Court Opinion

ID: 4709828
Source: CourtListenerOpinion
Date Created: 2021-08-07 00:03:04.232096+00
Date Added: 2024-06-11T08:06:59.712876
License: Public Domain

Case: 20-30707     Document: 00515968820         Page: 1    Date Filed: 08/06/2021

           United States Court of Appeals
                for the Fifth Circuit                                 United States Court of Appeals
                                                                               Fifth Circuit

                                                                             FILED
                                                                        August 6, 2021
                                  No. 20-30707                          Lyle W. Cayce
                                                                             Clerk

   Damian Francois,

                                                           Plaintiff—Appellant,

                                      versus

   Our Lady of the Lake Hospital, Incorporated,

                                                           Defendant—Appellee.

                  Appeal from the United States District Court
                      for the Middle District of Louisiana
                            USDC No. 3:17-CV-393

   Before Jones, Southwick, and Costa, Circuit Judges.
   Leslie. H. Southwick, Circuit Judge:
          Damian Francois sued Our Lady of the Lake Hospital for disability
   discrimination. He now appeals the district court’s grant of summary
   judgment to the Hospital, which dismissed his claims that the Hospital
   violated the Rehabilitation Act and Affordable Care Act by failing to provide
   an on-site interpreter until the sixth day of his hospital stay. We AFFIRM.
Case: 20-30707      Document: 00515968820          Page: 2   Date Filed: 08/06/2021

                                    No. 20-30707

              FACTUAL AND PROCEDURAL BACKGROUND
          According to the record, Damian Francois is a deaf and “virtually
   illiterate” individual who communicates primarily in American Sign
   Language (“ASL”). This appeal concerns whether there is evidence in the
   summary-judgment record that creates a genuine dispute of material fact
   about whether the Hospital had actual notice that an on-site interpreter was
   necessary to provide appropriate medical care to Francois.
          On April 11, 2017, Francois was admitted to the Hospital after his
   uncle shot him in the back. Francois’ grandmother, Leona Deemer, testified
   in a deposition that she told the ambulance crew, the “lady at the front desk,”
   and a doctor that Francois was deaf and “needed an interpreter.” She also
   testified that she told Francois’ attendant nurses that he was unable to
   understand many written or complex words. That first night, Francois
   underwent emergency surgery that saved his life but did not prevent his
   permanent paralysis.
          The next morning, Francois met with John Deshotel, who was a Care
   Coordinator at the Hospital. Deshotel communicated with Francois in ASL,
   which is Deshotel’s second language. He also spoke in English because
   Deemer was there too. According to Deshotel’s sworn affidavit, he told
   Francois during this meeting that “the hospital wanted to meet his needs
   throughout his admission”; asked Francois if he needed any additional
   services, and Francois answered that he did not; and told Francois “if he
   needed any additional services, that he could ask for me and that I would
   come meet with him.” According to Deshotel’s affidavit, neither Francois
   nor Deemer requested an interpreter during that meeting.
          During Francois’ first five days, the Hospital relied on several
   methods of communication other than an on-site interpreter. It relied
   primarily on the use of a whiteboard/dry-erase board and nonverbal cues. At

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   various times, the Hospital also relied for interpretive assistance on a board
   with pictures, Francois’ family, and a video remote interpreter. 1
           The nurses attending Francois testified that he appeared to
   understand their written and nonverbal communications. Allison Berry,
   assigned to Francois on April 12, testified to multiple instances when she
   communicated with Francois using the whiteboard and Francois nonverbally
   indicated that he understood. Another nurse, Katelyn Ferachi, was assigned
   to Francois on April 15. She testified that Francois “never gave any
   indication that he did not understand [whiteboard notes] or that [using the
   whiteboard] was not appropriate for him.” She also testified that, when the
   Hospital’s staff would use the whiteboard to communicate, Francois would
   “answer with either a nonverbal cue or a written answer on the board.”
           There are hospital records showing that difficulties arose in
   communicating with Francois. On several occasions, communications with
   Francois about his medical history were “limited.” Two of those records,
   though, indicate that the Hospital was able to obtain Francois’ medical
   history using methods other than an on-site interpreter, i.e., “by writing
   questions and interviewing [Francois’] grandmother,” and by the “use of a
   dry erase board and sign language through family member at bedside.”
           As of April 14, his third full day in the Hospital, Francois’ medical
   condition was stable, but the Hospital knew that Francois was paralyzed. At
   that point, the Hospital was ready to transfer him from a trauma unit to a
   rehabilitation unit. That day, one of Francois’ friends, Paula Rodriguez, sent

