Court Opinion

ID: 9410290
Source: CourtListenerOpinion
Date Created: 2023-07-20 19:00:47.437945+00
Date Added: 2024-06-11T17:20:56.573832
License: Public Domain

Case: 21-11134        Document: 00516827274             Page: 1      Date Filed: 07/20/2023

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

                                                                                       FILED
                                                                                     July 20, 2023
                                        No. 21-11134                             Lyle W. Cayce
                                                                                      Clerk

   Raul Garcia,

                                                                   Plaintiff—Appellant,

                                            versus

   City of Lubbock, Texas; Lubbock County, Texas; Mark
   Ellison; Joshua Conklin; Paul Cartwright;
   Christopher Mendez; Natalie Ybarra; M. Monzingo;
   Cleadon S. Bigham; Monica Lopez; Kelly Rowe; Dustin
   Hood; Laura Maldonado; Christopher Martinez,

                                                                Defendants—Appellees.

                     Appeal from the United States District Court
                         for the Northern District of Texas
                               USDC No. 5:20-CV-53

   Before Stewart, Dennis, and Higginson, Circuit Judges.
   Per Curiam:*
          Raul Garcia appeals the district court’s dismissal of his claims against
   numerous police officers and jail staff involved in his arrest and subsequent
   booking in Lubbock County (“the County”) jail. He sufficiently alleged an

         *
             This opinion is not designated for publication. See 5th Cir. R. 47.5.
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                                      No. 21-11134

   unconstitutional practice which demonstrates deliberate indifference under
   a failure-to-train theory by Sheriff Rowe, so we REVERSE the district
   court’s grant of qualified immunity as to him. Regarding the remaining police
   officers and jail staff, Garcia’s pleadings either fail to state a claim or they do
   not defeat qualified immunity. Therefore, we AFFIRM the district court’s
   dismissal of these parties.
          Garcia also appeals the district court’s summary judgment in favor of
   the County for alleged constitutional and Americans with Disabilities Act
   (“ADA”) violations. Because he does not create a genuine dispute of
   material fact on these claims, we AFFIRM.
                                 I.   Background
                                 A.     Garcia’s Arrest
          On May 18, 2018, the Lubbock Police Department (“LPD”) received
   a call from a United Supermarket reporting that a customer refused to leave.
   LPD Officers Mark Ellison and Joshua Conklin were sent to the scene. They
   arrived at the supermarket and found the store manager and Garcia standing
   outside in the entryway. Officer Ellison talked to the store manager to get his
   account of the events that had taken place while Officer Conklin engaged
   Garcia.
          Officer Conklin first asked Garcia if anyone could come pick him up
   or if he drove himself to the supermarket. He was unresponsive. He then
   asked Garcia where he lived, to which he stated, “down the street.” Garcia
   was in a fatigued state throughout the discussion but was able to tell Officer
   Conklin that he knew he was at a United Supermarket, although he was
   wrong about the specific location. Officer Ellison asked him how much he
   had to drink. He did not respond directly to Officer Ellison’s question,
   instead only nodding and shaking his head.

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          After questioning Garcia for some time and not receiving clear
   answers, the officers placed him in handcuffs. Officer Ellison’s body-camera
   footage shows that Garcia was wearing two silicone wristbands when he was
   handcuffed, but it is unclear whether there were any words on the wristbands
   or some other indicator that the bracelets were designed to alert others to a
   medical condition that Garcia suffered from. While Garcia was cuffed, the
   officers continued to question him and he was able to provide his full name
   and date of birth. Before placing him in their vehicle, the officers again asked
   if there was anyone that they could call to pick him up. He did not respond.
          Because the officers could not call anyone to pick Garcia up, Officer
   Ellison transported him to the Lubbock County Detention Center (the
   “LCDC”). Officer Ellison testified that, on the way to the detention center,
   Garcia fell asleep and had to be woken up. When they arrived, Officer Ellison
   called for assistance in removing him from the vehicle because he was
   uncooperative. The LCDC Response Team assisted him out of the vehicle
   and escorted him to a processing cell. Members of the LCDC staff testified
   that he appeared intoxicated, slurred his speech, and was unsteady on his
   feet. Sergeant Cartwright decided to temporarily bypass medical screening
   because he thought Garcia needed to sober up before he could answer the
   screening questions.
                 B.       Garcia’s Processing Following His Arrest
          After delivering Garcia to LCDC, Officer Ellison completed the arrest
   intake form and indicated that he did not believe that Garcia was at risk due
   to a medical condition. The form also indicated that Garcia was offered
   medical assistance but declined it. Laura Maldonado booked Garcia into the
   jail. After the booking process, he was placed in a processing cell, patted
   down, and was uncuffed. Maldonado then catalogued his property, but never
   included any medical bracelets in the inventory of his belongings.

