Felicia Robinson, et al. v. Canton Harbor Healthcare Center, Inc., No. 2169, September 

Term, 2022, filed April, 24, 2024. Opinion by Beachley, J.

HEALTH CLAIMS ARBITRATION ACT – CERTIFICATE OF QUALIFYING 

EXPERT – CAUSATION – PRESSURE ULCERS

Facts: In the Circuit Court for Baltimore City, the wife and children of decedent, 

Everett Robinson, filed a medical malpractice claim against Canton Harbor Healthcare 

Center, a skilled nursing facility. With their complaint, the Robinsons provided a 

certificate of qualifying expert (“CQE”). The CQE was authored by a registered nurse, 

who opined both that Canton Harbor breached the standard of care for skilled nursing 

facilities and that this breach caused Mr. Robinson to develop pressure ulcers. Canton 

Harbor moved to dismiss the complaint, arguing that a registered nurse is not qualified to 

provide an opinion on medical causation. The circuit court agreed and dismissed the 

complaint. The Robinsons then appealed.

Held: Reversed.

After reviewing the statutory and regulatory framework, the Appellate Court held 

that, in a case against a skilled nursing facility alleging pressure ulcer injury, a nurse with 

sufficient training and experience can attest to the cause of a patient’s pressure ulcer injury 

in a CQE. CJP § 3-2A-02 provides that a “health care provider” may serve as the expert 

in a CQE. Registered nurses are included in the statutory definition of “health care 

provider.” Various Maryland and federal statutes and regulations relating to RNs and 

skilled nursing facilities indicate that the prevention and treatment of pressure ulcers are 

tasks entrusted primarily to nursing staff. Furthermore, COMAR 10.27.09.02 provides that 

the functions of registered nurses include nursing diagnosis, developing a plan of care that 

prescribes interventions to achieve expected outcomes, and revising the plan of care based 

on the effectiveness of the interventions. Together, these statutes and regulations indicate 

that a sufficiently experienced and trained RN may qualify as an expert on the cause of 

pressure ulcers.
Circuit Court for Baltimore City

Case No.: 24-C-22-001200

REPORTED

IN THE APPELLATE COURT 

OF MARYLAND

No. 2169

September Term, 2022

FELICIA ROBINSON, ET AL.

v.

CANTON HARBOR HEALTHCARE 

CENTER, INC.

Arthur,

Beachley,

Eyler, Deborah S.

 (Senior Judge, Specially Assigned),

JJ.

Opinion by Beachley, J.

Filed: April 24, 2024
In this appeal from the dismissal of a complaint against a skilled nursing facility 

under Maryland’s Health Care Malpractice Claims Act (the “HCMCA”), alleging 

negligent failure to prevent and treat decubitus ulcers, we resolve a question of first 

impression by holding that the statutorily required certificate of qualified expert (“CQE”) 

may be predicated on a proximate cause attestation from a registered nurse (“RN”), rather 

than a physician. See Md. Code (1974, 2020 Repl. Vol.), § 3-2A-04 of the Courts &

Judicial Proceedings Article (“CJP”).

As personal representative of her late husband Everett Robinson’s estate, and in her 

capacity as his survivor, Felicia Robinson, appellant, sued Canton Harbor Healthcare 

Center, Inc., appellee (“Canton Harbor”), where Mr. Robinson was an inpatient for 

approximately five months following his hospitalization for a stroke.1

 Mrs. Robinson 

alleged that this skilled nursing facility was negligent in its care of her husband, causing 

him to suffer injuries from decubitus (or pressure) ulcers. 

The Circuit Court for Baltimore City dismissed her complaint, ruling that a 

registered nurse is not qualified to attest to proximate causation for the purpose of 

satisfying Maryland’s statutory requirement that “[a] person having a claim against a health 

1 Mr. Robinson’s surviving children, Sharetta Moyd, Jason Blake, and Everett B. 

Robinson, III, also sued and appeal from the judgment dismissing their claims. We note, 

however, that Mrs. Robinson and the surviving children later abandoned their claim for 

wrongful death. See generally Spangler v. McQuitty, 449 Md. 33, 53 (2016) (“The 

wrongful death statute allows the decedent’s beneficiaries or relatives to recover damages 

for loss of support or other benefits that would have been provided, had the decedent not 

died as a result of another’s negligence.”); CJP § 3-904(a)(1)-(b). Thus, this appeal 

involves only the circuit court’s dismissal of the survival claim alleged by Mrs. Robinson 

in Count One of the complaint.
2

care provider for damage due to a medical injury” must timely file a CQE “attesting to 

departure from standards of care, and that the departure from standards of care is the 

proximate cause of the alleged injury[.]” See CJP § 3-2A-04(a)(1)(i), (b)(1)(i). The court 

also denied Mrs. Robinson’s request for leave to amend her CQE and complaint, effectively 

foreclosing any further relief given the expiration of limitations.

Interpreting Maryland’s statutory language in light of its purpose and related 

regulations, we conclude that in a medical negligence case alleging ulcer injury, a CQE 

may be predicated on a proximate causation attestation by a registered nurse with sufficient 

education and experience in skilled nursing standards for preventing and treating pressure 

ulcers.2

 Because Mrs. Robinson’s CQE is sufficient based on the certifying registered 

nurse’s expertise, the Circuit Court for Baltimore City erred in dismissing this action. 

Consequently, we will vacate the judgment and remand for further proceedings. 

BACKGROUND

The Complaint and Certificate of Qualified Expert

On March 7, 2022, Felicia Robinson, as personal representative of the Estate of 

Everett Robinson and as his surviving widow, filed a complaint against Canton Harbor. 

She alleged that Mr. Robinson was admitted to this long-term care facility “after being 

transferred from Johns Hopkins Hospital for follow up care due to a stroke.” “During his 

admission, the deceased developed left leg ulcers which were brought to the attention of 

2 As we explain, our holding is narrow. Although we conclude that the registered 

nurse in this case may certify that a breach in the standard of care caused ulcer injury to 

Mr. Robinson, we express no opinion concerning a nurse’s qualifications to attest to the 

causation of other injuries, including death.
3

the facility in which [he] should have been properly treated and care[d] for.” Yet “[t]he 

bedsores were allowed to develop and spread to the buttocks area as well as the inner 

thigh.” “As a direct and proximate result of the Defendant’s neglect,” Mrs. Robinson 

contended, “the areas became infected and deceased was transferred and received further 

treatment and care for his condition at other facilities[;] however, this condition worsened 

and he became septic and died.” Canton Harbor allegedly “breached the standard of care 

by failing to proper[ly] turn the deceased, failure to do proper skin checks, failure to 

respond to complaint[s] about the pressure ulcers and was otherwise negligent.”

In Count One, Mrs. Robinson alleged that “[a]s a direct and proximate result, the 

deceased suffered pain, incurred medical bills and the Estate incurred funeral expenses.” 

In Count Two, she and Mr. Robinson’s three surviving children alleged that “[a]s a result 

of the negligence” by Canton Harbor, they “suffered and continue to suffer enormous grief, 

sadness, and emotional pain and suffering as a direct and proximate result of the wrongful 

death and were otherwise injured and damaged.” Mrs. Robinson and her children later 

abandoned their wrongful death claim.