           1
              The district court credited the Hospital’s reliance on Francois’ family for
   interpretive assistance as assisting effective communication. An ADA regulation, though,
   prohibits reliance on family members for interpretive assistance absent exceptions that are
   not applicable here, 28 C.F.R. § 35.160(c)(2), and an ACA regulation incorporates this
   prohibition by reference, 45 C.F.R. § 92.102(a).

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   a text message to the Civil Rights Coordinator at the Hospital requesting an
   interpreter for Francois. It appears that the text message resulted in the
   Hospital’s attempting, unsuccessfully, to use a virtual remote interpreter.
          On April 15, Rodriguez visited the Hospital, told medical personnel
   that the virtual remote interpreter was ineffective, and requested an on-site
   interpreter for Francois. Rodriguez later testified that on April 15, Francois
   still did not know that he was permanently paralyzed. Instead, he thought
   that he would have another surgery and walk again.
          The Hospital provided an on-site interpreter the next day, April 16.
   On that day, with an on-site interpreter present, Francois met with Dr. Malia
   Eischen, who explained to Francois his diagnosis and prognosis of permanent
   paralysis. A medical record indicates that, during this meeting, Francois’
   family “expressed concern that [Francois] was not understanding
   communication that had previously been provided.”
          Francois remained in the Hospital until May 17. From April 16 to May
   17, the Hospital provided an on-site interpreter on 61 occasions.
          Francois sued the Hospital in the United States District Court for the
   Middle District of Louisiana. In the live complaint, Francois asserted claims
   against the Hospital under Section 504 of the Rehabilitation Act (“RA”), 29
   U.S.C. § 794; Title III of the Americans with Disabilities Act (“ADA”), 42
   U.S.C. § 12182; Section 1557 of the Patient Protection and Affordable Care
   Act (“ACA”), 42 U.S.C. § 18116; and the Louisiana Commission on Human
   Rights, La. Rev. Stat. § 51:2231. Francois sought a declaratory judgment,
   injunctive relief, compensatory damages, costs and attorneys’ fees, and any
   other relief necessary and appropriate. In February 2018, the district court
   dismissed Francois’ state-law claims. In October 2019, Francois voluntarily
   dismissed his ADA claim. Only his RA and ACA claims remained. The
   Hospital filed for summary judgment on those two remaining claims.

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           After briefing, the district court granted summary judgment in favor
   of the Hospital. As for Francois compensatory-damages claims, the court
   held that Francois failed to establish the requisite intentional discrimination
   because he “failed to present evidence that [the Hospital’s] staff had actual
   notice that [Francois’] rights were being violated.” The court reasoned that
   the Hospital “made good faith efforts to accommodate [Francois] and
   believed that communication via written messages and family assistance was
   effective, especially considering [Francois] never indicated a lack of
   understanding or requested an interpreter or to meet with Deshotel.”
   According to the court, the summary-judgment evidence “may demonstrate
   negligence or carelessness,” but not intentional discrimination. As for the
   injunctive-relief claims, the court held that Francois lacked standing because
   he failed to show an injury in fact. As for available damages, the court
   correctly observed that that emotional-distress damages are unavailable
   under Cummings v. Premier Rehab Keller, P.L.L.C., 948 F.3d 673 (5th Cir.
   2020), cert. granted, --- S. Ct. ----, 2021 WL 2742781 (July 2, 2021) (No. 20-
   219). The district court then determined that compensatory damages for
   “denial of self-determination” are unavailable too. 2
           The district court dismissed all of Francois’ remaining claims with
   prejudice and entered final judgment for the Hospital. Francois timely
   appealed.

