Robertson v. Wexford Health Services

CourtDistrict Court, S.D. Illinois
DecidedMarch 28, 2025
Docket3:22-cv-00750
StatusUnknown

This text of Robertson v. Wexford Health Services (Robertson v. Wexford Health Services) is published on Counsel Stack Legal Research, covering District Court, S.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Robertson v. Wexford Health Services, (S.D. Ill. 2025).

Opinion

UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF ILLINOIS

SHAUNTAE ROBERTSON, ) ) Plaintiff, ) ) vs. ) Case No. 3:22-cv-00750-GCS ) MICHAEL MOLDENHAUER, ) ) Defendant. ) )

MEMORANDUM & ORDER

SISON, Magistrate Judge:

In this suit under 42 U.S.C. § 1983, Shauntae Robertson, an inmate at the Illinois Department of Corrections (“IDOC”), claims that he experienced sudden shoulder pain while lifting weights at Menard Correctional Center (“Menard”) and received inadequate medical treatment for his pain. Defendant Michael Moldenhauer, a nurse practitioner at Menard, insists that the Eighth Amendment claim against him must be dismissed because he did not treat Plaintiff’s shoulder pain with deliberate indifference. The Court agrees and grants summary judgment in favor of Defendant Moldenhauer. FACTUAL BACKGROUND The following facts are taken from the record and presented in the light most favorable to Plaintiff, the non-moving party, and all reasonable inferences are drawn in his favor. See Ricci v. DeStefano, 557 U.S. 557, 586 (2009). A. Plaintiff’s Medical Records: Sometime in June 2021, while incarcerated at Menard, Plaintiff experienced a sudden pain in his shoulder while he was lifting weights during yard time. (Doc. 66-2, p. 1). He was seen by an LPN/CMT on June 24, 2021, for non-specific discomfort. Id. Plaintiff

reported pain in the right side of his chest and the front of his right shoulder. Id. He indicated the pain had begun approximately three to four weeks prior while he was doing bench presses of approximately 200 lbs. Id. He rated the pain an “8/10 when present.” Id. The LPN/CMT noted “deformity to upper right pectoral area” and gave Plaintiff 325 mg of Acetaminophen for 3 days and a referral to an MD or NP. Id. On July 6, 2021, Plaintiff was seen by Moldenhauer for his right shoulder pain.

(Doc. 66-1, p. 1; 66-2, p. 3). Plaintiff complained that it hurt when he placed his shirt over his head. (Doc. 66-1, p. 1-2; 66-2, p. 3). Moldenhauer noted that Plaintiff, who was cuffed, was able to complete all cuffed range of motion without difficulty. (Doc. 66-1, p. 1; 66-2, p. 3). He ordered chest and right shoulder X-rays for Plaintiff; he also prescribed 500 mg of Robaxin (a muscle relaxer) to be taken twice daily for two weeks, and 600 mg of

Ibuprofen to be taken three times a day for two weeks, as needed. (Doc. 66-1, p. 2; 66-2, p. 3). He further referred Plaintiff for a physical therapy evaluation. Id. Plaintiff was unable to receive X-rays as scheduled on July 29, 2021, due to his cell house being on lockdown. (Doc. 66-2, p. 3). His X-rays were rescheduled for August 25, 2021. (Doc. 66-2, p. 7-8).

On August 18, 2021, Plaintiff was seen by an RN for his shoulder pain. (Doc. 66-2, p. 5). He reported that, while doing bench presses in June 2021, he heard and felt a “pop” in his right shoulder, and, since then, there was a “lump” in his right chest. Id. The RN noted a “right chest/pectoral area palpable mass” that was “tender to touch, non-mobile, no discoloration, no redness,” but that Plaintiff’s motion in his right shoulder range of motion was normal, and his daily activities were unaffected by pain. Id. The RN

instructed Plaintiff to avoid weightlifting with his right arm and shoulder, pushups, and pull-ups, referred him to an MD/NP, and continued his 325 mg of Acetaminophen. Id. Plaintiff was assessed by a physical therapist the following day. (Doc. 66-2, p. 6). Upon evaluation, the physical therapist noted that Plaintiff appeared to have a significant pectoral major tear. Id. The physical therapist discontinued physical therapy and referred Plaintiff back to an MD/NP for an orthopedic evaluation. Id.