Canton Harbor was served with the complaint and corresponding documents, 

including a CQE in which a registered nurse, Anjanette Jones-Singh, attested:

1. I am a registered nurse and am familiar with and knowledgeable of the 

standards of care applicable to the treatment and care of an individual under 

the circumstances of the treatment and care as provided to Everette [sic] 

Robinson in this matter.

. . .

3. I have reviewed the pertinent medical records pertaining to the deceased’s 

treatment and care.
4

4. In my opinion to a reasonable degree of medical certainty [Canton Harbor] 

breached the standard of care and the breach was the proximate cause of Mr. 

Robinson’s injuries, i[.]e., the development of his pressure ulcers.

5. I hereby incorporate my report herein dated September 7, 2021.

Consequently, we next examine the contents of Jones-Singh’s detailed report.

Jones-Singh’s Affidavit and Report

Jones-Singh prepared a 19-page report and affidavit, reviewing Mr. Robinson’s care 

at Canton Harbor, where “he was completely dependent for care” and unable to either 

communicate effectively or move independently. Jones-Singh had been a registered nurse 

for over sixteen years, during which she had “routinely perform[ed] skin evaluations on 

[her] patients, identified pressure ulcers, classified the staging[3] of each ulcer and proposed 

a treatment and care plan to heal the ulcer” for more than “500 patients.” She had “worked 

as a wound care nurse . . . at Arcola Nursing and Rehabilitation Center,” from 2006-2008, 

during which she “routinely diagnosed the cause of pressure ulcers.” In her current position 

as “a long-term care Director of Nursing and Resident Assessment Coordinator[,]” she has 

“received annual updates in the field of wound care and pressure ulcers.” She stated that 

she is “abundantly qualified by background, education and experience to address the issues 

as to whether Mr. Robinson’s treatment was within the standard of care and whether the 

failure to comply with the standard caused him injury, which it did, in the form of a pressure 

ulcer.”

3 A pressure ulcer is categorized into one of four stages based on its severity. Stage 

1 is least severe, and stage 4 is most severe. Syed Rafay H. Zaidi & Sandeep Sharma, 

Pressure Ulcer, National Library of Medicine, https://www.ncbi.nlm.nih.gov/books/

NBK553107/ (last updated Jan. 3, 2024).
5 

Jones-Singh reviewed Canton Harbor’s records related to Mr. Robinson, which 

included those relevant to the “development of wounds in this case,” i.e., the “[a]dmission 

assessment” and “[s]ubsequent skin” and “[n]utritional assessments,” “[c]are [p]lans” and 

“progress notes” by physicians and nurse practitioners, “[w]ound [e]valuations,” and the 

“MDS.”4

 In addition, she reviewed Mr. Robinson’s medical history showing his 

“admitting diagnoses” and medications.

Mr. Robinson was admitted on August 16, 2018, and discharged on January 5, 2019. 

According to Jones-Singh, given Mr. Robinson’s physical and cognitive limitations 

throughout his admission, he “was only oriented to himself” and “relied heavily on staff to 

turn and reposition him, assist him with ADL care,[5] provide him with nutrition, and 

anticipate his needs.” 

At his “initial admission assessment, conducted by Tracey Tralany, RN on August 

16, 2018[,] . . . Mr. Robinson did not have a pressure ulcer on admission.” According to 

Jones-Singh, although he presented “with a surgical incision to the left side of his head[,]” 

it was “[d]uring his stay at Future Care” that “Mr. Robinson developed pressure ulcers to 

4 The term “MDS” is an abbreviation for “Minimum Data Set,” which is a “tool for 

implementing standardized assessment and for facilitating care management in nursing 

homes.” See Minimum Data Set (MDS) 3.0 for Nursing Homes and Swing Bed Providers, 

Centers for Medicare & Medicaid Services, https://www.cms.gov/medicare/quality/

nursing-home-improvement/minimum-data-sets-swing-bed-providers (last updated Jan. 

12, 2024). 

5 “ADL” means “activities of daily living,” and includes eating, bathing, getting 

dressed, and using the bathroom. Peter F. Edemekong et al., Activities of Daily Living, 

National Library of Medicine, https://www.ncbi.nlm.nih.gov/books/NBK470404/ (last 

updated June 26, 2023). 
6

his right buttock and left buttock, which were then merged into a sacral ulcer.”

Jones-Singh recounted Mr. Robinson’s deteriorating skin condition following his 

admission to Canton Harbor. Given his “initial Braden scale, which is a tool used to 

determine the risk that a person has to develop pressure ulcer[s],” Mr. Robinson “was at 

high risk for developing pressure ulcers, with a score of 11.” Initial orders called for the 

facility to implement orders to “Float heels[,]” “Turn and Reposition[,]” and use “Barrier 

Cream[,]” a “Pressure reducing Mattress[,]” and a “Pressure reducing cushion[.]”

According to facility records, on August 20, just four days after admission, Mr. 

Robinson had “developed a right buttock ulcer” and “a left buttock ulcer.” Moreover, the 

same day, Mr. Robinson was noted to have “skin impairment to his sacral area.” According 

to Jones-Singh,

[i]nitially, this area was classified as Incontinence Associated Dermatitis 

(IAD). The standard of practice states that any wound noted on a pressure 

ulcer site must be classified as such. Therefore, IAD cannot be the etiology 

of a sacral ulcer. The same sacral ulcer was initially observed as a stage 2 

ulcer and had declined to a stage 3 ulcer, where it needed a topical debriding 

agent in which Santyl was ordered.

Mr. Everett Robinson was noted with a Suspected Deep Tissue Injury 

surrounding his sacral ulcer in a weekly skin note[] dated September 28, 

2018. A suspected deep tissue injury is damage[] to underlying skin only 

caused by friction and/or shearing. Therefore, Future Care Canton Harbor 

directly caused the SDTI to the sacrum noted on Mr. Robinson as there is no 

other etiology for this type of wound. 

Jones-Singh noted that Mr. Robinson “was not started on Eliquis until September 

11, 2018,” even though such anti-coagulant “intervention . . . should have [been] put in 

place” from the outset “to assist with tissue perfusion[,]” given the patient’s high risk of 

developing pressure ulcers. In turn, “this delay led to a decrease in Mr. Robinson’s tissue 
7

perfusion” that contributed to his development of pressure ulcers. By the time he began 

receiving Eliquis, Mr. Robinson’s “very high risk” had materialized, because he “had 

already developed multiple ulcers and was undergoing treatment to resolve them.”

In addition, Jones-Singh concluded that “the facility failed to meet [his] nutritional 

requirements thereby contributing to his skin breakdown.” She noted that Mr. Robinson’s 

nutritional assessment on September 13 indicated that he had been losing weight since 

admission and that his protein level was low. Despite these indicators and that Mr. 

Robinson was being treated for pressure ulcers, he “never had any supplements ordered for 

wound healing such as Vitamin C, Zinc Sulfate, or Prosource.”

On October 8, Canton Harbor’s records show that he “also developed excoriation to 

his perineal area[.]” Jones-Singh explained that skin condition “more than likely . . . 

develops with prolonged exposure to both urine/fecal matter” and “would have been 

prevented if Barrier Cream was being used with each incontinent change.”