           2
             Francois argues that Cummings was incorrectly decided as to the availability of
   emotional-distress damages. He also argues that, under Cummings, damages for “denial of
   self-determination” should be available. We do not address these issues because of our
   holding that Francois did not make a summary-judgment showing of intentional
   discrimination.

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                                  DISCUSSION
          We review the grant of summary judgment de novo, applying the same
   standards as the district court. Smith v. Harris Cnty., 956 F.3d 311, 316 (5th
   Cir. 2020). Summary judgment is appropriate “if the movant shows that
   there is no genuine dispute as to any material fact and the movant is entitled
   to judgment as a matter of law.” Fed. R. Civ. P. 56(a). “A dispute is
   genuine if the evidence is such that a reasonable jury could return a verdict
   for the nonmoving party.” Dyer v. Houston, 964 F.3d 374, 379 (5th Cir.
   2020). “A fact is material if its resolution could affect the outcome of the
   action.” Id. (quotation marks and citation omitted). On appeal from
   summary judgment, we view the facts in the light most favorable to the
   nonmoving party and draw all reasonable inferences in its favor. SEC v.
   Kahlon, 873 F.3d 500, 504 (5th Cir. 2017).
          Francois contends that his need for an on-site interpreter was “open
   and obvious” and that the Hospital’s failure to provide one until April 16
   constitutes intentional discrimination.      He claims that, because of the
   Hospital’s delay in providing an on-site interpreter, Francois did not
   understand until the sixth day in the Hospital that he was paralyzed and
   wrongfully believed that he would have surgery and walk again.
          The Hospital disagrees with Francois’ view of the evidence. It asserts
   that the evidence shows that its staff had no reason to know that their means
   of communication were ineffective. The Hospital contends that an on-site
   interpreter was not requested until April 15, and at no time did Francois’
   nurses or Deshotel have reason to believe that an on-site interpreter was
   necessary. The Hospital’s position is that it took reasonable steps to
   accommodate Francois and arranged for an on-site interpreter as soon as it
   learned of Francois’ need for one.

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          First, we will explain the analytical frameworks for Francois’ claims
   for disability discrimination under Section 504 of the RA and Section 1557 of
   the ACA. Second, we will analyze whether Francois presented sufficient
   evidence to survive summary judgment. We conclude that Francois failed to
   make a summary-judgment showing of intentional discrimination because
   the evidence, viewed in the light most favorable to Francois, is not sufficient
   for a reasonable jury to determine that the Hospital had actual knowledge of
   the need for an on-site interpreter.
   I.     The analytical frameworks
          Section 504 of the RA prohibits disability discrimination by recipients
   of federal funds. 29 U.S.C. § 794(a). 3 The RA’s implementing regulations
   provide additional requirements and guidance. First, a recipient of federal
   funds must “provide appropriate auxiliary aids to persons with impaired
   sensory, manual, or speaking skills, where necessary to afford such persons an
   equal opportunity to benefit from the service in question.” 45 C.F.R.
   § 84.52(d)(1) (emphasis added). Second, “aids, benefits, and services, to be
   equally effective, are not required to produce the identical result or level of
   achievement for handicapped and nonhandicapped persons, but must afford
   handicapped persons equal opportunity to obtain the same result, to gain the
   same benefit, or to reach the same level of achievement, in the most
   integrated setting appropriate to the person’s needs.” Id. § 84.4(b)(2).