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          Garcia was subsequently placed in his cell under close watch protocol,
   with LCDC staff Cleadon S. Bigham and Monica Lopez responsible for
   checking on him every fifteen minutes. After almost three hours, they
   discovered Garcia lying on his stomach and snoring loudly. Bigham stated
   that he and Sergeant Dustin Hood rolled him onto his side and called for
   medical assistance. Both medical staff and detention officers attempted to
   wake him, but he remained unresponsive. Emergency medical services were
   called, and he was transported to University Medical Center (“UMC”).
          UMC diagnosed Garcia with diabetic ketoacidosis, a life-threatening
   complication of diabetes. Lab tests at UMC confirmed that no alcohol or
   narcotics were present in his system. Garcia now alleges that he suffered
   complications and permanent effects because the County and its employees
   failed to treat his condition. He sued all parties involved in his arrest and jail
   booking.
                              C.      District Court Proceedings
          Garcia filed his Original Complaint on March 6, 2020. He alleged
   numerous civil rights violations under 42 U.S.C. § 1983. On April 2, 2020,
   the County, Sheriff Kelly Rowe, Sergeant Hood, and the jail employees
   (except Bigham, Mendez, and Lopez) moved to dismiss Garcia’s claims
   against them under Rule 12(b)(6). Bigham, Mendez, and Lopez later filed
   separate motions to dismiss on the same grounds. Officers Conklin and
   Ellison did not move to dismiss the claims against them, instead asserting the
   affirmative defense of qualified immunity. The district court granted all of
   the motions and dismissed Garcia’s suit with prejudice, but granted him
   leave to amend his failure-to-train claims against Rowe and Hood. 1

          1
              Garcia never amended his failure-to-train claims against Rowe and Hood.

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          The City of Lubbock (“the City”) and the County both moved for
   summary judgment and the district court granted their motions. Regarding
   the City, the district court reasoned that Garcia failed to raise a genuine
   dispute of material fact that: (1) there was a constitutional violation; (2) the
   officers acted with deliberate indifference; and (3) there was an official policy
   in place that resulted in a constitutional violation.
          As to the County, the district court held that Garcia failed to raise a
   genuine dispute of material fact that: (1) there was an official policy that
   resulted in a constitutional violation; (2) the detention officers were
   deliberately indifferent; (3) the officers were not adequately trained; or (4)
   the detention officers were aware of his medical condition prior to calling for
   emergency medical assistance. Garcia timely appealed.
          On appeal Garcia argues that the district erred in dismissing Rowe,
   Hood, Bigham, Mendez, Lopez, and the other individual employees under
   Rule 12(b)(6) and on qualified immunity grounds. He also asks that we
   reconsider the district court’s summary judgment in favor of the County. 2
                         II.    Standards of Review
                               A.      Motion to Dismiss
          We review dismissals under Rule 12(b)(6) de novo, “accepting all
   well-pleaded facts as true and viewing those facts in the light most favorable
   to the plaintiffs.” Littell v. Hous. Indep. Sch. Dist., 894 F.3d 616, 622 (5th Cir.
   2018). To survive a motion to dismiss, a plaintiff must plead “enough facts
   to state a claim to relief that is plausible on its face.” Bell Atl. Corp. v.
   Twombly, 550 U.S. 544, 570 (2007). “A claim has facial plausibility when the

          2
             Garcia does not appeal the district court’s summary judgment for the City,
   instead choosing only to pursue his claim against the County.

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   plaintiff pleads factual content that allows the court to draw the reasonable
   inference that the defendant is liable for the misconduct alleged.” Ashcroft v.
   Iqbal, 556 U.S. 662, 678 (2009).
                             B.       Summary Judgment
           “We review grants of summary judgment de novo, applying the same
   standard as the district court.” In re La. Crawfish Producers, 852 F.3d 456,
   462 (5th Cir. 2017). Summary judgment is appropriate when “there is no
   genuine dispute as to any material fact and the movant is entitled to judgment
   as a matter of law.” Davidson v. Fairchild Controls Corp., 882 F.3d 180, 184
   (5th Cir. 2018) (quoting Fed. R. Civ. P. 56(a)).
           “All reasonable inferences must be viewed in the light most favorable
   to the party opposing summary judgment, and any doubt must be resolved in
   favor of the non-moving party.” La. Crawfish Producers, 852 F.3d at 462. We
   may affirm “on any ground supported by the record, including one not
   reached by the district court.” Gilbert v. Donahoe, 751 F.3d 303, 311 (5th Cir.
   2014) (internal quotations and citation omitted).
                               III. Discussion
      A.      Defendants Dismissed Under Rule 12(b)(6) & Qualified Immunity
           The district court dismissed numerous defendants at the pleading
   stage, reasoning that Garcia either failed to state a claim or did not defeat the
   qualified immunity defense as to each defendant. Garcia argues that the
   district court’s determinations were erroneous. We disagree.
           “The Fourteenth Amendment guarantees pretrial detainees a right
   not to have their serious medical needs met with deliberate indifference on
   the part of the confining officials.” Dyer v. Houston, 955 F.3d 501, 506 (5th
   Cir. 2020). To succeed on a deliberate indifference claim, a plaintiff must
   demonstrate that: “(1) the official was ‘aware of facts from which the