Although the same Primary Care Physician examined Mr. Robinson eight times 

between August 21 and December 26, 2018, not one of that doctor’s assessments 

mentioned Mr. Robinson’s wounds. Nor was any medication provided to prevent pain. 

According to Jones-Singh,

[t]he standard of practice would require that a patient/resident who has 

multiple wounds or stage 3-4 wounds receive pain medication 30 minutes to 

an hour prior to dressing changes. Mr. Robinson’s wounds had declined to 

a stage 3, meeting the aforementioned criteria. Because the attending 

Physician never addressed Mr. Robinson’s wounds and failed to provide pain 

medication prior to dressing changes, it is in my professional opinion that 

Mr. Robinson suffered unnecessary pain during his dressing changes, 

which could have been prevented with the proper interventions prior to the

treatment.
8

(Emphasis added).

Jones-Singh offered the following opinions based on her comprehensive review of 

Mr. Robinson’s records:

[I]t is my opinion to a reasonable degree of nursing certainty, that Future 

Care of Canton Harbor breached the standard of care for skilled nursing 

facilities/post-acute rehabilitation. Their failure increased the risk of 

harm, in fact harm did occur.

The facts and clinical analysis in this report represent a deviation from the 

acceptable standard of nursing care. This includes violations of federal and 

state regulations, which are part of the acceptable standard of care and also 

their own policies and procedures, which are part of the acceptable standard 

of care.

[Canton Harbor’s] statutory breaches include, but are not limited to 

causing the following injuries: left buttock, right buttock, sacral ulcer, and 

a suspected deep tissue injury.

Future Care Canton Harbor breached the standard of care by:

• Failure to prevent, monitor, document, manage and treat skin 

injury[;]

• Failure to provide personal hygiene such that actual harm 

occurred[;]

• Failure to train and monitor staff compliance related to: Routine 

skin and pain assessments, ITD communication and coordination 

of care, and care of blistering (lower leg extremity) skin[;]

• Failure to provide adequate nutrition[;]

• Failure to address abnormal labs[; and]

• Failure to accurately complete MDS assessments driving the care 

planning process:

o Failing to write and maintain up to date care plan 

interventions that support skin breakdown prevention, 

healing[.]
9

(Emphasis added).

In support of her conclusions, Jones-Singh cited and quoted specific federal 

regulations establishing relevant care standards for a skilled nursing facility offering longterm care for incontinent and bed-bound patients like Mr. Robinson, then described how 

Canton Harbor’s care failed to meet those standards.

First, Jones-Singh concluded that the facility failed to “develop a comprehensive 

care plan . . . that includes measurable objectives and timetables to meet a resident’s 

medical, nursing and mental and psychosocial needs, as identified in the comprehensive 

assessment.” She specifically opined that the following care plans “did not meet the 

standard of care for Mr. Robinson in order to safely and compassionately” care for him:

• “Potential for Impaired Skin integrity”: “the facility failed to implement a 

comprehensive nursing care plan that could assist and aid[] in the prevention o[f] 

pressure ulcer formation,” so that “the nursing department did not have a guide 

to assist them in these preventative measures.”

• “Pain related to multiple wounds”: Canton Harbor “[d]id not reflect other 

reasons for pain,” meet goals to interrupt pain, or “[p]rovide pain medication 30 

mins to an hour prior to dressing change[.]”

• Failure to develop care plans required to meet the standards of care for 

nutritional deficit, weight loss, and pain related to wounds.

Second, Jones-Singh identified violations of specific federal standards requiring 

treatment to prevent and heal pressure ulcers.

Based on the comprehensive assessment of a resident, the facility must 

ensure that (1) A resident who enters the facility without pressure sores does 

not develop pressure sores unless the individual’s clinical condition 

demonstrates that they were unavoidable; and (2) A resident having pressure 

sores receives necessary treatment and services to promote healing, prevent 

infection and prevent new sores from developing.
10

See 42 C.F.R. § 483.25(b)(1).

Likewise, Jones-Singh specified the applicable standards for treatment of a pressure 

ulcer:

For a resident who . . . has a pressure ulcer that is not healing, or is at risk of 

developing subsequent pressure ulcers, the facility is in compliance with this 

requirement if they:

• Accurately or consistently assess a resident’s skin integrity on 

admission and as indicated thereafter

• Recognized and assessed factors placing the resident at risk of 

developing a new pressure ulcer or experiencing non-healing 

or delayed healing of a current pressure ulcer, including 

specific conditions, causes and/or problems, needs and 

behaviors

• Defined and implemented interventions for pressure ulcer 

prevention and treatment in accordance with resident needs, 

goals, and recognized standards of practice

• Address the potential for infection management

• Revised approaches.

“Despite Mr. Robinson’s underlying comorbidities, Future Care Canton Harbor had 

the duty to provide prevention-oriented interventions to reduce the incidence of skin 

breakdown.” Over the course of his admission until discharge on January 5, 2019, “several 

breaches occurred causally related to Mr. Robinson’s decline in health such that harm 

occurred[,] including” failures to complete “Braden Scales correctly to proactively adapt 

the careplanning process based on accurate assessment findings[,]” particularly during the 

critical “first four weeks after admission to a long-term care facility[,]” and failure to 

“[c]onduct a comprehensive and routine pain assessment.” Jones-Singh explained that
11

[t]he standard of care and duty of Future Care Canton Harbor called for the following:

√ Routine (daily) skin inspections, reporting to the charge nurse an[y] changes 

to the skin during showers and/or peri-care

√ Routine skin (risk) assessments (i.e., Braden Scale)

o Care plan interventions and physician orders identified from risk 

assessment findings

√ Removal of devices to routinely assess the skin (i.e., heel-booties)

√ Utilizing a Group II bed (alternating air loss) before heel breakdown occurred

√ Interventions to address complications related to immobility (i.e., 

repositioning, off-loading, foot cradles and air loss mattress function)

√ Shear and friction considerations (i.e., head of bed elevation < to 30 degrees, 

OT seating and positioning modifications, off-loading)

√ Incontinence care (i.e., skin cleansers, barrier creams, briefs)

√ Family education

o Skin safety interventions related to non-adherence

√ Following physician’s orders.

In Jones-Singh’s opinion as a registered nurse with training and experience in 

preventing and caring for pressure ulcers in incontinent patients at federally regulated 

skilled nursing facilities, 

[t]he facts and clinical analysis in [her] report represent a deviation from the 

acceptable nursing standard of care. This includes violations of federal and 

state regulations, which are part of the acceptable standard of care and also 

their own policies and procedures, which are part of the acceptable standard 

of care. 

Given “what happened to Mr. Robinson,” she concluded that “there was a lack of oversight; 

utilization of nursing process; care planning; critical thinking and lack of urgency resulting 
12

in substandard care.” In turn, “[t]hese actions resulted in avoidable pressure ulcers to Mr. 

Robinson’s left buttock, right buttock, and sacral area.”

Motion to Dismiss

In response to Mrs. Robinson’s complaint and CQE, Canton Harbor filed a

“Preliminary Motion to Dismiss.” Citing CJP § 3-2A-04(b)(1)(i), the statutory requirement 

for a CQE attesting to breach of the standard of care that proximately caused the alleged 

injury, and Md. Rule 5-702 requiring an expert witness to be “qualified as an expert by 

knowledge, skill, experience, training, or education,” Canton Harbor argued that JonesSingh’s CQE did not comply because “a registered nurse cannot provide expert testimony 

[on] the issue of proximate causation.”

