Case Study
I have attached the instructions for the assignment
Florida National University
HSA-4421 Legal Aspects and Legislations: Assignment Week 3
Case Study: Chapters 10, 11, 12.
Objective: The students will complete a Case study assignments that give the opportunity to synthesize and apply the thoughts learned in this and previous coursework to examine a real-world scenario. This scenario will illustrate through example the practical importance and implications of various roles and functions of a Health Care Administrator. The investigative trainings will advance students understanding and ability to contemplate critically about the public relations process, and their problem-solving skills. As a result of this assignment, students will be better able to comprehend, scrutinize and assess respectable superiority and performance by all institutional employees.
ASSIGNMENT GUIDELINES (10%):
Students will critically measure the readings from Chapters 10, 11, 12 in your textbook. This assignment is planned to help you examination, evaluation, and apply the readings and strategies to your Health Care organization, and finance.
You need to read the PowerPoint assigned for week 4 and develop a 3-4 page paper reproducing your understanding and capability to apply the readings to your Health Care organization and finance. Each paper must be typewritten with 12-point font and double-spaced with standard margins. Follow APA style 7th edition format when referring to the selected articles and include a reference page.
EACH PAPER SHOULD INCLUDE THE FOLLOWING:
1. Introduction (25%) Provide a brief synopsis of the meaning (not a description) of each Chapter and articles you read, in your own words that will apply to the case study presented.
2. Your Critique (50%): Case Study
Lauren was taken to the hospital ED. Hospital personnel contacted the physician by phone. He returned the call & prescribed a Phenergan injection. He did not go to the hospital & had not been given Lauren’s vital signs when he suggested such an injection, & further failed to order any blood or urine tests. Hospital records revealed that Laurens glucose level was 507 at the time of admission. Lauren’s went into respiratory failure & eventually died. (Futch v. Attwood)
Was the physician liable?
CASE STUDY CHALLENGE
1. Was the physician liable? if so why?
2. Describe the wide variety of negligent errors by various health care professionals.
3. Discuss the purpose of certification, licensure, & reasons for revocation of licenses.?
3. Conclusion (15%)
Briefly summarize your thoughts & conclusion to your critique of the case study and provide a possible outcome for the Health Care Center. How did these articles and Chapters influence your opinions about Legal aspects?
Evaluation will be based on how clearly you respond to the above, in particular:
a) The clarity with which you critique the case study;
b) The depth, scope, and organization of your paper; and,
c) Your conclusions, including a description of the impact of these Case study on any Health Care Setting.
ASSIGNMENT DUE DATE:
The assignment is to be electronically posted in the Assignments Link on Blackboard no later than noon on Sunday, September 20, 2020.
ASSIGNMENT RUBRICS
Assignments Guidelines
1 Points
10%
Introduction
2.5 Points
25%
Your Case Study Critique: Challenges
5 Points
50%
Conclusion
1.5 Points
15%
Total
11 points
100%
ASSIGNMENT GRADING SYSTEM
A
90% – 100%
B+
85% – 89%
B
80% – 84%
C+
75% – 79%
C
70% – 74%
D
60% 69%
F
50% – 59% Or less.
Dr. Gisela Llamas 2
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Library of Congress Cataloging-in-Publication Data
Pozgar, George D.
Legal and ethical essentials of health care administration / George D. Pozgar.2nd ed.
3
mailto:[emailprotected]
http://www.jblearning.com
http://www.jblearning.com
mailto:[emailprotected]
p. ; cm.
Rev. ed. of: Legal essentials of health care administration / George D. Pozgar ; legal review, Nina M. Santucci. c2009.
Related ed. of: Legal aspects of health care administration / George D. Pozgar ; legal review, Nina M. Santucci. 11th
ed. c2012.
Includes bibliographical references and index.
ISBN-13: 978-1-4496-9434-0 (pbk.)
ISBN-10: 1-4496-9434-9 (pbk.)
I. Pozgar, George D. Legal essentials of health care administration. II. Pozgar, George D. Legal aspects of health care
administration. III. Title.
[DNLM: 1. Delivery of Health Carelegislation & jurisprudenceUnited States. 2. Delivery of Health Care
ethicsUnited States. 3. Legislation, MedicalUnited States. W 32.5 AA1]
KF3821
344.7304’1dc23
2013010477
6048
Printed in the United States of America
17 16 15 14 13 10 9 8 7 6 5 4 3 2 1
4
Dedication
Mary Ann Pozgar-Berkebile
My Sister
Precious moments when she took my hand,
And said,
Lets Dance.