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   inference could be drawn that a substantial risk of serious harm exists,’ and
   (2) the official actually drew that inference.” Id. (quoting Domino v. Tex.
   Dep’t of Criminal Justice, 239 F.3d 752, 755 (5th Cir. 2001)). We have
   recognized that “[d]eliberate indifference is an extremely high standard to
   meet.” Domino, 239 F.3d at 756.
                                  1.      Qualified Immunity
          Garcia challenges the district court’s dismissals of Rowe, Hood,
   Conklin, Ellison, Bigham, Lopez, Cartwright, Mendez, and Martinez
   (collectively “Appellees”) on qualified immunity grounds. 3 Specifically, the
   district court granted qualified immunity to: (1) Rowe and Hood for Garcia’s
   failure-to-train claim; (2) Conklin and Ellison for his false-arrest and
   deliberate-indifference claims; and (3) Bigham, Lopez, Cartwright, Mendez,
   and Martinez for his deliberate-indifference claim. In response, Appellees
   argue that Garcia has either inadequately briefed the issue of qualified
   immunity or failed to establish that they are not entitled to qualified
   immunity. We agree.
          Qualified immunity shields a public official “from suit when she
   makes a decision that, even if constitutionally deficient, reasonably
   misapprehends the law governing the circumstances she confronted.” Taylor
   v. Riojas, 141 S. Ct. 52, 53 (2020). “When a defendant invokes qualified
   immunity, the burden shifts to the plaintiff to demonstrate the inapplicability
   of the defense.” Club Retro LLC v. Hilton, 568 F.3d 181, 194 (5th Cir. 2009).
   To meet this burden, a plaintiff must plead specific allegations
   demonstrating: “(1) the violation of a constitutional right that (2) was clearly
   established at the time of the alleged misconduct.” Linicomn v. Hill, 902 F.3d
   529, 533 (5th Cir. 2018). “A clearly established right is one that is sufficiently

          3
              Garcia does not appeal the district court’s dismissal of Ybarra and Monzingo.

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   clear that every reasonable official would have understood that what he is
   doing violates that right.” Mullenix v. Luna, 577 U.S. 7, 11 (2015).
          In the failure-to-train context, we have explained that “[t]o
   establish § 1983 liability against supervisors, the plaintiff must show that: (1)
   the [supervisor] failed to supervise or train the officer; (2) a causal
   connection existed between the failure to supervise or train and the violation
   of the plaintiff’s rights; and (3) the failure to supervise or train amounted to
   deliberate indifference to the plaintiff’s constitutional rights.” Roberts v. City
   of Shreveport, 397 F.3d 287, 292 (5th Cir. 2005). Where a failure-to-train
   claim rests on an alleged pattern that amounts to deliberate indifference by
   city officials, a plaintiff must show a pattern “so common and well-settled as
   to constitute a custom that fairly represents municipal policy.” Peterson v.
   City of Fort Worth, 588 F.3d 838, 852 (5th Cir. 2009) (citation omitted).
                        i.      Sergeant Hood & Sheriff Rowe
          The district court initially held that Garcia established a failure-to-
   train claim against Hood and Rowe. But it granted them qualified immunity
   because he did not provide any instances of adjudicated liability that would
   have put Hood or Rowe on notice of constitutionally deficient behavior by
   their staff. It relied on another district court case in reaching this conclusion.
   See Dotson v. Edmonson, No.16-5371, 2018 WL 501512 (E.D. La. Jan. 22,
   2018). Garcia asserts that the district court’s reliance on Dotson was
   misplaced and led to an improper extension of qualified immunity. Instead,
   he avers that the proper inquiry is simply whether he has established “the
   existence of a pattern of tortious conduct by inadequately trained employees
   [that] may tend to show . . . the lack of proper training[.]” Bd. of Cty.
   Comm’rs of Bryan Cty. v. Brown, 520 U.S. 397, 407 (1997).
          Hood and Rowe make two arguments in response. First, Hood avers
   that Garcia’s brief fails to mention him during its failure-to-train analysis,

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   thus waiving Garcia’s claims against him. Second, they contend that even if
   Garcia has not waived his claims, he failed to adequately brief qualified
   immunity. While we agree that Garcia has inadequately briefed this issue as
   to Hood, we hold that he has done so sufficiently on Rowe.
          Beginning with Hood, Garcia has waived any claims he had against
   him because Garcia’s initial brief on appeal fails to mention or include him in
   its analysis. Garcia includes Hood’s name in the heading of his
   “Supervisory/Liability/Failure to Train” section. But his subsequent
   analysis never mentions Hood, Hood’s conduct, or what connects Hood to
   Rowe. Thus, Garcia cannot maintain that we should understand him to be
   analyzing the two individuals together. Because Garcia failed to argue
   Hood’s liability under a failure-to-train theory, he has waived the argument
   as to Hood. See Roy v. City of Monroe, 950 F.3d 245, 251 (5th Cir. 2020)
   (“Failure adequately to brief an issue on appeal constitutes waiver of that
   argument.”).
          Garcia’s failure-to-train claim against Rowe remains and warrants
   reversal of the district court’s grant of qualified immunity. The district court
   misconstrued Dotson and, in doing so, distorted Garcia’s burden to establish
   deliberate indifference and defeat qualified immunity. In Estate of Davis ex
   rel. McCully v. City of North Richland Hills, we thoroughly explained a
   plaintiff’s burden when alleging deliberate indifference in the supervisory-
   liability context:
               To succeed on his claim of failure to train or
               supervise[,] the plaintiff must demonstrate deliberate
               indifference, which usually requires a plaintiff to
               demonstrate a pattern of violations . . . [that is,] similar
               incidents in which the citizens were injured . . . Moreover,
               a showing of deliberate indifference requires that the
               [p]laintiff[] show that the failure to train reflects a