Although Canton Harbor acknowledged that “there are no reported Maryland 

decisions that directly address this issue,” it maintained that “the language of the applicable 

statutes and regulations makes clear that registered nurses are not qualified to provide such 

testimony.” In support, Canton Harbor relied on the difference between nursing and 

medical diagnoses. Under Maryland law, “practice registered nursing” is statutorily 

defined to

mean[] the performance of acts requiring substantial specialized 

knowledge, judgment, and skill based on the biological, physiological, 

behavioral, or sociological sciences as the basis for assessment, nursing 

diagnosis, planning, implementation, and evaluation of the practice of 

nursing in order to:

(i) Maintain health;

(ii) Prevent illness; or

(iii) Care for or rehabilitate the ill, injured, or infirm.
13

Md. Code, (1981, 2021 Repl. Vol.), § 8-101(o)(1) of the Health Occupations Article 

(“HO”) (emphasis added). In turn, “Nursing diagnosis” is defined by Maryland regulation 

as “a description of the actual or potential, overt or covert health problems which 

registered nurses are licensed to treat.” COMAR 10.27.09.01(b)(16) (emphasis added).

In contrast, Canton Harbor emphasized, the statutory definition of the “[p]ractice of 

medicine” means to “engage . . . in medical: (i) Diagnosis; (ii) Healing; (iii) Treatment; or 

(iv) Surgery.” HO § 14-101(o)(1) (emphasis added). Practicing medicine expressly 

encompasses “[d]iagnosing, healing, treating, preventing, prescribing for, or removing any 

physical . . . ailment.” HO § 14-101(o)(2). Acknowledging that there is no definition for 

“medical diagnosis” in the statutory scheme, Canton Harbor cited dictionary definitions of 

“diagnosis” as a “determination of a medical condition (such as a disease) by physical 

examination or by study of its symptoms,” Diagnosis, Black’s Law Dictionary (11th ed. 

2019), and “the art or act of identifying a disease from its signs and symptoms” and 

“investigation or analysis of the cause or nature of a condition, situation or problem,”

Diagnosis, Merriam-Webster, https://www.merriam-webster.com/dictionary/diagnosis

(last updated March 18, 2024).

According to Canton Harbor, because

the term “medical diagnosis” is used in its definition of “practice medicine” 

and “nursing diagnosis” is used in its definition of “practice registered 

nursing,” the Maryland legislature made clear that registered nurses are not 

permitted to make a medical diagnosis; they are only permitted to make a 

nursing diagnosis which is limited to providing a description of a health 

problem. With that in mind, a nurse cannot provide medical causation 

testimony because, by its very nature, such testimony requires the nurse to 

opine as to whether the tortfeasor’s breach of the standards of care caused 
14

the plaintiff’s injuries and/or damages. It requires more than providing a 

mere “description” of the plaintiff’s health problem.

In support of its narrow reading of the statute, Canton Harbor cited “[a]ppellate 

decisions from other jurisdictions” that it maintained “held similar views[,]” arguing that 

its narrow view of the proximate causation requirement for a CQE is “consistent with the 

public policy considerations” underlying the Act to “weed[] out non-meritorious claims.” 

In Canton Harbor’s view, “[a]llowing a nurse to offer expert opinions outside the scope of 

her profession[] would be the quintessential scenario the Act was intended to prevent.” In 

turn, because Mrs. Robinson’s CQE lacks proper attestation that “breach[ing] the standard 

of care proximately caused the injuries at issue as statutorily required[,]” the circuit court 

was “required to dismiss” the complaint under CJP § 3-2A-04(b)(1)(i) (“[A] claim or 

action . . . shall be dismissed” for failure to comply with CQE requirement.), and Breslin 

v. Powell, 421 Md. 266, 299 (2011) (“[A]ny deficiency in the Certificate requires the 

arbitration panel or court to dismiss the claim or action without prejudice.” (emphasis 

added)).

In her opposition, Mrs. Robinson argued that, under Debbas v. Nelson, 389 Md. 364 

(2005), when, as in this case, the CQE text satisfies the breach and causation elements on 

its face, the defendant health care provider is “not allowed to collaterally impeach” it. 

Given “her knowledge, training, experience and education,” Jones-Singh “qualif[ied] as an 

expert pursuant to Rule 5-702” who could “determine the cause of [Mr. Robinson’s] altered 

skin condition and . . . opine that due to various breaches in care that these breaches caused 

pressure ulcers.”
15

Because the complaint alleges claims against a skilled nursing facility, Mrs. 

Robinson contended that Jones-Singh is “providing peer to peer review, which is within 

the statutory scheme of the” Act and consistent with federal laws governing nursing home 

care. Specifically, under the Federal Nursing Home Reform Act, enacted in 1965, 

standards of care are enumerated in 42 C.F.R. § 483.25, as detailed in Jones-Singh’s report. 

Pointing out that no Maryland “case has established a bright line rule holding that causation 

opinions can only be established by physicians[,]” Mrs. Robinson asserted that “the 

majority of states which have considered the specific issue raised by the defense have held 

that a nurse can render causation opinions as to decubitus ulcers.” Moreover, “[i]f the 

legislators wanted a bright line rule on the issue of causation, then the statutory scheme 

would have stated that . . . the CQE must be signed by a physician.”

In reply, Canton Harbor argued that “Debbas does not support Plaintiffs’ position” 

that this CQE cannot be collaterally impeached, because that decision involved an improper 

attempt to impeach a CQE that was valid at the time it was filed, with evidence that the 

expert subsequently testified inconsistently with the opinion expressed in that CQE. See 

Debbas, 389 Md. at 380-84. Here, in contrast, Canton Harbor properly challenged the 

validity of Mrs. Robinson’s CQE on the ground that it was invalid when filed “because a 

registered nurse cannot provide a medical diagnosis in Maryland and therefore cannot 

opine as to medical causation.”

Moreover, Canton Harbor disputed that the CQE merely attested to a breach in the 

standard of care causing “the development of pressure wounds,” because “to be valid” for 

purposes of supporting a wrongful death claim, the CQE had to “make that causal 
16

connection” between the breach in the standard of care and Mr. Robinson’s death. Any 

such opinion attesting to cause of death “would require an assessment of the Decedent’s 

litany of pre-existing, underlying, comorbidities and the role those comorbidities played in 

the dying process, along with the impact the Decedent’s pressure wounds had on those 

underlying comorbidities.” Canton Harbor continued, “[s]uch an assessment certainly falls 

well outside of the scope of a registered nurse’s professional licensure and expertise[,]” 

making it “inconsistent with the purpose of the” HCMCA.

At a motion hearing on January 25, 2023, counsel for both parties reasserted that 

“there is no reported Maryland decision on this exact issue” and there is “no one case 

dealing with this issue.” Canton Harbor, again citing to “decisions from other 

jurisdictions” holding that “a nurse is not qualified to opine on the issue of proximate 

causation,” argued that 

a nurse evaluates the patient, provides a description of the medical condition 

for the doctor, and then the doctor is left to make the decision as to what 

caused that condition, what the condition is and what treatment to provide. 