At that moment,
I knew from her touch,
How much she loved me.
5
Contents
Epigraph
Preface
About the Book Layout
Acknowledgments
Chapter 1 Government, Law, and Ethics
Learning Objectives
Government Organization
Sources of Law
Government Ethics
Chapter 2 Healthcare Ethics
Learning Objectives
Ethics Overview
Morality
Ethical Theories
Principles of Ethics
Virtues and Values
Spirituality and Religion
Secular Ethics
Situational Ethics
Reasoning and Decision-Making
Summary Thoughts
6
Chapter 3 Reflections on the Past
Learning Objectives
Early Hindu and Egyptian Hospitals
Greek and Roman Hospitals
Hospitals of the Early Christian Era
Islamic Hospitals
Early Military Hospitals
Medieval Hospitals
The Dark Age of Hospitals
Hospitals of the Renaissance
Hospitals of the 18th Century
Early Hospitals in the United States
Late 19th-Century Renaissance
20th-Century Progress
Health Care in the 21st Century
The Challenge Ahead
Chapter 4 Tort Law
Learning Objectives
Negligence
Intentional Torts
Products Liability
Chapter 5 Criminal Aspects of Health Care
Learning Objectives
Criminal Procedure
Healthcare Fraud
Patient Abuse
Criminal Negligence
Murder
Theft
Chapter 6 Contracts
Learning Objectives
What Is a Contract?
Types of Contracts
7
Elements of a Contract
Breach of Contract
Corporate Contracts
Partnerships
Agents
Independent Contractor
Legality of Object
Conditions
Performance
Nonperformance Defenses
Remedies
Employment Contracts
Exclusive Contracts
Noncompetitive Contract Clauses
Transfer Agreements
Insurance Contract
Chapter 7 Civil Procedure and Trial Practice
Learning Objectives
Pleadings
Discovery
Motions
Pretrial Conference
Notice of Trial
Memorandum of Law
The Court
The Jury
Subpoenas
Burden of Proof
Res Ipsa Loquitur
Opening Statements
Examination of Witnesses
Evidence
Defenses Against Plaintiffs Claims
Closing Statements
Judges Charge
Jury Deliberation
8
Awarding Damages
Appeals
Execution of Judgments
Chapter 8 Corporate Structure and Legal Issues
Learning Objectives
Authority of Healthcare Corporations
Corporate Committee Structure
Organizational Ethics
Corporate Negligence
Doctrine of Respondeat Superior
Independent Contractor
Duties of Healthcare Corporations
CEO/Administrator
Medical Staff
Corporate Reorganization
Chapter 9 Medical Staff Organization and Physician Liability
Learning Objectives
Medical Staff Ethics
Medical Staff Organization
Medical Staff Privileges
Common Medical Errors
PhysicianPatient Relationship
Chapter
10 Nursing and the Law
Learning Objectives
Scope of Practice
Nursing Diagnosis
Nurse Licensure
Classification of Nurse Staff
Advance Practice Nurses
Legal Risks of Nurses
Chapter
11 Hospital Departments and Allied Health Professionals
9
Learning Objectives
Professional Ethics
Chiropractor
Emergency Department
Laboratory
Medical Assistant
Nutritional Services
Paramedic
Pharmacy
Physical Therapy
Physician Assistant
Podiatrist
Respiratory Therapist
Certification of Health Professionals
Licensing Health Professionals
Professional Misconduct
Helpful Advice for Caregivers
Chapter
12 Patient Rights and Responsibilities
Learning Objectives
Patient Rights
Patient Responsibilities
Chapter
13 Patient Consent
Learning Objectives
Informed Consent
Information to Be Disclosed
Assessing Decision-Making Capacity
Adequacy of Consent
Verbal Consent
Written Consent
Consent for Routine Procedures
Consent for Specific Procedures
Implied Consent
Statutory Consent
10
Judicial Consent
Who May Consent
Right to Refuse Treatment
Defenses for Failure to Provide Consent
Ethics and Informed Consent
Chapter
14 Procreation and Ethical Dilemmas
Learning Objectives
Abortion
Sterilization
Artificial Insemination
Surrogacy
Wrongful Birth, Life, and Conception
Chapter
15 End-of-Life Issues
Learning Objectives
Patient Autonomy and Case Law
Legislative Response
Preservation of Life with Limits