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               deliberate or conscious        choice     to    endanger
               constitutional rights.
   406 F.3d 375, 383 (5th Cir. 2005). We have stated that previously adjudicated
   instances of liability are helpful in determining whether a supervisor had
   notice of unconstitutional behavior by their staff. But we have never gone as
   far as holding that these instances are required for a plaintiff to prevail. See
   Davidson v. City of Stafford, 848 F.3d 384, 396 (5th Cir. 2017) (observing that
   Davidson provided “no evidence that any of the previous arrests resulted in
   subsequent litigation,” but continuing to analyze the validity of his alleged
   pattern).
          The district court correctly concluded that Garcia established a
   pattern of constitutionally deficient medical screening practices, thus
   demonstrating deliberate indifference, and defeating qualified immunity.
   The only portion of the district court’s reasoning that gives us pause is its
   determination that these deaths satisfy the similarity requirement. See
   Davidson, 848 F.3d at 396 (“A pattern requires similarity, specificity, and
   sufficiently numerous prior incidents.”). While his complaint does not
   expressly state that the ten deaths occurred in the pretrial detainee process—
   where his alleged violation happened—we still must construe these deaths in
   favor of his allegation that they establish “the existence of a pattern of
   tortious conduct by inadequately trained employees [that] may tend to
   show . . . the lack of proper training[.]” Brown, 520 U.S. at 407; Littell, 894
   F.3d at 622 (requiring that we view the “facts in the light most favorable to
   the plaintiffs”).
          Because Garcia inadequately briefed Hood’s liability under a failure-
   to-train theory, he has waived that claim as to him. But because he sufficiently
   pleaded a pattern that demonstrates deliberate indifference on behalf of
   Rowe, we reverse the district court’s grant of qualified immunity.

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                                  ii.      Conklin & Ellison 4
           Garcia asserts, for the first time in his reply brief, that Conklin and
   Ellison are not entitled to qualified immunity because they believed that he
   was drunk, and the law clearly establishes that officers may not simply put an
   intoxicated person with an obvious need for medical attention in a cell to
   detox. It is likely that this argument is waived because it was not made in his
   initial brief on appeal. See Wright v. Excel Paralubes, 807 F.3d 730, 736 (5th
   Cir. 2015) (“[T]his court will not consider issues raised for the first time in a
   reply brief.”).
           However, assuming arguendo that Garcia has not waived this
   argument, he has still failed to meet his burden. To prevail on his deliberate-
   indifference claim, he must show that Conklin and Ellison “kn[e]w of and
   disregard[ed] an excessive risk” to his safety. 5 See Garza v. City of Donna,
   922 F.3d 626, 636 (5th Cir. 2019) (holding that establishing civil liability
   requires a plaintiff to first show “that the municipal employee violated the
   pretrial detainee’s clearly established constitutional rights with subjective
   deliberate indifference”). For Garcia to make a successful claim, he must
   plead facts supporting that the officers knew he was intoxicated and
   disregarded an excessive risk to his safety.

           4
            Garcia sued Conklin and Ellison for false arrest at the district court, which granted
   them qualified immunity. He does not pursue this claim on appeal, so he has waived it. See
   Roy, 950 F.3d at 251.
           5
             Much has been made about the subjective prong of the deliberate indifference
   analysis in this court. See, e.g., Garza, 922 F.3d at 636 (collecting cases on the subjective
   requirement). In Garza, we clarified that the subjective inquiry in a deliberate indifference
   analysis focuses on the knowledge that a defendant has, not the defendant’s intent to cause
   harm. Thus, we only analyze: (1) what Officers Conklin and Ellison knew when they
   arrested Garcia and (2) whether they consciously disregarded an excessive risk despite this
   knowledge.