A nurse cannot stand in the shoes of a doctor in the course of her practice and 

diagnose and treat medical conditions without consulting a doctor. If she did 

that, she would lose her license. And so . . . a nurse should not be able to 

stand in the shoes of a doctor in . . . a CQE or frankly testify at trial that a 

particular condition was proximately caused by any breach in the standard of 

care because, again, that is going outside the scope of her practice.

Because “pressure wounds can develop because of all kinds of different issues, . . . a nurse 

consults a doctor to ultimately assess the issue and provide a treatment plan.” Moreover, 

even if a “nurse could opine as to the issue of causation to support the survival claim, . . . 

there’s no basis for a nurse to be qualified to opine on cause of death.”

In response, counsel for Mrs. Robinson maintained that Canton Harbor was 
17

asking [the court] to create a bright-line rule in decubitus ulcer cases that 

there’s going to be a mandatory requirement of two certificates: One by a 

nurse who judges the standard of care as to whether it’s been breached in 

long-term healthcare facilities such as the one in the settings we’re in; and 

second, a physician’s certificate of qualified expert which then discusses the 

issue of causation. That is simply not in the statute. That is simply not in the 

case law. . . . 

We dealt with the issue and looked at it from different states, and 

under item 5 of our reply provided to the [c]ourt, at least six cases that have 

concluded the other way. Understanding that the nature of the claims deals 

with bedsores. And, particularly, one of the cases from Missouri states that 

nurses were qualified to give expert testimony regarding bedsores, their 

cause and treatment. One of the important function[s] of nurses is to prevent 

the formation of decubitus ulcers in bedridden patients. 

Counsel emphasized that under “federal standards for nursing home care[,]” 

compliance is “squarely on the shoulders of like and similar healthcare providers -- not 

physicians” so that nurses working in “long-term care facilities addressing decubitus ulcers 

are intimately familiar with this area of . . . medicine, . . . and should be able to provide 

witness testimony.” Notably, counsel announced that “we are not pursuing a claim that . . . 

the Defendant’s negligence caused the death of the patient. We are abandoning that and 

limiting it to the cause [of] the decubitus ulcers, the treatment and care . . . to address that 

issue and the medical expenses associated with that.”

The circuit court granted Canton Harbor’s motion to dismiss, without leave to 

amend, explaining:

The issue involved in this matter is whether a registered nurse can 

serve as a qualified expert under Maryland Code Courts and Judicial 

Proceedings section 3-2A-04(b)(1)(1). The [c]ourt finds that the Plaintiff’s 

designated expert Ms. Jones-Sing[h] is a healthcare provider as -- that’s 

defined under Courts and Judicial Proceedings section 3-2A-01(f)(1). The 

[c]ourt further finds that she is qualified to attest to the standard of care and 

deviation there[from] for nurses.
18

However, when considering Maryland Code Health Occupations 14-

101(o) and 8-101(o) as well as COMAR section 10.27.09.01.B(16), the 

[c]ourt finds that a registered nurse cannot make a medical diagnosis, and 

therefore, cannot determine a medical condition nor the cause of a 

condition. Therefore, the [c]ourt concludes that a registered nurse cannot 

attest that there was a departure from the standard of care that’s the 

proximate cause of the alleged injury as required by Courts and Judicial 

Proceedings section 3-2A-04(b)(1)(1).

As such, the [c]ourt finds that the certificate of qualified expert is 

defective. And Courts and Judicial Proceedings section 3-2A-04(b)(1)(1) 

mandates dismissal. Furthermore, the [c]ourt finds that . . . there has been 

no showing of good cause for an extension of time. And, therefore, the 

[c]ourt will not grant such. So the [c]ourt is going to enter an order of 

dismissal of this matter for those reasons.

(Emphasis added).

Appeal

Mrs. Robinson noted this timely appeal, raising three questions, which we have 

consolidated and rephrased: Did the circuit court err in granting Canton Harbor’s motion 

to dismiss based on the court’s interpretation of CJP § 3-2A-04’s CQE requirement?

As we shall explain, we conclude that in a negligence case against a skilled nursing 

facility for decubitus ulcer injury, Maryland’s CQE requirement under the HCMCA may 

be predicated on a proximate causation opinion by a registered nurse with sufficient 

education and experience in preventing and treating the ulcer injury alleged in the 

complaint. Here, the CQE and Jones-Singh’s accompanying report and affidavit are 

sufficient to support her attestation that Canton Harbor breached nursing standards of care 

in a manner that proximately caused ulcer injuries to Mr. Robinson, as alleged in Count 

One of the complaint.
19

STANDARDS GOVERNING REVIEW

Maryland’s Health Care Malpractice Claims Act establishes the statutory 

framework for negligence claims against health care providers. In pertinent part, CJP 

§ 3-2A-04 provides:

(b) Unless the sole issue in the claim is lack of informed consent:

(1)(i)1. Except as provided in item (ii) of this paragraph, a claim or action 

filed after July 1, 1986, shall be dismissed, without prejudice, if the 

claimant or plaintiff fails to file a certificate of a qualified expert with 

the Director attesting to departure from standards of care, and that the 

departure from standards of care is the proximate cause of the alleged 

injury, within 90 days from the date of the complaint . . . .

(Emphasis added).

This Court recently reviewed the history and purpose of the CQE requirement. “The 

HCMCA and its amendments evolved in response to multiple reported crises in Maryland’s 

marketplace for medical malpractice insurance.” Jordan v. Elyassi’s Greenbelt Oral & 

Facial Surgery, P.C., 256 Md. App. 555, 570 (2022). “[I]n 1986, the General Assembly 

passed a significant amendment to the HCMCA, introducing CQE requirements[.]” Id. at 

571 (citing DeMuth v. Strong, 205 Md. App. 521, 538-39 (2012)). This provision is 

“designed to serve a gatekeeping function,” by “‘eliminat[ing] excessive damages and 

reduc[ing] the frequency of claims’” in order to “‘weed[] out non-meritorious claims and 

ultimately reduc[e] medical malpractice insurance expenditures.’” Id. (first two alterations 

in original) (quoting DeMuth, 205 Md. App. at 539).

Pertinent to this appeal, we summarized the standards governing dismissal of a 

negligence claim for failing to satisfy the CQE requirement:
20

The sufficiency of a CQE is a question of law, and the standard “is the 

same as determining whether a complaint is legally sufficient”—that is, after 

assuming the truth of all assertions in the CQE and taking all permissible 

inferences in favor of its validity, we ask whether the CQE meets the 

requirements set forth in the HCMCA. See Carroll v. Konits, 400 Md. 167, 

179-80 & n.11 (2007). As with other questions of law, our review is de novo. 

In interpreting statutory language, we bear in mind that the “cardinal rule” of 

statutory construction is to ascertain and give effect to the General 

Assembly’s intent. As such, we first assess whether the statutory language 

is clear and unambiguous. If it is, we will not add or delete words or force a 

particular interpretation; we will simply interpret the language as written and 

end our inquiry . . . . 