          3
              Section 504 of the RA provides in relevant part:
          No otherwise qualified individual with a disability in the United States, as
          defined in section 705(20) of this title, shall, solely by reason of her or his
          disability, be excluded from the participation in, be denied the benefits of,
          or be subjected to discrimination under any program or activity receiving
          Federal financial assistance or under any program or activity conducted by
          any Executive agency or by the United States Postal Service.
   29 U.S.C. § 794(a).

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   “The remedies, procedures, and rights available under the Rehabilitation Act
   parallel those available under the ADA.” Cadena v. El Paso Cnty., 946 F.3d
   717, 723 (5th Cir. 2020). Thus, precedent interpreting or applying the ADA
   applies with equal force to a claim under the RA. Id.
           Section 1557 of the ACA prohibits discrimination based on any of the
   grounds protected under Title VI, Title IX, the Age Discrimination Act, and
   the RA, during the provision of health care. 42 U.S.C. § 18116(a). 4 The
   ACA’s implementing regulations also provide additional requirements and
   guidance. First, a health program or activity receiving federal funds must
   “provide appropriate auxiliary aids and services, including interpreters and
   information in alternate formats, to individuals with impaired sensory,
   manual, or speaking skills, where necessary to afford such persons an equal
   opportunity to benefit from the service in question.” 45 C.F.R. § 92.102(b)
   (emphasis added). Under the ACA, auxiliary aids include, among other
   things, “[i]nterpreters on-site or through video remote interpreting (VRI)
   services,” “note takers,” “written materials,” “exchange of written notes,”

           4
               Section 1557 of the ACA provides in relevant part:
           Except as otherwise provided for in this title (or an amendment made by
           this title), an individual shall not, on the ground prohibited under title VI
           of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX of the
           Education Amendments of 1972 (20 U.S.C. 1681 et seq.), the Age
           Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), or section 794 of title
           29, be excluded from participation in, be denied the benefits of, or be
           subject to discrimination under, any health program or activity, any part of
           which is receiving Federal financial assistance, including credits,
           subsidies, or contracts of insurance, or under any program or activity that
           is administered by an Executive Agency or any entity established under
           this title (or amendments). The enforcement mechanisms provided for
           and available under such title VI, title IX, section 794, or such Age
           Discrimination Act shall apply for purposes of violations of this subsection.
   42 U.S.C. § 18116(a).

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   and “other effective methods of making aurally delivered information
   available to individuals who are deaf or hard of hearing.” Id.
   § 92.102(b)(1)(i).
           Section 504 of the RA and Section 1557 of the ACA provide private
   causes of action. See RA, 29 U.S.C. § 794a; ACA, 42 U.S.C. § 18116(a)
   (incorporating the “enforcement mechanisms” of the other civil rights
   statutes). For disability-discrimination claims, the ACA incorporates the
   substantive analytical framework of the RA. Doe v. BlueCross BlueShield of
   Tenn., Inc., 926 F.3d 235, 239 (6th Cir. 2019) (“By referring to four statutes,
   Congress incorporated the legal standards that define discrimination under
   each one.”). 5 Accordingly, we will analyze Francois’ RA and ACA claims
   together.
           To establish a prima facie case for disability discrimination under the
   RA, and by extension the ACA, a plaintiff must show that: (1) he has a
   qualifying disability; (2) he is being excluded from participation in, denied
   the benefits of, or otherwise discriminated against by a covered entity; and
   (3) such discrimination is by reason of his disability. Miraglia v. Bd. of
   Supervisors of La. State Museum, 901 F.3d 565, 574 (5th Cir. 2018). A prima
   facie case requires evidence that the plaintiff’s disability, limitation, and
   necessary reasonable accommodation were “known by” the covered entity.