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           Here, the record does not support that Conklin or Ellison ever knew
   that Garcia was intoxicated. For example, the officers asked Garcia how
   much he had to drink, but he never provided a clear answer. Moreover, as
   Garcia concedes in his reply brief, the officers could not smell alcohol on him.
   Thus, they could not have known, without more, that he was drunk or
   otherwise intoxicated during his arrest. Because the officers were never
   certain of what ailed Garcia, they could not have “violated [his] clearly
   established rights with subjective deliberate indifference.” Garza, 922 F.3d
   at 636. Therefore, the district court correctly determined that Garcia failed
   to meet the required burden and that the officers were entitled to qualified
   immunity.
               iii.    Bigham, Lopez, Cartwright, Mendez, and Martinez
           Garcia asserts that Bigham, Lopez, Cartwright, Mendez, and
   Martinez (collectively “the jailors”) violated clearly established law from our
   decisions in Dyer and Thompson v. Upshur County by failing to get him medical
   attention during the booking process. See 955 F.3d at 506; 245 F.3d 447, 464
   (5th Cir. 2001). The district court dismissed the jailors from the suit on two
   grounds. It first held that Garcia only alleged that the jailors were negligent,
   which is insufficient to establish deliberate indifference. 6 It then explained
   that even if it was satisfied with Garcia’s pleadings on deliberate indifference,
   it would still grant the jailors qualified immunity. Consequently, it dismissed
   the jailors from this suit. We agree.
           Here, Garcia does not establish that the jailors’ failure to get him
   medical assistance amounted to deliberate indifference instead of negligence.

           6
             See Thompson, 245 F.3d at 459 (explaining that “deliberate indifference cannot be
   inferred merely from a negligent or even a grossly negligent response to a substantial risk
   of serious harm”).

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   He likewise fails to prove that the jailors are not entitled to qualified
   immunity. He maintains that the jailors’ failure to: (1) notice his medical
   bracelets; (2) check his cell every fifteen minutes; and (3) recognize he was
   suffering through a diabetic episode amounts to deliberate indifference.
   However, he provides no legal authority or facts in the record that support
   overturning the district court’s determination that the jailors’ conduct was
   simply negligent. At best, he alleges gross negligence by the jailors. But that
   is not enough to carry his burden. See Thompson, 245 F.3d at 459.
          Garcia also reargues that Dyer and Thompson provide a basis for
   denying the jailors qualified immunity. But we can only find support in those
   cases by viewing them at a high level of generality—a task that the Supreme
   Court has expressly instructed we avoid. See City of Tahlequah v. Bond, 142
   S. Ct. 9, 11 (2021) (instructing appellate courts “not to define clearly
   established law at too high a level of generality”). Viewing these cases
   narrowly, we hold that the jailors are entitled to qualified immunity.
          In Dyer, we held that the paramedics were only negligent when they
   arrived at a scene, observed a victim’s “serious head injury” and “LSD-
   induced behavior,” yet still did not provide additional medical care—“such
   as sending [the victim] to the hospital, accompanying him to jail, providing
   further assessment or monitoring, or sedating him.” See 955 F.3d at 506–07
   (internal quotations omitted). And in Thompson we denied summary
   judgment on qualified immunity grounds because a question of fact existed
   as to whether the defendant, Sergeant Whorton, acted with deliberate
   indifference to a pretrial detainee’s self-sabotaging behavior and intoxicated
   status. See Thompson, 245 F.3d at 463–64 (noting that “1) Thompson’s blood
   alcohol level was over 0.3% when he was arrested; 2) Thompson was
   hallucinating and, at times, speaking incoherently; 3) Thompson was injuring
   himself in his cell; and 4) Thompson was experiencing [delirium tremens]”).

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          On this record, the jailors did not observe and ignore any serious
   external injuries to Garcia, like in Dyer. Nor did they fail to obtain medical
   assistance for him after they were certain that it was necessary, like in
   Thompson. Accordingly, even if we held that the jailors’ negligence was
   comparable to deliberate indifference, neither Dyer nor Thompson provide an
   adequate basis for denying the jailors qualified immunity because those cases
   do not establish that the jailors acted objectively unreasonable or violated
   clearly established law. Therefore, we affirm the district court’s dismissal of
   the jailors.
                           2.      Failure to State a Claim
                                  i.      Maldonado
          The district court dismissed Maldonado from Garcia’s suit because
   he failed to state a claim for deliberate indifference against her. He challenges
   that determination, arguing that Maldonado violated his Fourteenth
   Amendment rights by ignoring his obvious need for medical attention
   throughout the booking process. We are unpersuaded.
          Garcia anchors his deliberate-indifference claim against Maldonado
   on her alleged failure to account for his medical bracelets as she began his
   booking process at the jail. He avers that she “ignored the medical alert
   bracelets, ignored the obvious signs of serious medical need, and bypassed
   medical screening.” To him, all of Maldonado’s decisions amounted to an
   intentional decision to avoid “obtain[ing] medical assistance” when he
   clearly needed it. Maldonado disputes that she ever saw medical bracelets
   when doing his initial processing into the jail. However, given that we are at
   the Rule 12(b)(6) stage, we accept his allegation as true in our analysis. See
   Littell, 894 F.3d at 622.
          Here, Garcia fails to establish that Maldonado was deliberately
   indifferent to his medical needs. As the district court aptly explained:

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              There are few cases—none of which Garcia cites—
              involving the application of deliberate-indifference
              claims to facts involving the removal of medical alert
              bracelets, and none of the cases permits the [district
              court] to indulge Garcia’s ‘unwarranted factual
              inference’ that the alleged presence and removal of
              Garcia’s medical bracelets indicates that Maldonado
              actually drew the inference that the failure to promptly
              seek medical treatment for Garcia presented a
              substantial risk of serious harm to him.
   One of those few cases grappling with a plaintiff’s medical bracelets and the
   deliberate indifference standard is Partridge v. Two Unknown Police Officers of
   the City of Houston, 791 F.2d 1182, 1184 (5th Cir. 1986). In that case, we held
   that a plaintiff sufficiently alleged facts demonstrating that officers were
   deliberately indifferent to his deceased son’s mental-health condition by
   disregarding his medical bracelets and placing him alone in a cell where he
   eventually hanged himself. Id. The plaintiff told the officers of his son’s
   mental-health problems and the medical bracelets served to supplement that
   knowledge. See id. We held that the officers’ decision to place his son in
   solitary confinement despite the two medical bracelets indicating “heart and
   mental” struggles and explanation of those same struggles by the plaintiff
   amounted to deliberate indifference to the son’s psychological needs. Id.
          Partridge provides little support to Garcia’s position. To begin with,
   he does not allege that he ever informed Maldonado of his medical condition.
   Nor has he pleaded facts that suggest she should have known from the
   existence of his bracelets that he was suffering from a diabetic episode during
   the booking process. Furthermore, even if we hold that she was on notice of
   a potential medical need from Garcia’s bracelets, he has still failed to
   demonstrate that the mere existence of the bracelets created an issue of fact
   as to a substantial risk of serious harm that she ignored when processing him.
   See Dyer, 955 F.3d at 506. Therefore, he has failed to state a deliberate-

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   indifference claim against Maldonado and the district court properly
   dismissed her.
                         B.        The County’s Summary Judgment
           Garcia contests the district court’s grant of summary judgment on his
   conditions-of-confinement and ADA claims against the County. 7 We address
   each in turn.
                              1.       Conditions of Confinement
           Garcia avers that Rowe’s testimony details a de facto policy of leaving
   intoxicated detainees in detox cells. He contends that the County’s failure to
   medically screen him, provide him with medical treatment, and properly
   monitor his condition once celled, amounts to a violation of his Fourteenth
   and Eighth Amendment rights. The district court rejected his assertions,
   granting summary judgment to the County because he failed to prove the
   existence of a de facto policy. We agree.
           Constitutional claims by pretrial detainees can take two forms: (1)
   conditions of confinement or (2) episodic acts or omissions. 8 See Garza, 922
   F.3d at 632. “A condition of confinement case is a constitutional attack on

           7
             Garcia advanced two more arguments in addition to conditions of confinement
   and violation of the ADA at the district court: An episodic-acts-or-omissions claim and a
   failure-to-train claim. He has expressly abandoned his episodic-acts-or-omissions claim.
   Also, he failed to brief his failure-to-train claim on appeal, so he has waived that argument.
   See Roy, 950 F.3d at 251.
           8
             Appellees argue that this case is better characterized as an episodic-acts-or-
   omissions claim, contending that Garcia incorrectly directs our focus to conditions of
   confinement. We take no stance on which theory best characterizes Garcia’s claims
   because he advanced both theories before the district court. His decision to only appeal one
   of those theories is entirely at his discretion. See Estate of Henson v. Wichita Cty., 795 F.3d
   456, 464 (5th Cir. 2015) (“[T]here is no rule barring a plaintiff from pleading both
   alternative theories, and a court may properly evaluate each separately.”).

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   general conditions, practices, rules, or restrictions of pretrial confinement.”
   Scott v. Moore, 114 F.3d 51, 53 (5th Cir. 1997) (internal quotations and citation
   omitted). To prevail on this claim, a plaintiff must “prove (1) a rule or
   restriction or . . . the existence of an identifiable intended condition or
   practice . . . [or] that the jail official’s acts or omissions were sufficiently
   extended or pervasive; (2) which was not reasonably related to a legitimate
   governmental objective; and (3) which caused the violation of [the
   detainee’s] constitutional rights.” Duvall v. Dallas Cty., 631 F.3d 203, 207
   (5th Cir. 2011) (first alteration in original) (internal quotations and citations
   omitted).
          We have explained that “[a] formal, written policy is not required to
   establish a condition or practice.” Montano v. Orange Cty., 842 F.3d 865, 875
   (5th Cir. 2016). More specifically, we have recognized that sometimes “a
   condition may reflect an unstated or de facto policy, as evidenced by a pattern
   of acts or omissions sufficiently extended or pervasive, or otherwise typical
   of extended or pervasive misconduct by [jail] officials, to prove an intended
   condition or practice.” Shepherd v. Dallas Cty., 591 F.3d 445, 452 (5th Cir.
   2009) (internal quotations and citation omitted) (alteration in original)
   (emphasis omitted). Put differently, if the policymakers are aware that
   officials routinely ignore the governing written policy, that may be evidence
   of an alternative policy’s existence. “Proving a pattern is a heavy burden, one
   that has rarely been met in our caselaw.” Shepherd, 591 F.3d at 452.
          Garcia does not argue that the County had a written policy that
   created the conditions he purports to sue for in this appeal. Rather, he limits
   his argument to the existence of a de facto policy that permits booking and
   processing employees to avoid medically screening intoxicated people. He
   contends that Rowe’s testimony details this alleged de facto policy and
   proves that skipping medical screenings for intoxicated people was the usual
   practice for all pretrial detainees in the booking process. He relies on Montano