If the statutory language is ambiguous, however, we engage in a 

broader inquiry by resolving the ambiguity “in light of the legislative intent, 

using all the resources and tools of statutory construction at our disposal.” In 

that case, we may consider “not only the literal or usual meaning of the 

words, but their meaning and effect in light of the setting, the objectives[,] 

and [the] purpose of the enactment[.]” And we may interpret the language 

with regard to various indicia of legislative intent, including “the structure of 

the statute, including its title; how the statute relates to other laws; the 

legislative history[;] . . . the general purpose behind the statute; and the 

relative rationality and legal effect of various competing constructions.”

Id. at 567-69 (last five alterations in original) (footnote omitted) (some citations omitted).

DISCUSSION

Mrs. Robinson renews her contention that for CQE purposes, a registered nurse can 

opine as to the proximate cause of a decubitus ulcer. In her view, the CQE filed in this 

action was properly predicated on the expertise of a registered nurse who had sufficient 

education and experience to attest that Canton Harbor breached nursing standards for 

preventing and treating decubitus ulcers in a manner that proximately caused the ulcer 

injuries alleged in Mrs. Robinson’s complaint.

Canton Harbor again counters that a proximate cause opinion in a CQE is 

necessarily a “medical diagnosis” requiring a level of expertise that a registered nurse does 
21

not have. In support, Canton Harbor points to the relevant portion of the statutory 

definition of the “practice of registered nursing” as encompassing “nursing diagnosis[,]” 

which in turn is defined by regulation as “a description of the actual or potential, overt or 

covert health problems which registered nurses are licensed to treat.” COMAR 

10.27.09.01(B)(16) (emphasis added). Comparing this language to the definition of 

practicing medicine as engaging “in medical . . . [d]iagnosis[,]” HO § 14-101(o)(1), Canton 

Harbor contrasts the dictionary meaning of that term, as “the determination of medical 

conditions, as well as the cause or nature of said conditions.”

Based on its narrow interpretation of “nursing diagnosis,” Canton Harbor argues 

that Maryland’s “legislature did not intend for nurses to attest in a CQE to proximate 

causation[,]” because that “would, in effect, require the nurse to opine on issues outside 

the scope of the practice of registered nursing” by “determin[ing] the cause of a medical 

condition – i.e., a medical diagnosis.” In Canton Harbor’s view, “[t]hat is the quintessential 

scenario the Act was intended to prevent.” In turn, “[b]ecause a registered nurse cannot 

attest to proximate causation, [Mrs. Robinson’s] CQE . . . fails to satisfy the requirements 

of CJP § 3-2A-04(b)(1)(i)” and dismissal is required. CJP § 3-2A-04(b)(1)(i) (“[A] claim 

or action . . . shall be dismissed without prejudice” if the plaintiff fails to file a valid CQE.). 

For that reason, Canton Harbor argues, the circuit court correctly dismissed the complaint.

As the parties acknowledge, nothing in the language of the HCMCA expressly 

precludes a registered nurse from being a qualified expert for purposes of the CQE 

requirement. Indeed, the statute provides that a “health care provider” may serve as the 

expert in a CQE, CJP § 3-2A-02(c)(2)(ii), and a registered nurse falls within the statute’s 
22

definition of “health care provider.” CJP § 3-2A-01(f). Canton Harbor concedes that 

Jones-Singh “may be a qualified expert who can attest in a certificate to departures of the 

standard of care for nurses,” but contends that nurses may not opine as to proximate 

causation. As noted, this presents an issue of first impression in Maryland.6

We conclude that under Maryland’s statutory and regulatory framework governing 

nursing services at a skilled nursing facility like Canton Harbor, a CQE may be predicated 

on the attestation of a registered nurse that breach of nursing standards for preventing and 

treating decubitus ulcers proximately caused the ulcer injury alleged in the negligence 

complaint. Federal statutes and regulations governing skilled nursing facilities like Canton 

Harbor require such facilities to “be licensed under applicable State and local law[,]” 42 

U.S.C. § 1395i-3(d)(2)(a), and to “operate and provide services in compliance with all 

applicable Federal, State, and local laws and regulations . . . and with accepted professional 

standards and principles which apply to professionals providing services in such a facility.” 

42 U.S.C. § 1395i-3(d)(4)(A). “A skilled nursing facility must care for its residents in such 

6 Although no reported Maryland case has addressed whether a registered nurse may 

satisfy the proximate cause requirement for a CQE in a medical negligence case, our 

Supreme Court has rejected a related contention that a pharmacist is per se disqualified 

from giving an expert opinion in an informed consent case. In Shannon v. Fusco, 438 Md. 

24 (2014), the family of a patient who died after taking a medication prescribed by his 

oncologist sued for lack of informed consent regarding the risks of taking the drug while 

undergoing radiation therapy. The Court “reject[ed] [the defendant physician’s] argument 

that a pharmacist is per se unqualified to testify in an informed consent action when a 

physician has been sued.” Id. at 55. Even though that pharmacist “had the requisite 

expertise to testify about the material risks of the administration of” that particular drug, 

the Court concluded that his proffered testimony did not in fact address the material risks 

at issue in that case. Id. at 56.
23

a manner and in such an environment as will promote maintenance or enhancement of the 

quality of life of each resident[,]” 42 U.S.C. § 1395i-3(b)(1)(A), and provide “nursing 

services and specialized rehabilitative services to attain or maintain the highest practicable 

physical, mental, and psychosocial well-being of each resident[,]” 42 U.S.C. § 1395i3(b)(4)(A)(i). 

Under Md. Code (1982, 2023 Repl. Vol.), § 19-1401(e)(1) of the Health-General 

Article (“HG”), a “nursing home” is 

a facility that offers nonacute inpatient care to patients suffering from a 

disease, chronic illness, condition, disability of advanced age, or terminal 

disease requiring maximal nursing care without continuous hospital 

services and who require medical services and nursing services rendered by 

or under the supervision of a licensed nurse together with convalescent, 

restorative, or rehabilitative services.

(Emphasis added). Like nursing homes, registered nurses are subject to licensing and 

practice requirements established by statute and regulation. Under HO § 8-101(o), the 

General Assembly has defined the practice of registered nursing as follows:

(o)(1) “Practice registered nursing” means the performance of acts 

requiring substantial specialized knowledge, judgment, and skill based on 

the biological, physiological, behavioral, or sociological sciences as the 

basis for assessment, nursing diagnosis, planning, implementation, and 

evaluation of the practice of nursing in order to:

(i) Maintain health;

(ii) Prevent illness; or

(iii) Care for or rehabilitate the ill, injured, or infirm.

(2) For these purposes, “practice registered nursing” includes:

(i) Administration;

(ii) Teaching;
24

(iii) Counseling;

(iv) Supervision, delegation, and evaluation of nursing practice;

(v) Execution of therapeutic regimen, including the administration 

of medication and treatment;

(vi) Independent nursing functions and delegated medical 

functions; and

(vii) Performance of additional acts authorized by the Board under § 

8-205 of this title.

(Emphasis added).