           5
              The Ninth Circuit recently agreed with the Sixth Circuit’s BlueCross BlueShield
   holding that the ACA incorporates the substantive analytical framework of the RA for
   disability-discrimination claims, but it implicitly disagreed with the BlueCross BlueShield
   holding about whether the RA prohibits disparate-impact discrimination. See Doe v. CVS
   Pharmacy, Inc., 982 F.3d 1204, 1210–12 (9th Cir. 2020), cert. granted in part, --- S. Ct. ----,
   2021 WL 2742790 (July 2, 2021) (No. 20-1374). The grant of certiorari in CVS Pharmacy
   is limited to “[w]hether section 504 of the Rehabilitation Act, and by extension the ACA,
   provides a disparate-impact cause of action for plaintiffs alleging disability discrimination.”
   Petition for Writ of Certiorari, CVS Pharmacy, Inc. v. Doe, No. 20-1374 (U.S. Mar. 26,
   2021).

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   Windham v. Harris Cnty., 875 F.3d 229, 236 (5th Cir. 2017). “Plaintiffs
   ordinarily satisfy the knowledge element by showing that they identified their
   disabilities as well as the resulting limitations to [the covered] entity or its
   employees and requested an accommodation in direct and specific terms.”
   Smith, 956 F.3d at 317. “When a plaintiff fails to request an accommodation
   in this manner, he can prevail only by showing that ‘the disability, resulting
   limitation, and necessary reasonable accommodation’ were ‘open, obvious,
   and apparent,’ to the entity’s relevant agents.” Windham, 975 F.3d at 237. 6
           Establishing a prima facie case entitles a plaintiff to pursue equitable
   relief. Miraglia, 901 F.3d at 574. Compensatory damages, however, require
   a showing of intentional discrimination. Id. This circuit has declined to
   “delineate the precise contours” of intentional discrimination. Id. at 575. At
   a minimum, though, “intent requires that the defendant at least have actual
   notice of a violation.” Id.
           Francois expressly abandoned his claim for injunctive relief, so all that
   remains for us are his claims for declaratory relief, nominal damages, and
   compensatory monetary damages. Francois has not pressed on appeal that
   his claims for declaratory relief should survive even in the absence of
   intentional discrimination. 7 Likewise, he has made no attempt to argue that

           6
            We have not resolved “what type of knowledge is required” for a showing of an
   “open, obvious, and apparent” disability, limitation, and necessary reasonable
   accommodation. Windham, 975 F.3d at 237. “Although our caselaw speaks generally in
   terms of the entity’s subjective knowledge, we do not appear to have confronted this
   question directly.” Id. (footnote omitted).
           7
              On appeal, Francois’ briefs focus on two questions: (1) whether the Hospital
   committed intentional discrimination, and (2) whether he can pursue damages for “denial
   of self-determination.” A claim for declaratory relief is equitable in nature and not subject
   to the intentional-discrimination standard. See Miraglia, 901 F.3d at 574. Francois,
   however, has not pressed that his claims for declaratory relief (or equitable relief generally)
   are subject to a lower evidentiary burden, that the district court erred by dismissing those
   claims, and that we should reverse and remand on that ground. As they are not pressed on

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   his nominal-damages claims, if any exist, are not subject to the same
   intentional-discrimination standard as a claim for compensatory monetary
   damages. As a result, to survive summary judgment, Francois must have
   offered evidence of intentional discrimination, which as we just stated means
   he must at least show the Hospital’s actual notice. Miraglia, 901 F.3d at 574.
           The district court granted the Hospital’s motion for summary
   judgment because Francois failed to show intentional discrimination. A
   claim of intentional discrimination requires evidence sufficient for a
   reasonable jury to conclude that the Hospital had actual notice that its failure
   to provide an on-site interpreter until April 16 denied Francois an equal
   opportunity to participate in the medical process. We agree with the
   Eleventh Circuit that when “effective communication under the
   circumstances is achievable with something less than an on-site interpreter,
   then the hospital is well within its ADA and RA obligations to rely on other
   alternatives.” Silva v. Baptist Health S. Fla., Inc., 856 F.3d 824, 836 (11th
   Cir. 2017). Here, the claims of intentional discrimination fail unless there is
   evidence the Hospital actually knew that it was not effectively
   communicating with Francois with the methods it was using.
           We have affirmed a district court’s finding of intentional
   discrimination when a hearing-impaired arrestee could not understand the
   police officer, the officer was aware that his attempts to communicate were
   ineffective, and the officer failed to try more effective methods of
   communication. Delano-Pyle v. Victoria Cnty., 302 F.3d 567, 575–76 (5th Cir.
   2002). We have held in a non-precedential opinion that a plaintiff raised a
   genuine dispute of material fact where “on several occasions, an interpreter