Euthanasia
Advance Directives
Futility of Treatment
Withholding and Withdrawal of Treatment
Do-Not-Resuscitate Orders
Ethics Committee
Autopsy
Organ Donation
Research, Experimentation, and Clinical Trials
Human Genetics
Stem Cell Research
Chapter
16 AIDS
Learning Objectives
Spread of AIDS
11
Confidentiality
Discrimination
Negligence
Reporting Requirements
AIDS Emergency Act
Occupational Safety and Health Act
AIDS Education
Chapter
17 Legal Reporting Requirements
Learning Objectives
Child Abuse
Elder Abuse and Neglect
Births and Deaths
Communicable Diseases
Adverse Drug Reactions
Hospital-Acquired Infections
Physician Competency
Incident Reporting
Chapter
18 Medical Records
Learning Objectives
Managing Information
Contents of the Medical Record
Ownership and Release of Records
Documentation of Treatment
Retention of Records
Electronic Records
Medical Record Battleground
Legal Importance of Records
Illegible Handwriting
Timely Completion of Records
Confidential and Privileged Communications
HIPAA
ChartingSome Helpful Advice
12
Chapter
19
National Health Insurance and Managed Care
Learning Objectives
National Health Insurance
Managed Care
PPACA and State Law
Chapter
20 Professional Liability Insurance
Learning Objectives
Insurance Policy
Liability of the Professional
Medical Liability Insurance
Self-Insurance
Trustee Coverage
Mandated Medical Staff Insurance Coverage
Investigation and Settlement of Claims
Chapter
21 Labor Relations
Learning Objectives
U.S. Department of Labor
National Labor Relations Act
Norris-LaGuardia Act
Labor-Management Reporting and Disclosure Act
Fair Labor Standards Act
Civil Rights Act
Occupational Safety and Health Act
Rehabilitation Act
Family and Medical Leave Act
State Labor Laws
Labor Rights
Management Rights
Patient Rights During Labor Disputes
Affirmative Action Plan
Injunctions
Administering a Collective Bargaining Agreement
13
Discrimination in the Workplace
Chapter
22 Employment at Will and Discharge
Learning Objectives
Employment at Will
Public Policy Issues
Retaliatory Discharge
Fairness: The Ultimate Test
Termination
Constructive Discharge
Effective Hiring Practices
Clear Communications
Chapter
23 Employee Rights and Responsibilities
Learning Objectives
Employee Rights
Employee Responsibilities
Helpful Advice
Caregivers Pledge
Chapter
24 Tort Reform
Learning Objectives
Arbitration and Mediation
Structured Awards
Pretrial Screening Panels
Collateral Source Rule
Contingency Fee Limitations
Countersuits and Frivolous Claims
Joint and Several Liability
Malpractice Caps
No-Fault System
Regulation of Insurance Practices
Physician Participation in Tort Reform
14
Chapter
25
Culture of Safety
Learning Objectives
Developing a Culture of Safety
Improve Communications
Evaluating Safe Patient Care
CQI Approach to Performance Improvement
Implementation of Best Practices
Risk Management
Failure Mode Effects Analysis
Sentinel Events
Chapter
26 World Wide Search
Learning Objectives
Searching the Web
Legal Websites
Ethics Websites
Government Websites
Best Practices
Hospital and Physician Finders
International Medical Websites
Chapter
27 Journey to Excellence
Learning Objectives
Ideas for Getting Started
Adopt a Hospital
Funding Your Dreams
Baldrige Performance Excellence Program
Glossary
Case Index
Subject Index
15
Epigraph
In civilized life, law floats in a sea of ethics.
EARL WARREN, CHIEF JUSTICE OF THE UNITED STATES (18911974)
I consider ethics, as well as religion, as supplements to law in the government of man.
THOMAS JEFFERSON, PRESIDENT OF THE UNITED STATES (17431826)
In law a man is guilty when he violates the rights of others. In ethics he is guilty if he only
thinks of doing so.
IMMANUEL KANT, PHILOSOPHER (17241804)
It is curiouscurious that physical courage should be so common in the world, and moral
courage so rare.
