends "each witness, fact and expert, presented a piece of the puzzle, each one leading into the next such that a reasonable jury could dispel the smoke of defendants' arguments and see clearly how the multiple failures and inexplicable lack of any diagnostic testing or symptom recognition led to Mr. Rivera's premature discharge and death." Citing Verdicchio v. Ricca, 179 N.J. 1 (2004), plaintiff argues she did not have to prove that each deviation from the standard of care had to cause decedent's death. We are satisfied the judge's entry of a directed verdict in favor of Adal, JCMC/RWJ, and EMA was sound. Plaintiff failed to present expert testimony or evidence of proximate cause against each defendant, including Adal, JCMC/RWJ, and EMA. To demonstrate proximate cause, plaintiff had to show more than mere negligence; plaintiff had to establish that defendants' conduct was a substantial factor in bringing about the harm. See Gardner, 150 N.J. at 379 (citing Scafidi, 119 N.J. at 109 ). She failed to do so. In dismissing plaintiff's claims against defendants, the judge cited Gardner, 150 N.J. 359 , stating: The reality is that it's a fair ruling under Gardner to be fair to plaintiffs. There's no way they can get an expert A-3099-23 29 to say, doing a test that they honestly admit would have unknown results, they can't say that that would have increased the risk of harm in any way. If they admit, it wouldn't have given us any results. So, in Gardner v. Pawliw, they relaxed that requirement. That is not this case. Every one of plaintiff's experts, both of them were emphatic, of course he had the aortic dissection. If they had done the CAT scan, particularly, it would have shown it. X- rays would have helped show it. It would have been diagnosed, and then we call somebody else in. That's a hundred percent given to the plaintiff's expert. . . . Under the sequence of [the model jury charge] and accompanying interrogatory, the plaintiff has to prove, (1) a deviation from the acceptable standards of medical practice. Proven, here in this case. Number (2) that that deviation increased the risk of harm posed by the preexisting condition without any expert testimony in any way to help a jury understand to what extent, if any, there was any increased risk of harm. Not a possibility of it, but to a reasonable degree of probability, there would have been an increased risk of harm. Plaintiff has not met its burden to meet [n]umber 2. For that reason, I'm going to grant the motion, and the case is dismissed. The judge correctly concluded plaintiff failed to meet her burden. None of plaintiff's experts opined that decedent's death was caused, even in part, by the nurses, doctors, or JCMC/RWJ. The judge did not base his decision on the fact that plaintiff was unable to trace decedent's death back to each failure in the A-3099-23 30 standard of care, but rather that plaintiff failed to demonstrate through qualified expert testimony that decedent would not have died but for the alleged deviations. Plaintiff's assertion was that decedent was misdiagnosed, not that any other specific act by the hospital or staff, if performed differently, would have prevented decedent's death. The record supports dismissal under Rule 4:37-2(b), as plaintiff failed to present sufficient proof from which a rational juror could conclude that defendants' alleged negligence was a substantial factor in bringing about Romeo's demise. See Prager, 447 N.J. Super. at 134 (quoting Godfrey, 196 N.J. at 197 ). Accordingly, the judge correctly found plaintiff failed to establish proximate causation as to all defendants and did not err in granting Adal, JCMC/RWJ, and EMA a directed verdict. VII. In Point V, plaintiff argues the judge abused his discretion when he did not allow plaintiff to investigate decedent's EMR and restricted the discovery of decedent's EMR trail. We disagree. An audit trail is a document that shows the sequence of events related to the use of and access to an individual patient's [EMR]. For instance, the audit trail will reveal who accessed a A-3099-23 31 particular patient's records, when, and where the health care provider accessed the record. . . . Each time a patient's [EMR] is opened, regardless of the reason, the audit trail documents this detail. The audit trail cannot be erased and all events related to the access of a patient's [EMR] are permanently documented in the audit trail. Providers cannot hide anything they do with the medical record. No one can escape the audit trail. [Est. of Lasiw v. Pereira, 475 N.J. Super. 378 , 385 n.3 (App. Div. 2023) (alterations in original) (quoting Gilbert v. Highland Hosp., 31 N.Y.S.3d 397, 399 (Sup. Ct. 2016)).] On July 17, 2018, the judge denied plaintiff's motion to compel the production of the audit trail and audit reports of Romeo's EMR, which specifically included a request to compel the production of the "revision log" associated with the EMR. The judge subsequently granted several protective orders on behalf of defendant JCMC/RWJ. The first order granted defendants' motion for a protective order in part as to Bakhtin, limiting discovery to only those items needed to confirm Bakhtin's job title. The second protective order limited the depositions of Drs. Deven Unadkat and Chang-tang Wang to only "the circumstances under which they reviewed Romeo Rivera's EMR." The third protective order limited questioning of party and fact witnesses to documents with which they were familiar. A-3099-23 32 Plaintiff argues the protective orders prevented her from obtaining fact witness testimony, "prevented EMR inspection and rendered the audit trail unusable at trial." According to plaintiff, the EMR audit trail "included undisputed facts related to the deficient medical care Romeo Rivera received at [JCMC/RWJ] Emergency Department." Plaintiff asserts the audit trail was relevant evidence under N.J.R.E. 402. Plaintiff claims her health information systems expert was able to identify discrepancies in the audit trail and JCMC/RWJ paper medical records. However, because the judge granted a protective order, she was unable to address those discrepancies at trial. Plaintiff asserts the audit trail "provided valuable information about Romero Rivera's [JCMC/RWJ] ED treatment course." She contends the denial of the discovery blocking metadata, EMR, and audit trail discovery "was an abuse of discretion and caused a prejudicial dearth of EMR evidence at trial." Plaintiff's argument is unavailing. Although the audit trail may have been relevant, plaintiff's experts did not establish any causal link between JCMC/RWJ's alleged negligence and Romeo's death and plaintiff has not identified what specific information she hoped to extract from the audit trail that would establish such a link. Plaintiff also argues the judge abused his discretion by entering protective orders that limited testimony on Romeo's EMR and audit A-3099-23 33 trail. Even if the limitations were overly restrictive, plaintiff offers no explanation of how the outcome would have been different to warrant reversal. See Pomerantz Paper Corp., 207 N.J. at 371 . Plaintiff never identified any specific audit trail or revision log information that would have established liability, nor did she explain how the information would establish proximate cause. Plaintiff has not shown how the protective orders, which limited testimony to those familiar with the audit trail, prevented her from presenting evidence or expert testimony that JCMC/RWJ's conduct was a substantial factor in causing decedent's death. Plaintiff's assertion that the material was relevant does not satisfy her burden to prove proximate causation. Instead, reliance on the JCMC/RWJ EMR records in this context is speculative at best. Affirmed. A-3099-23 34