i i i i i i



### MEM ORA ND UM OP INION No
. 04 -0 9- 00 40 2- CV REGENT CARE CENTER OF OAK WELL F ARMS a/k/a Reg ent Care Center of San Antonio I IL imited Partnership d/b/a Reg ent Care Center of Oakwe ll Far

ms, Rege nt Care Cente r of San Antonio I I , L imited Partners, Reg ent Care Gene ral Partne r, Inc., Reg ent Care Oper ations

Gene ral Partne r, I nc., and Re g ent Care Center of San Antonio, Ap pe lla nts
v . Dianne CR

AI G , A nd

y Sic hi, and

Jean B ra nnum, Appellee s Fr om the 288th J udicial District Court, Be x ar County , Texas

Trial Court No. 2008-CI -20152 Honora ble Antonia Arte ag a, Judge Pre siding Opinion by : Catherine Stone, Chief Justice Sitt ing: Catherine Stone, Chief Justice

Kar en Ang elini, J ustice Sandee B ry an Mar ion, J ustice Deliver ed and F iled: Dec ember 9, 2009 AFF I RMED Reg ent Care Center of Oakwe ll Fa rms a/k/a Reg ent Care Center of San Antonio I IL imited P art n e r s h i p d

/ b / a R e g e n tC ar e C e n t e r o f O a k w e l l F ar m s , R e g e n tC ar e C e n t e r

o f S anA n t o n i o II, L imited Partners, Reg ent Care Gene ral Partne r, Inc., Reg ent Care Oper ations Gene ral Partne r, I nc.,04

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- 2- and Re g e nt Care Ce nte r of San A nto nio (“ Re g e nt C are ” ) a pp e a l th e tr ia l c ourt ’s or de r d e nyingthe ir motion to di smiss t he under ly ing c ause f or fa ilu re t o timely

serve an expert re port under se ction 74.351 of the Te x as Civil P rac tice and Re medies Code (“ Code”). Reg ent C are prese nts four issues
on a pp e a l a sse rt ingthe tr ia l c ourt a bu se d it s d isc re tio n in : ( 1) fa il in g to di smi ss t he c a us e a s to
c e rt a in d e fe nd ants no t me nti on e d in the e xpe rt

re po rt; (2) c on sid e ri ngthe re po rt of a nurs e wh os e curriculum vitae was not timely serve d; (3) conside ring causation opinions of nurses; and ( 4) finding a phy sician’s re port containing an ana ly tical g ap to be adequate. We aff irm the trial cour

t’s order
. B ACKG ROUND Dianne Cra ig, a

temporar

y resi d en t at R eg ent Care Center of San Antonio I I , L imited Partnership d/b/a Reg ent Care Center of Oakwe ll Far

ms, was found on the f

loor of her room at 4:00 a.m., unattende d, with injuries to her ey es and f ace . Craig wa s t ra n s fe rr ed to a hospit al for
emer g ency

treatment and surg ery . Craig , her husba nd, and her

daug hter (collec tively ref err ed to as “Craig ”) subse quently

sued Reg ent Care for ne g lige nt car e. I n an eff ort to c omply with se ction 74.351 of the Code, Craig serve d Reg ent Care with expert
re po rt s f ro m tw o nur se s and

on e ph y sic ian. Re g e nt C are fi le d a mot ion c ha lle ng ingthe tim e lin e ss and ade quacy

of the re ports, which the tria l court denie d.

S TA N D A R D O F R EVIEW We reviewa trial c ourt’s dec ision on a motion t o dismiss for a n abuse of d i s cr et i o n . Am. Transit ional Care Ctrs. of Tex., Inc . v. Palacios , 46 S.W. 3d 87 3, 87 8 (T e x. 20 01 ); U. S. Imaging, Inc. v . Gardner , 274 S.W .3d 693, 695 (Tex. App.—San Antonio 2007), rev’d on other grounds , 274 S.W. 3d 66 9 ( Te x. 20 08 ). A tri a l c ourt a bu se s its dis c re tio n if

it a c ts i n a

n a rb itr ary or un re a so na

ble04

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- 3- manner or without ref

ere nce to any g uiding rules or pr inciples. W alker v . Gutierrez , 111 S.W .3d 56, 62 (T e x. 20 03 ); Downer v. Aquam arine Operators, Inc