Canton Harbor’s argument that “nursing diagnosis” is merely a “description of . . . 

health problems” and therefore precludes nurses from opining on proximate causation in 

all cases ignores how nursing diagnosis fits within the regulations concerning standards of 

practice for registered nurses. COMAR 10.27.09.02 provides an overview of the functions 

of a registered nurse, which requires that registered nurses:

1) “collect client health data” “using appropriate assessment techniques[,]” 

COMAR 10.27.09.02A(1), (4);

2) “analyze the assessment data in determining nursing diagnoses[,]” COMAR 

10.27.09.02B(1);

3) “identify expected outcomes” based on the diagnoses, COMAR 

10.27.09.02C(1), (2)(a)(i);

4) “develop a plan of care that prescribes interventions to attain expected 

outcomes[,]” COMAR 10.27.09.02D(1);

5) “implement the interventions identified in the plan of care[,]” COMAR 

10.27.09.02E(1);

6) “evaluate the client’s progress toward attainment of outcomes[,]” COMAR 

10.27.09.02F(1); and
25

7) “revise the nursing diagnosis, outcomes, and the plan of care” based on 

“effectiveness of interventions,” COMAR 10.27.09.02F(2)(c), (e).

Performance of these functions, which focus on identifying and attaining expected 

outcomes, implicitly requires registered nurses, acting within the scope of their duties, to 

assess the probable cause of further injury if nursing intervention is unsuccessful.

As we read this statutory and regulatory framework, pressure ulcers are among the 

“health problems which registered nurses are licensed to treat[,]” COMAR 

10.27.09.01(B)(16), so that preventing and caring for them fall within the scope of “nursing 

diagnosis” and “nursing services” that may properly be “rendered by or under the 

supervision of a licensed nurse.” See HG § 19-1401(e)(1). Indeed, we find it significant 

that federal regulations expressly classify care of decubitus or pressure ulcers as “skilled 

nursing care.” Among other nursing duties that require comparably specialized education, 

training, protocols, and physician supervision, federal public health regulations define 

“[s]ervices that qualify as skilled nursing services” to include “[t]reatment of extensive 

decubitus ulcers or other widespread skin disorder[.]” 42 C.F.R. § 409.33(b)(6) 

(emphasis added).7

 Consistent with federal regulations, a Maryland statute mandating 

7 Under 42 C.F.R. § 409.33(b), “skilled nursing services” also encompass the 

following:

(1) Intravenous or intramuscular injections and intravenous feeding[;]

(2) Enteral feeding that comprises at least 26 per cent of daily calorie 

requirements and provides at least 501 milliliters of fluid per day[;]

(3) Nasopharyngeal and tracheostomy aspiration;
26

quality assurance programs in nursing homes lists “prevention of decubitus ulcers” as 

“nursing care.” HG § 19-1410(b)(5)(ii).

Maryland nursing home regulations similarly identify the scope of services that 

nurses may perform. COMAR 10.07.02.18, titled “Nursing Services,” provides that a 

nursing home must employ sufficient staff to “[e]nsure that a resident . . . [r]eceives proper 

care to prevent pressure ulcers.” COMAR 10.07.02.18C(3)(c). The same regulation also 

provides that a restorative nursing care program “shall include . . . [e]ncouraging and 

assisting residents to change positions at least every 2 hours to . . . prevent pressure ulcers.” 

COMAR 10.07.02.18G(3). Notably, the “Physician Services” regulation in the same 

chapter makes no mention of pressure ulcers, COMAR 10.07.02.14, suggesting that 

prevention of pressure ulcers in nursing homes is primarily a nursing function not requiring 

the expertise of a physician.

(4) Insertion and sterile irrigation and replacement of suprapubic catheters;

(5) Application of dressings involving prescription medications and aseptic 

techniques;

. . .

(7) Heat treatments which have been specifically ordered by a physician as 

part of active treatment and which require observation by nurses to 

adequately evaluate the patient’s progress;

(8) Initial phases of a regimen involving administration of medical gases;

[and]

(9) Rehabilitation nursing procedures, including the related teaching and 

adaptive aspects of nursing, that are part of active treatment, e.g., the 

institution and supervision of bowel and bladder training programs.
27

We note that in 2010 the president of the American Nurses Association issued a 

statement clarifying that, despite “pressure ulcer” being a medical diagnosis,

RNs would not be practicing outside their scope of practice if the 

nurse identifies the alteration in skin integrity as a pressure ulcer and stages 

it before the admitting provider. On the contrary, it is the expectation that 

the RN actually does that. Anything less does not fulfill our professional 

standard and commitment to the patient.

Rebecca M. Patton, Is Diagnosis of Pressure Ulcers Within an RN’s Scope of Practice?, 

American Nurse (Jan. 11, 2010), https://www.myamericannurse.com/is-diagnosis-ofpressure-ulcers-within-an-rns-scope-of-practice/.

Because managing decubitus ulcers constitutes the type of core “skilled nursing 

services” that may be within the expertise of a registered nurse, we agree with Mrs. 

Robinson that in a medical negligence case, a registered nurse may be qualified to attest 

that breach of applicable standards of nursing care for preventing and treating decubitus 

ulcers proximately caused the plaintiff’s ulcer injury. Nothing in our decision contravenes 

the established principle that expert witnesses must be “qualified . . . by knowledge, skill, 

experience, training, or education” to “assist the trier of fact to understand the evidence or 

to determine a fact in issue.” See Md. Rule 5-702.

The scope of our holding is narrow. We hold only that in negligence cases alleging 

breach of nursing standards for preventing and treating decubitus ulcers, a registered nurse 

is not disqualified per se to attest that failure to adhere to such standards proximately 

caused the plaintiff’s ulcer injury. In these limited circumstances, we do not share Canton 

Harbor’s concerns about registered nurses overstepping their expertise in managing 

pressure ulcers by predicating their proximate cause opinions on impermissible medical 
28

diagnoses. If and when that happens in a particular case, the same remedy at issue here—

dismissal—will be available to court and counsel.

Nor does our construction of the CQE requirement otherwise undermine its purpose 

to screen out meritless claims. See DeMuth, 205 Md. App. at 539. To the contrary, that 

has already happened in this case. As we detailed, this CQE was predicated on JonesSingh’s attestation that breaches in the standards of nursing care for preventing and treating 

ulcers proximately caused Mr. Robinson’s ulcer injuries while at Canton Harbor. Because 

the CQE lacks any opinion that Mr. Robinson’s death was proximately caused by Canton 

Harbor’s breaches in the standards of nursing care, however, there is no proximate 

causation attestation to support Mrs. Robinson’s wrongful death claim.8

 In apparent 

recognition of that insufficiency, plaintiffs’ counsel stated at the motion hearing that Mrs. 

Robinson was no longer pursuing a wrongful death claim, but instead limited her damages 

claim to the ulcer injuries Mr. Robinson allegedly suffered while he was at Canton Harbor.9

8 “Maryland’s wrongful death statute allows the maintenance of an action ‘against 

a person whose wrongful act causes the death of another.’” Spangler, 449 Md. at 47-48 

(quoting CJP § 3-902(a)). “The primary beneficiaries of a wrongful death action are the 

spouse, parent, and child of the decedent.” Id. at 48 (citing CJP § 3-904(a)(1)). “Where 

the decedent is a spouse, . . . the wrongful death statute provides damages for ‘pecuniary 

losses,’ if any, in addition to damages for ‘mental anguish, emotional pain and suffering, 

loss of society, companionship, comfort, protection, marital care, parental care, filial care, 

attention, advice, counsel, training, guidance, or education where applicable[.]’” Id.

(quoting CJP § 3-904(c)-(d)).