On August 25, 2021, Plaintiff received x-rays for his right shoulder and chest. (Doc. 66-2, p. 7-8). The x-rays revealed a “high riding humerus and mild osteoarthritis of the AC and glenohumeral joints” but showed no acute bony fracture in the right shoulder region. Id. at p. 8. The chest views showed clear lungs and normal cardio mediastinal silhouette. Id. The radiologist found no active disease. Id.

On August 30, 2021, Plaintiff was seen by Dr. Tawanna King for his right chest and shoulder pain. (Doc. 66-2, p. 2). Dr. King agreed with the physical therapist’s assessment that Plaintiff had a “complete tear of pectoral muscle.” Id. at p. 2, 9-10, 11. Dr. King referred Plaintiff for a right chest MRI; she also noted that he would most likely need a referral to an orthopedist depending on the MRI findings. Id. at p. 9. Dr. King renewed

Plaintiff’s Robaxin but did not prescribe new pain medications; she instructed him to avoid upper extremity and chest strengthening exercises. Id. Defendant Moldenhauer reviewed Plaintiff’s x-ray results on September 7, 2021, and concluded the results were normal or stable because “the x-rays did not show bony fractures, and the radiologist’s impression (diagnosis) was that there was ‘no active disease.’” (Doc. 66-1, p. 2; 66-2, p. 13).

On September 23, 2021, Plaintiff was admitted to the emergency department at Chester Memorial Hospital (“Memorial Hospital”) for acute gastroenteritis. (Doc. 66-2, p. 103). Plaintiff complained of abdominal pain, nausea, and “muscle pain from an injury in June 2021[,]” but denied having chest pain. Id. Upon his return to Menard the following day, he reported to a nurse that he felt “so much better” and had “no complaints at this time.” Id. at p. 51.

Plaintiff received a chest MRI on October 27, 2021. (Doc. 66-2, p. 20-22). On November 17, 2021, Defendant Moldenhauer noted that Plaintiff had been scheduled for medical furlough review for evaluation of his shoulder, but that no documents regarding that visit had been received. (Doc. 66-1, p. 2; 66-2, p. 23). Two days later, Plaintiff was seen by an MD for sharp left chest pain and was

transferred to the emergency room at Memorial Hospital. (Doc. 66-2, p. 24-33). On November 23, 2021, at a follow-up visit at Menard, Plaintiff noted that his left-side chest pain had since improved, and his EKG test showed normal results. Id. at p. 27, 32. Plaintiff was scheduled for a follow-up call with a nurse regarding his shoulder MRI results. Id. at p. 25.

Plaintiff received his MRI results on January 21, 2022. (Doc. 66-2, p. 35). The results indicated a “tear of the distal myotendinous junction of the right pectoralis major with retraction and scarring . . . and overall appearance favoring a subacute to chronic injury.” Id. at p. 49. He was referred for an orthopedics consultation that same day. Id. at p. 36. However, on January 31, 2022, a medical furlough clerk noted that the orthopedist refused to see Plaintiff for the referral listed, cancelled the visit, and advised Plaintiff to

see a general surgeon. Id. at p. 38. Accordingly, Plaintiff was referred to a general surgeon consultation that same day. Id. On March 15, 2022, Plaintiff saw an LPN/CMT regarding his right shoulder pain, MRI results, and plans for pain management. (Doc. 66-2, p. 47). The LPN/CMT noted no redness in Plaintiff’s shoulder area or other signs of discomfort, prescribed 200mg of Ibuprofen for 3 days, and referred Plaintiff to an MD. Id.

On April 1, 2022, Plaintiff was referred to a cardiothoracic surgery consultation because the general surgeon had cancelled Plaintiff’s consultation and advised that Plaintiff needed to be referred to a cardiothoracic surgeon. (Doc. 66-2, p. 51). His evaluation was approved on April 7, 2022. Id. at 52. On April 10, 2022, Plaintiff reported to a nurse regarding chest pain with a pain

level of 8/10. (Doc. 66-2, p. 53). He complained that nothing relieved his pain, and deep breaths and palpitations intensified his pain. Id.

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Robertson v. Wexford Health Services, Counsel Stack Legal Research, https://law.counselstack.com/opinion/robertson-v-wexford-health-services-ilsd-2025.