   appeal, those arguments are forfeited. Adams v. Unione Mediterranea Di Sicurta, 364 F.3d
   646, 653 (5th Cir. 2004); see also United States v. Sineneng-Smith, 140 S. Ct. 1575, 1579
   (2020) (explaining that courts must “follow the principle of party presentation”).

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   was requested but not provided,” the hospital’s chosen means of
   communication were “often ineffective,” and the hospital “ignored clear
   indications” that further accommodation was necessary. Perez v. Drs. Hosp.
   at Renaissance, Ltd., 624 F. App’x 180, 185 (5th Cir. 2015). Most recently,
   we held that a plaintiff had shown intentional discrimination when a jail’s
   staff was subjectively aware of a detainee’s need for a wheelchair,
   accommodated her only with crutches, watched her fall while using the
   crutches, and still refused to provide a wheelchair. Cadena, 946 F.3d at 726.
          Accordingly, our intentional-discrimination cases turn on the
   defendant’s subjective awareness of the need for further accommodation.
   II.    Analysis of the summary-judgment evidence
          We now review the summary-judgment record.
          First, the testimony of Francois’ linguistics expert establishes, at
   most, constructive notice of Francois’ need for an on-site interpreter. The
   expert, Dr. Judy Shepard-Kegl, stated that “writing, lipreading, and speech”
   were “wholly inadequate for communication access” for Francois. She
   explained that it would be “wishful thinking on the part of the service
   providers” to assume that writing, lipreading, and speech were sufficient
   methods of communication, and that such an assumption was “evidence of
   how little communication was actually happening.” A reasonable jury could
   conclude from the expert’s testimony that the Hospital should have known
   that Francois needed further accommodation. What the Hospital should have
   known, though, is not evidence of actual notice.
          Second, evidence that Francois in fact did not understand the nurses’
   communications does not show that the Hospital (or its staff) knew that
   Francois was not understanding. By contrast, the nurses testified that
   Francois   appeared    to   understand     their   written     and   nonverbal
   communications. We do not suggest that the nurses’ testimony about

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   successful communication is enough to secure summary judgment. 8 Here,
   though, the record is devoid of evidence that the Hospital knew that its
   efforts to communicate with Francois were ineffective.
           Only Deemer testified as to some evidence that made the Hospital’s
   staff aware that Francois was not understanding. She testified that after a
   nurse wrote Francois a note, he “was just looking at her” because “he didn’t
   understand what she was saying.” She also testified that he “will draw up in
   his shoulders or flop his hands” when he does not understand but did not
   indicate whether this ever happened at the Hospital. This evidence, though,
   does not defeat the Hospital’s motion for summary judgment because there
   is no indication that the Hospital quit trying to communicate with Francois
   or that its efforts were ultimately unsuccessful. As a result, Deemer’s
   testimony does not constitute evidence that the Hospital actually knew that
   only an on-site interpreter would suffice.
           Third, Francois argues that his medical records show that the
   Hospital “knew Mr. Francois was not communicating effectively and
   nonetheless failed to summon or provide an ASL interpreter.” Several
   medical records do support that communications with Francois about his
   medical history were “limited.” The medical records also show, though,
   that Francois’ medical history was obtained by several methods short of
   bringing in an on-site interpreter, including writing questions on the

           8
              As the Eleventh Circuit explained, “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.” Silva, 856 F.3d at 835. Rather, the opportunity must focus on whether the
   plaintiff is receiving an equal opportunity to participate in the overall informational
   exchange. RA, 45 C.F.R. § 84.52(d)(1); ACA, 45 C.F.R. § 92.102(b). In this case, we must
   consider these statutory requirements in light of the additional burden that Francois show
   intent.