. , 701 S.W .2d 238, 241-42 (Te x . 1985). D I S CUS S I ON I n its first issue, Rege nt Care c omplains that the trial court abused its discre tion in deny ing its mot ion to dism iss a s to thr ee defe ndants who wer e not mentioned in the expert repor ts. At the hear ing on Re g ent Care ’s motion, however , the attorne y s for both Re g ent Care and Craig informed the trial cour

t that a Rule 11 ag ree ment was signe d by both a ttorney s pursuant to w hich Craigag ree d t o am en d h er p l ea d i n gs t o re m o v e t h e t h re e d ef en d an t s i nqu es t i o n , an d

R ege n tC ar e a gre edt o fo re go the statut or

y mot ion to dis mis s re g ard ing tho se e nti tie s. Ac c or din g ly , th e tr ia l c ourt did no t a bu se its dis c re tio n in

de nyingthe motio n to di smi ss t he thr e e de fe nd ants sin c e Re g e nt C are a g re e d to fo re g o th e mot ion

a s to tho se de fe nd ants
. I n it s second is su e, Re g e nt C are c omp la ins that th e tr ia l c ourt a bu se d it s d isc re tio n in consideringa re port provided by Patsy Henr y , R.N. beca

use her cu r r iculum vitae wa s n ot t ime ly
serve d. At the hea

ri n g o n Reg ent Care ’s motion, Craig’ s attorney responde d to Reg ent Care ’s
a sse rt ion that N ur se He nr

y ’s curriculum vitae wa s n o tt i m el y s er v edb y

as s er t i n g: MR. B RA I

N [Cr a ig ’s a tto rney ] : On th e iss ue of the fax tha t w a s se nt, if Ic ou ld prese nt to the court – I

have e vidence here. I h ave a re cord showingthat the fa x es wer e sent a

nd rec eived. I ’d off

er my own statement in the wa

y of – as a n office r of the cour t that Irepe atedly

tried fa x ing the resume of Ms. Henry

an d s ucce eded on Marc h 30th at 3:44 in the after noon, and the r ecor d from my send log indicates it was c omp le te d, and an a dd iti on a l tw o pa g e s we re se nt te n min ute s la te r a ll a

bo ut N ur se He nr y ’s qu a lif ic a tio ns . I ta lke d to Ms. Com e ri o a bo ut t his . I su g g e ste d th a t sh e ta lk to her staf

f and g et bac k to me, but until y esterda y Ithought this was a

nonissue. The trial c ourt did not abuse its discretion in finding that the curriculum vitae of Nurse Henr y was t i m ely serve d by

fac simil e tra

nsmissi on. Se e Ba nd

a v . G ar c ia , 955 S.W .2d 270, 272 (Tex. 1997)04

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- 4- (attorne y ’s unsworn state ments considere d evidenc e whe re othe r par ty fails to object). More over, Reg ent Care does not cha lleng e the a dequac y of the e x pert re port submitted by another nurse, Mildred A. Toth, M.S., R.N., A.O.C.N., who also addr essed the a pplicable standa

rd of c are . I n its thi rd issue, Reg ent Care assets the trial court abused its discr etion by consideringthe
causation opinions of Nurse Henr y and Nurse Toth contra

ry to se ction 74.403(a) of the Code which
r e qu ir e s a p h y s ic ia

n to o p in e o n c a

u sation. See T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.403(a) (Ve rnon 2005). Nothingcontained in the re cord, how ever , supports Reg ent Care ’s asser tion that the trial court c onsidered the nurses’ causation opinions. I nstead, the rec ord contains an e x pert re port of a ph y sic ian w hic h the tr ia l c ourt c ou ld pr op e rl y have c on sid e re d in fi nd ing the re po rt s a de qu a te with reg ard to c ausation. Se e id
. I n it s f ourt h is su e , Re g e nt C are c on te nd s th a t th e e xpe rt re po rt of Dr . Wil liam G a rr e tt contained an analy