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   in support of his position. See 842 F.3d at 875. This argument is without
   merit.
            Here, Garcia fails to create a genuine dispute of a material fact
   regarding the existence of an unconstitutional de facto policy in the County’s
   booking process. First, his reliance on Montano is misplaced. In that case, we
   held that Orange County had an unconstitutional de facto policy of leaving
   pretrial detainees in cells to detox “for as long as it t[ook]” the detainee to
   sober up. Montano, 842 F.3d at 875. That Orange County left detainees in
   detox cells was not the primary issue—in fact, there was a written policy
   permitting to place intoxicated detainees in these cells. Rather, the issue was
   whether the jail staffs’ practices adhered to the written policy—we
   concluded that it did not. We reached this determination after analyzing
   extensive testimony from the jailors, who testified to leaving detainees in
   detox cells for days at a time, despite the existence of a written policy
   prohibiting doing so. Id. at 875–76 (observing that “[t]he county’s de facto
   policy is even at odds with its own written policy . . . [which] provides [that]
   corrections staff should attempt to use a guideline of four to eight hours for
   detoxification” (internal quotations omitted)).
            Garcia asserts that the County’s de facto policy of leaving detainees in
   cells until they detox is, by itself, a violation sufficient for holding in his favor.
   But his understanding fundamentally misconstrues what we considered and
   held in Montano. There, Orange County’s written policy permitted holding
   pretrial detainees in detox cells for “four-to-eight hours.” Id. at 875. We
   never declared that policy unconstitutional. Instead, we recognized that
   Orange County’s employees adhered to a different policy—one where
   officers left detainees in detox cells for days at a time. We explained that this
   unconstitutional practice supplanted the written policy. Applied here,
   Montano cannot be Garcia’s only basis for a constitutional violation because,

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   despite his assertions to the contrary, that case does not prohibit the County
   from using detox cells for short durations. See id.
          Even if we accept that Garcia is correct about the County’s practice
   of using cells to hold detainees until they detox, he has not pleaded that he
   was detained for a constitutionally deficient amount of time. See id. at 875.
   Ultimately, our decision in Montano does not bar the use of detox cells
   entirely, but merely acknowledges that a stopping point for detaining
   intoxicated persons exists. Garcia spent three hours in the County’s detox
   cell—an amount of time we did not hold unacceptable in Montano. See id.
          Garcia’s reliance on Rowe’s testimony is similarly unpersuasive.
   True, Rowe commented on whether other intoxicated detainees were held in
   a cell to sober up before processing, and even admitted that its occurrence
   was not “abnormal.” But that hardly meets the heavy burden of proof that
   Garcia carries here. Ultimately, all Rowe admitted is that “there have been
   some instances” where pretrial detainees have been taken directly to a
   holding cell, and that “under some circumstances” it was necessary to place
   them in jail cells prior to booking and processing. A vague string of one-off
   occurrences is not indicative of the County’s practice for all pretrial
   detainees.
          Garcia also failed to acknowledge that Rowe testified that he did not
   receive medical treatment, at his own request. The County provided a Jail
   Incident Report which stated that Officer Cartwright asked “Garcia if he
   wanted to speak to Medical Staff and he stated, [n]o.” He cannot maintain
   that he was the victim of an unconstitutional practice when there is an
   independent, constitutional basis for his not receiving medical attention
   before he was discovered in critical condition in his cell. Because Garcia failed
   to prove that there is a genuine dispute of a material fact regarding the

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   constitutionality of the County’s pretrial detention policies and practices, we
   affirm the district court’s grant of summary judgment.
                               2.     ADA Violations
          Garcia makes two ADA claims: (1) that the County failed to
   accommodate his disability and (2) that it discriminated against him because
   of his disability. Regarding his latter argument, he asserts that his condition
   was the cause of the County’s decision to not provide him a medical
   evaluation or screening. The district court rejected his contentions, granting
   summary judgment to the County because he failed to provide evidence that
   the County ever knew of his medical condition. We see no error in its
   decision.
          Title II of the ADA provides that “no qualified individual with a
   disability shall, by reason of such disability, be excluded from participation in
   or be denied the benefits of the services, programs, or activities of a public
   entity, or be subjected to discrimination by any such entity.” See 42
   U.S.C. § 12132. To make a prima facie case under the ADA, a plaintiff must
   demonstrate: (1) “that he is a qualified individual within the meaning of the
   ADA”; (2) “that he is being excluded from participation in, or being denied
   benefits of, services, programs, or activities for which the public entity is
   responsible, or is otherwise being discriminated against by the public entity”;
   and (3) “that such exclusion, denial of benefits, or discrimination is by reason
   of his disability.” Windham v. Harris Cty., 875 F.3d 229, 235 (5th Cir. 2017)
   (internal quotations and citation omitted).
          A failure-to-accommodate claim requires a plaintiff to prove that: “(1)
   he is a qualified individual with a disability; (2) the disability and its
   consequential limitations were known by the covered entity; and (3) the
   entity failed to make reasonable accommodations.” Ball v. LeBlanc, 792 F.3d
   584, 596 n.9 (5th Cir. 2015) (internal citation omitted). “To satisfy the