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   whiteboard, asking Francois’ grandmother about his medical history, and
   utilizing   Francois’     grandmother        for    ASL    interpretive     assistance.
   Accordingly, the records do not show that the Hospital actually knew that
   nothing short of an on-site interpreter was enough. Rather, the evidence
   shows only that, from the Hospital’s perspective, “effective communication
   under the circumstances [was] achievable with something less than an on-site
   interpreter.” Silva, 856 F.3d at 836.
           Fourth, Francois argues that the Hospital’s failure to comply with its
   internal policy is evidence of intent. 9 The policy mirrors the regulatory
   requirements in that an interpreter must be utilized only if “necessary.” See
   RA, 45 C.F.R. § 84.52(d)(1); ACA, 45 C.F.R. § 92.102(b). It follows that the
   Hospital did not violate the policy unless other methods were not effective.
   Ultimately, this argument fails because it does not dispute the otherwise-
   uncontroverted evidence that the Hospital’s staff believed that effective
   communication was achievable with something less than an on-site
   interpreter.
           Finally, Francois argues that Deemer made a satisfactory request for
   an interpreter. Deemer testified that she told hospital staff upon Francois’
   admittance that he “was speech and hearing impaired, and [that] he needed
   an interpreter.” Even with this evidence, the summary-judgment record falls
   short of establishing that the Hospital had actual knowledge that only an on-
   site interpreter would meet Francois’ needs. A patient is not entitled to an
   on-site interpreter merely because he or someone on his behalf requests one.

           9
            The policy states that “[i]nterpreter services will be provided in all necessary
   circumstances where there is a need for complex diagnostic or treatment information to be
   communicated effectively with a sensory-impaired patient.” It also states that
   circumstances which “may” require an interpreter include, among other things,
   “[d]iscussing presenting symptoms, medications, [and] medical history,” as well as
   “[e]xplaining diagnosis, prognosis[,] or treatment options.”

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   See Silva, 856 F.3d at 835–36. Rather, a patient is entitled to an on-site
   interpreter when necessary. RA, 45 C.F.R. § 84.52(d)(1); ACA, 45 C.F.R.
   § 92.102(b). The morning after Deemer made the request, the Hospital sent
   an employee who communicated in ASL to Francois’ room. During that
   meeting, Francois never asked for an interpreter in response to a direct
   question about the services he needed. Later, when another request was
   made, the Hospital promptly provided an ASL interpreter and continued to
   do so throughout Francois’ hospital stay.         Considered along with the
   evidence showing that the Hospital’s staff subjectively believed that they
   were adequately communicating with Francois via other means, the record
   does not support a finding of intentional discrimination.
          The summary-judgment evidence, viewed in the light most favorable
   to Francois, is sufficient for a reasonable jury to determine that the Hospital
   should have known that Francois needed an on-site interpreter. Fatal to
   Francois’ claims, the evidence is not sufficient for a reasonable jury to
   determine that the Hospital had actual knowledge of Francois’ need for an
   on-site interpreter.
          The Hospital is entitled to summary judgment because Francois failed
   to make a summary-judgment showing of intentional discrimination.
   Francois has made no attempt to argue in this appeal or in district court that
   his nominal-damage claims, if any exist, are not subject to the same
   intentional-discrimination standard.       Further, Francois has expressly
   abandoned his claims for injunctive relief and has not pressed his claim for a
   declaratory judgment on appeal. AFFIRMED.

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