MARK TWAIN, AMERICAN AUTHOR AND HUMORIST (18351910)
16
Preface
He has achieved success who has lived well, laughed often and loved much; who has gained
the respect of intelligent men and the love of little children; who has filled his niche and
accomplished his task; who has left the world better than he found it, whether by an improved
poppy, a perfect poem, or a rescued soul; who has never lacked appreciation of earths beauty or
failed to express it; who has always looked for the best in others and given them the best he had;
whose life was an inspiration; whose memory a benediction.
BESSIE STANLEY
Legal and Ethical Essentials of Health Care Administration, Second Edition has become more
than an abridged version of Legal Aspects of Health Care Administration, Eleventh Edition.
The content has been updated and fully expanded to bring excitement into the learning
process. This Second Edition delivers to the reader a comprehensive updated review of both
health law and ethics. The substantive material in the Second Edition has been carefully
selected based on the common legal and ethical issues the practitioner will face during his
or her career. Although this book is mandatory reading for many students enrolled in
health management and patient care courses, it is particularly valuable as a supplemental
reading in the curricula of many healthcare programs. The Second Edition is also an
invaluable desk reference for those in managerial positions and professionals providing
direct patient care.
The authors unique experience in health care includes consulting and surveying more
than 1,000 hospitals and ambulatory sites from Alaska to Puerto Rico, as well as his
experience as administrator, educator, consultant, and speaker. Every attempt has been
made to arm the student with the knowledge gained through his extensive healthcare
experiences.
As a result of his background, one of the unique features of this book is that in each
chapter the focus on the various issues includes more than merely definitions or
descriptions of words. There is an infusion of life into the material by using cases that have
been litigated or discussed in the press, as well as real-world events through reality checks
experienced by healthcare professionals. In that way, the law and ethics spring to life and
inspire dynamic discussion and excitement in the learning process, thus creating an
17
atmosphere of interest and participation, which is conducive to learning.
The study of Legal and Ethical Essentials of Health Care Administration, Second Edition
affords health professionals with the opportunity to apply the concepts learned to what they
will face on a daily basis in a practical way. It details the actions healthcare providers can
take to help prevent the wide variety of harmful events that occur in patient care settings.
Although there will always be a next time for human error, the reader who synthetizes the
contents in this book and understands its lessons will better understand how failures can
turn to success and the pain of past mistakes can turn to hope.
18
About the Book
Layout
Legal and Ethical Essentials of Health Care Administration, Second Edition lays a strong
foundation in both health law and ethics. Chapter 1 begins with an introduction to
government organization, sources of law, and government ethics and Chapter 2 progresses
to a discussion of ethical theories, principles, virtues and values, and related topics. Chapter
3 provides an overview of the historical development of hospitals as influenced by medical
progress, allowing the reader to look at their successes and failures through the centuries,
and then drawing conclusions about what can be done to avoid repeating the failures of the
past. In Chapter 4, the reader is introduced to negligent and intentional torts, progressing
to criminal acts in Chapter 5, and contract law in Chapter 6 as they relate to health care.
The reader is then introduced to civil procedure and trial practice in Chapter 7. The
journey continues with a discussion of legal issues involving corporations in Chapter 8,
medical staff organization and physician liability in Chapter 9, nursing and the law in
Chapter 10, and a discussion of various hospital departments and allied health professionals
in Chapter 11.
The first 11 chapters provide a solid basis for a more complete understanding of the
following remaining chapters: Chapter 12 provides an overview of patient rights and
responsibilities; Chapter 13 patient consent; Chapter 14 procreation and ethical issues;
Chapter 15 end-of-life issues; Chapter 16 AIDS; Chapter 17 legal reporting requirements;
Chapter 18 medical records; Chapter 19 national health insurance and managed care;
Chapter 20 professional liability insurance; Chapter 21 labor relations; Chapter 22
employment at will and discharge; Chapter 23 employee rights and responsibilities;
Chapter 24 tort reform; Chapter 25 culture of safety; Chapter 26 world wide search;
Chapter 27 the journey to excellence; and a glossary of common legal and ethics
vocabulary.