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   knowledge requirement, the entity must understand the limitations a plaintiff
   experience[s] as a result of his disability.” Valentine v. Collier, 993 F.3d 270,
   290 (5th Cir. 2021) (emphasis in original). Additionally, we have explained
   that the “burden falls on the plaintiff to identify the disability, the limitations,
   and to request an accommodation in direct and specific terms.” Id. (citation
   omitted). Where a plaintiff fails to meet his burden, he may only prevail by
   showing that his “disability, resulting limitations, and necessary reasonable
   accommodation were open, obvious, and apparent to the entity’s relevant
   agents.” Id. (citing Windham, 875 F.3d at 237) (internal quotations omitted).
          Garcia dedicates much of his brief to the first element—that diabetes
   qualifies as a disability under the ADA. The County does not refute that
   element and instead argues that its employees never knew that he suffered
   from diabetes. It avers that because it never knew of his disability, it could not
   have discriminated against him on the basis that he was disabled or provided
   accommodations. In response, Garcia asserts that his disability was open,
   obvious, and apparent because of his inability to walk or communicate. He
   maintains that because his limitations were known, his need for
   accommodations was readily apparent. We disagree.
          Here, Garcia fails to provide sufficient evidence to avoid summary
   judgment on his ADA claims. His Title II and failure-to-accommodate claims
   share a common element: the County’s knowledge of his disability. Garcia
   points to no evidence suggesting that the County knew of his disability, used
   it to discriminate against him, or failed to accommodate him. Instead, he
   makes conclusory statements about the County’s alleged knowledge of his
   diabetic condition. But each statement is easily dispelled after considering the
   record. For example, he relies on the existence of his medical bracelets, but
   fails to prove that the bracelets alerted anyone to his diabetic condition, or
   even that they would have suggested a medical condition at all. Moreover,
   the record establishes the officers’ confusion about whether he was drunk or

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                                          No. 21-11134

   suffering from a medical condition. 9 Absent proof that someone from the
   County had knowledge of his disability, he cannot establish that they
   discriminated against him because of it or failed to accommodate him.
           Likewise, Garcia’s contention that his condition at arrest and
   throughout the booking process made his disability open, obvious, and
   apparent is unpersuasive. We have explained that the open-and-obvious
   exception is “narrow.” Windham, 875 F.3d at 239. Garcia cites no authority
   to support application of this exception, but a brief survey of our precedent
   confirms its inapplicability. Consider our decision in Delano-Pyle v. Victoria
   Cty., 302 F.3d 567, 575–76 (5th Cir. 2002). There, we upheld a jury’s finding
   of disability discrimination when two officers arrested a deaf person, Pyle. Id.
   Notably, we did not apply the open-and-obvious exception simply because he
   was deaf. We, instead, applied the exception because the officers testified to
   communicating his rights and other commands orally while being aware of
   his hearing impediment. Id. In fact, one of the officers stated that he “knew
   [Pyle] had a hearing problem,” yet continued only communicating with him
   through oral instructions. Id. Simply put, the officers’ attempts to
   communicate critical rights to someone they understood to be deaf plainly
   violated the ADA.
           Unlike in Delano-Pyle, the record shows that none of the officers ever
   believed or understood Garcia’s symptoms to stem from diabetes or any
   other ADA-approved disability. Furthermore, his outwardly visible
   mannerisms did not suggest that he suffered from the type of disability that

           9
             Garcia cannot deny the officers’ confusion because he relies on it at various times
   throughout his briefing on appeal. For example, his deliberate-indifference claims against
   numerous officers and the jailors hinge on the fact that these defendants made a deliberate
   choice to put someone either suffering from a medical condition or intoxicated in a cell to
   detox for a lengthy period.

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   would put an officer on notice to accommodate him. See Windham, 875 F.3d
   at 238 (providing that “blindness, deafness [with a hearing aid], or being
   wheelchair-bound” are “well-understood” examples of open-and-obvious
   disabilities). Because he fails to identify evidence that the County knew of his
   diabetic status and because his disability was not open and obvious, we affirm
   the district court’s summary judgment.
                              IV.     Conclusion
          For the foregoing reasons, we REVERSE the district court’s
   dismissal of Rowe and AFFIRM its judgment dismissing the remaining
   Appellees and granting summary judgment to the County.

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