9 In light of Mrs. Robinson’s concession that the CQE would be insufficient to attest 

to the proximate cause of Mr. Robinson’s death, we surmise that Mrs. Robinson likewise 

abandons the Estate’s claim for funeral expenses. 
29

For these reasons, the circuit court erred in construing Maryland’s statutory scheme 

governing health care malpractice claims to disqualify a registered nurse in all cases from

attesting to proximate causation in a decubitus ulcer case. Because preventing and treating 

decubitus ulcers are within the recognized scope of skilled nursing services, a CQE may

be predicated on attestations by a registered nurse with sufficient education and experience

that breach of nursing standards proximately caused such ulcer injury.10

10 The parties rely extensively on out-of-state caselaw to support their respective 

positions. Our review of the relevant caselaw reveals that most of the cases are 

distinguishable from the present case. Nevertheless, it appears the weight of authority 

supports our conclusion that qualified nurses may give expert testimony regarding the 

treatment and cause of decubitus ulcers. See, e.g., Gaines v. Comanche Cnty. Med. Hosp., 

143 P.3d 203, 206 n.10 (Okla. 2006) (collecting extrajurisdictional cases holding that 

“nurses may offer expert testimony concerning the development or prevention of decubitus 

ulcers”); Mellies v. Nat’l Heritage, Inc., 636 P.2d 215, 224 (Kan. Ct. App. 1981) (ruling 

that “if a proper foundation is laid as to the nurse’s experience with decubitus ulcers, she 

or he can qualify as an expert as to causation”); Parris v. Uni Med, Inc., 861 S.W.2d 694, 

699 (Mo. Ct. App. 1993) (holding no abuse of discretion in allowing nurses to give expert 

testimony regarding cause and treatment of bedsores because they “had extensive 

experience” given that “[o]ne of the important functions of nurses is to prevent the 

formation of decubitus ulcers in bed-ridden patients”); Freed v. Geisinger Med. Ctr., 971 

A.2d 1202, 1212 (Pa. 2009) (overruling Flanagan v. Labe, 690 A.2d 183 (Pa. 1997), “to 

the extent it prohibits an otherwise competent and properly qualified nurse from giving 

expert opinion testimony regarding medical causation” in case alleging negligence in 

preventing and caring for pressure wounds), aff’d on reargument, 5 A.3d 212 (2010); cf. 

Rasor v. Nw. Hosp., LLC, 419 P.3d 956, 963 (Ariz. Ct. App. 2018) (noting that under 

Arizona law, a registered nurse may establish a “‘nursing diagnosis,’ which includes 

determining the ‘etiology’ or cause of a disorder” (citations omitted)). We recognize that 

there is contrary authority. Vaughn v. Miss. Baptist Med. Ctr., 20 So. 3d 645, 652 (Miss. 

2009) (“We now explicitly hold that nurses cannot testify as to medical causation.”); 

Esquivel v. El Paso Healthcare Sys., Ltd., 225 S.W.3d 83, 90-91 (Tex. App. 2005) (holding 

that nurse could not express opinion as to “causal link” related to alleged decubitus ulcer 

injuries); Kent v. Pioneer Valley Hosp., 930 P.2d 904, 907 (Utah Ct. App. 1997) (holding 

that nurse was not qualified “to opine as to nerve damage caused by an allegedly improper 

injection”). In our view, the relevant caselaw generally reflects what the medical and 
30

Sufficiency of This CQE

Finally, we examine the CQE from Jones-Singh, and her incorporated report and 

affidavit. “The sufficiency of a CQE is a question of law, and the standard ‘is the same as 

determining whether a complaint is legally sufficient[.]’” Jordan, 256 Md. App. at 567 

(quoting Carroll, 400 Md. at 180 n.11). Thus, we assume the truth of all well-pleaded 

allegations in the CQE, “taking all permissible inferences in favor of its validity[.]” Id. 

We conclude the CQE is prima facie sufficient to support both Jones-Singh’s breach and 

proximate cause attestations. 

We first note that Jones-Singh did not diagnose Mr. Robinson’s decubitus ulcers. 

Instead, his medical records establish that a registered nurse performed nursing 

assessments upon admission on August 16, 2018, and again on August 20, 2018,

documenting the appearance and progression of multiple pressure ulcers and other 

compromised skin conditions. Consistent with treating decubitus ulcer care as a core 

nursing function, the record cited in Jones-Singh’s report (and incorporated into her CQE) 

reflects that identifying, documenting, preventing, and treating decubitus ulcers were 

responsibilities undertaken by Canton Harbor’s registered nurses. 

Jones-Singh reviewed Mr. Robinson’s care in light of her education and experience 

in managing skilled nursing services for long term care patients. As Mrs. Robinson points 

out, Jones-Singh’s report and affidavit reflect her peer-to-peer review, i.e., examination by 

a registered nurse with education and experience in treating incontinent and immobile 

nursing communities already know—that nurses routinely engage in the prevention and 

treatment of decubitus ulcers.
31

patients at a skilled nursing facility providing long term care, based on records relating to 

the care rendered to that patient. 

In her CQE and affidavit, Jones-Singh identified herself as a registered nurse with 

more than 16 years of clinical and management experience that includes staffing and 

managing a skilled nursing facility providing long term care to patients requiring assistance 

with mobility and continence care. Reflecting her training and experience, she 

demonstrated her familiarity with the specific federal nursing standards of care cited in her 

Report regarding skilled nursing services to prevent and treat decubitus ulcers. After 

accepting those medical diagnoses and nursing records, Jones-Singh observed that Canton 

Harbor’s nurses were responsible for conducting and supervising skin checks, 

repositioning, and other preventive and therapeutic ulcer-care protocols throughout Mr. 

Robinson’s five months at Canton Harbor. Given the significant risk of Mr. Robinson 

developing pressure ulcers while at Canton Harbor, his documented medical and nursing 

care history, and Jones-Singh’s stated expertise in skilled nursing standards for the 

prevention and care of decubitus ulcers, Mrs. Robinson presented a sufficient factual basis 

to establish that Jones-Singh was qualified to attest to a reasonable degree of nursing 

certainty that Canton Harbor breached standards of nursing care in a manner that 

proximately caused Mr. Robinson’s pressure ulcer injury.

CONCLUSION

We hold that in a negligence action filed under Maryland’s HCMCA against a 

skilled nursing facility alleging pressure ulcer injury, a CQE may be predicated on 

attestations by a registered nurse that a skilled nursing facility’s breach of applicable 
32

nursing standards proximately caused a patient’s ulcer injury. See CJP § 3-2A-04(b)(1). 

Because Mrs. Robinson’s CQE was based on sufficient attestations by Jones-Singh, the 

circuit court erred in dismissing this complaint. Accordingly, we vacate the judgment and 

remand for further proceedings.11

JUDGMENT OF THE CIRCUIT COURT 

FOR BALTIMORE CITY VACATED AND 

CASE REMANDED FOR FURTHER 

PROCEEDINGS CONSISTENT WITH 

THIS OPINION. COSTS TO BE PAID BY 

APPELLEE.

11 Because we hold that Mrs. Robinson’s CQE was sufficient, we need not address 

her argument that the circuit court erred by denying her an extension of time to file a 

corrected CQE.