The practical application of ethics in the healthcare setting is accomplished by
interspersing the thoughts of great minds through Quotes, applicable Newspaper Clippings,
provider and organizational experiences through Reality Checks designated by a symbol,
and patient experiences through legal rulings and summaries through Case Law. When
reviewing the various cases in this book, the reader should consider both the ethical and
19
legal implications of a dilemma and how they intertwine with one another. It is important
to recognize that the decisions in the cases described are generally governed both by
applicable state and federal statutes and common-law principles. When reviewing a case,
the reader must keep in mind that the case law and statutes of one state are not binding in
another state.
There is no one magic legal or ethics book that can possibly compress the plethora of
issues that have bombarded the healthcare industry into one book. This book is merely a
beginning of the study of legal and ethical issues and is an adventure that all caregivers
should take. Although there is always much more that could be discussed on any one topic,
the good student will understand that this book provides a solid foundation for practical
everyday use as well as further study.
Each life is like a novel. Filled with moments of happiness, sadness, crisis, defeat, and
triumph. When the last page has been written, will you be happy or saddened by what you
read?
AUTHOR UNKNOWN
The reader is presented in the Second Edition with real-world life experiences that bring
the reader through a journey of learning that provides an effective transitional stage from
the classroom to the reality of the everyday work environment.
When people consider matters of law and ethics they are usually considering matters of
freedom in regard to personal choices, ones obligations to other sentient beings, or
judgments about human character and the right to choose. The authors objective is to
equip the reader with the background knowledge necessary to understand that legal and
ethical behavior begins with understanding that we have alternatives and choices in our
behavior. To make good decisions, we must first understand that they will be only as good
as our knowledge of what is right and what is wrong. This book is not an indictment of any
profession or organization. There is a deluge of ethical issues in every aspect of human
existence. Although cultural differences, politics, and religion influence who we are, it is all
of lifes experiences that affect who we will become. If we are compassionate it is most likely
compassionate people have influenced us.
Authors Note: This book is not a definitive treatise but is a portrait of the ever-
evolving story of health care through the study of law and ethics. It is educational in
nature and should not be considered a substitute for legal advice on any particular
issue. Moreover, each chapter presents an overview, rather than an exhaustive
treatment, of the various topics discussed.
The author, legal reviewers, and/or publisher cannot be responsible for any errors
or omissions, including: additions to, interpretations of, and/or changes in the
regulations presented in this book.
20
Acknowledgments
The author especially acknowledges the staff at Jones & Bartlett Learning whose guidance
and assistance was so important in making this Second Edition a reality. Special thanks to
Mike Brown, Publisher at Jones & Bartlett Learning, who has once again been truly an
amazing leader and mentor over the years. I would like to thank Chloe Falivene, Editorial
Assistant, who worked diligently and tirelessly with me on this Second Edition. I would also
like to thank the other Jones & Bartlett staff, including Rebekah Linga, Associate
Production Editor; Sean Fabery, Editorial Assistant; and Sophie Teague, Senior Marketing
Manager; who have also worked with me on this Second Edition. Thanks for allowing me to
leave behind this legacy of writing.
I am grateful to the very special people in the more than 1,000 hospitals and
ambulatory sites from Alaska to Puerto Rico with whom I have consulted, surveyed, and
provided education over many years. Their shared experiences have served to remind me of
the importance to make this book more valuable in the classroom and as a reference for
practicing healthcare professionals.
To my students in healthcare law and ethics classes at the New School for Social
Research, Molloy College, Long Island UniversityC.W. Post Campus, Saint Francis
College, and Saint Josephs College; my intern from Brown University; my resident in
hospital administration from The George Washington University; and those I have
instructed through the years at various seminars, I will always be indebted for your
inspiration.
Many thanks are also extended to all those special people at the National Library of
Medicine and the Library of Congress for their guidance over the years in locating research
materials.
21
1
Government, Law,
and Ethics
As the patriots of seventy-six did to the support of the Declaration of Independence, so to the
support of the Constitution and Laws, let every American pledge his life, his property, and his
sacred honorlet every man remember that to violate the law, is to trample on the blood of his
father, and to tear the character of his own, and his childrens liberty. Let reverence for the laws,
be breathed by every American mother, to the lisping babe, that prattles on her laplet it be
taught in schools, in seminaries, and in colleges; let it be written in Primers, spelling books, and
in Almanacslet it be preached from the pulpit, proclaimed in legislative halls, and enforced in
courts of justice. And, in short, let it become the political religion of the nation; and let the old
and the young, the rich and the poor, the grave and the gay, of all sexes and tongues, and colors
and conditions, sacrifice unceasingly upon its altars.
ABRAHAM LINCOLN
Figure 11 United States Constitution James Steidl/ShutterStock, Inc.
22
Learning Objectives
The reader upon completion of this chapter will be able to:
Discuss the three branches of government, and the importance of separation of powers.
Describe the organization structure of the Department of Health and Human Services.
Explain the development of case law and how it differs from statutory and
administrative law.
Describe the function of various government ethics committees herein presented.
This chapter introduces the reader to the purpose and sources of law, the functioning of the
legal system, and the roles of the three branches of government in creating, administering,
and enforcing the law. There is also a brief overview of the Department of Health and
Human Services and selected agencies within the department.
GOVERNMENT ORGANIZATION
The three branches of the federal government are the legislative, executive, and judicial
branches (Figure 12). A vital concept in the constitutional framework of government on
both federal and state levels is the separation of powers. Essentially, this principle provides
that no one branch of government is clearly dominant over the other two; however, in the
exercise of its functions, each can affect and limit the activities, functions, and powers of
the others.
Executive Branch
The primary function of the executive branch of government on the federal and state level is
to administer and enforce the law. The chief executive, either the president of the United
States or the governor of a state, also has a role in the creation of law through the power to
approve or veto legislative proposals.
The president serves as the administrative head of the executive branch of the federal
government. The executive branch includes 15 executive departments, as well as a variety of
agencies, both temporary and permanent. Each department is responsible for a different
area of public affairs, and each enforces the law within its area of responsibility.
On a state level, the governor serves as the chief executive officer. The responsibilities of
a governor are provided for in the states constitution. The Massachusetts State
Constitution, for example, describes the responsibilities of the governor as presenting an
annual budget to the state legislature, recommending new legislation, vetoing legislation,
appointing and removing department heads, appointing judicial officers, and acting as
Commander-in-Chief of the states military forces (the Massachusetts National Guard).
Legislative Branch
23
On the federal level, legislative powers are vested in the Congress of the United States, which
consists of the Senate and the House of Representatives. The function of the legislative branch
is to enact laws that can amend or repeal existing legislation and to create new legislation.
The legislature determines the nature and extent of the need for new laws and for changes
in existing laws. Committees of both houses of Congress are responsible for preparing
federal legislation.
Judicial Branch
As I have said in the past, when government bureaus and agencies go awry, which are
adjuncts of the legislative or executive branches, the people flee to the third branch, their courts,
for solace and justice.1
JUSTICE J. HENDERSON,
SUPREME COURT OF SOUTH DAKOTA
The function of the judicial branch of government is adjudicationresolving disputes in
accordance with law. As a practical matter, most disputes or controversies that are covered
by legal principles or rules are resolved without resort to the courts.
Scarcely any political question arises in the United States that is not resolved, sooner or
later, into a judicial question.
ALEXIS DE TOCQUEVILLE (18051859)
The decision as to which court has jurisdictionthe legal right to hear and rule on a
particular caseis determined by such matters as the locality in which each party to a
lawsuit resides and the issues of a lawsuit. Each state in the United States provides its own
court system, which is created by the states constitution and statutes. Most of the nations
judicial business is reviewed and acted on in state courts. Each state maintains a level of trial
courts that have original jurisdiction, meaning the authority of a court to first conduct a
trial on a specific case as distinguished from a court with appellate jurisdiction, where
appeals from trial judgments are held. This jurisdiction can exclude cases involving claims
with damages less than a specified minimum, probate matters (i.e., wills and estates), and
workers compensation. Different states have designated different names for trial courts
(e.g., superior, district, circuit, or supreme courts). Also on the trial court level are minor
courts such as city, small claims, and justice of the peace courts.
Each state has at least one appellate court. Many states have an intermediate appellate
court between the trial courts and the court of last resort. Where this intermediate court is
present, there is a provision for appeal to it, with further review in all but select cases.
Because of this format, the highest appellate tribunal is seen as the final arbiter for the
particular states system of jurisprudence.
The trial court of the federal system is the U.S. District Court. There are 94 district
courts in the 50 states (the larger states have more than one district court) and one in the
District of Columbia. The Commonwealth of Puerto Rico also has a district court with
jurisdi