tical g ap betwe en the standa rd of c are and ca

usation. Reg ent Care further
c o n t e n d s t h a tD r . G ar

r e t t ’ s r e p o rti s i n t e r

n a l l y i n c o n s i s t e n t , s p e c u l a t i v e , an d c o n c l u s o r

y. Whe n c on sid e ri nga

mot ion to d ism iss un de r s e c tio n 7 4. 35 1, the iss ue fo r the tr ia l c ourt is whether the plaintiff' s expert report c onstitut es a “g ood-fa ith effor t” to comply

with section 74.351. U. S. Imaging, Inc

. , 274 S.W .3d at 695. To constitut e a go o d -f ai t h eff ort, the re port must: (1) inform the defenda

nt of t he specific conduct called into question by the pl aintiff’s claims; and (2) p ro v i d e a ba sis from which the tria l court may conclude the claims have merit. Id . Although a n expert repor

t need not mar shal all of the plaintiff’ s proof, it must explain the basis for the expert’s opinion. Id
. The opini on may not mere ly state conc lusions reg ardingcausation, but mus t link the conclusions to the fa cts. Id
. A c o u rt lo o k s n o f u rth e r th an th e f

o u r c o r n e r s o f the doc ument. Id
.04

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- 5- This require ment prec ludes a c ourt from filling g aps in a repor t by draw ing infere nces or g uessing as to what the e x pert likely meant or intende d. Id . at 695-96. Both Nurse Toth and Nurse Henr y stated that the a

pplicable standa

rd of c are require d Reg ent Care to a ssess Craig for the r isk of fall and to implement fall pre cautions. Given Cra ig’ s history and the medicatio n s s h e wa s taking , she wa s in dang er of falling . Moreove r, the medic al re cords
reve aled that Reg ent Care failed to implement fa ll preca utions in accorda

nce wi t h R eg ent Care ’s protocols or even as order ed by Craig ’s phy sician. These fall prec autions would have inc luded a low bed, fa ll mats, and a bed a larm that would have aler ted Reg ent Care staff w hen Craigwas moving or trying to e x it her bed. Dr. Ga rre tt init ially

notes in his report that the pr ecise mecha nism of Crai g’s i n

j u ry was
unc le ar d

u e to Re g e n t Ca

r e ’ s “ in a d e qu a te an d s u b s ta n d ar d d o c ume n tati o n ” r e g ar d in g the circ ums t an ce s of Craig ’s fa ll and the assessment of her c ondition between the time she was discovere d on the floor a

nd the time she wa s transported to a hospital almost an hour and a half later
. Dr. Ga rre tt states that Reg ent Care ’s re port containe d littl e or no doc umentation of where Cra ig “ was found in the room in re lation to her bed, w hether she wa s found on a mat, whether there was blood on any objects in the room,” “ whether bed ra ils were in plac e, whe ther any nurse ha d attended to he r in the past few

hours, or a

ny other activity in relation to the patient that might shed light on her injury and the mec hanism of injury .” Dr . Gar rett fu rt h er state s that Reg ent Care ’s re cords c ontained no documentation of w hat questions wer e aske d when Craig was discove red on the floor or w hat her
answe rs wer e, despite r ecor ds showing that Craig was responsive and answe red que stions that were asked.04

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- 6- Wit h reg ard to c ausation, Dr. G arr ett o p i n es that the most likely explanation for Craig ’s injuries “is that [C raig ] di d not ha ve the fall prec autions such as low bed and bedside mats that were order ed by

the phy sician and that are not documented a s having been implemente d in the Reg ent Care c hart.” Be cause of Re g e nt C a r e ’ s inadequate re porting , Dr. Ga rre tt mentions t he possibility that Cr a ig c ou ld h a ve be e n h it i n th e e y e by ano the r re sid e nt or sta ff me mbe r. Dr
. Ga rr e tt the n d isc ounts thi s p os sib ili ty , s ta ti ng an attac k b y ano the r p a tie nt o r s ta ff

me mbe r “ se e m[e d] un lik e ly , ma inl y beca use one w ould expect to see some re port of cr iminal conduct b y t h e fa cil ity if that happe ned, espec ially since [Craig was] describe d as able to answer questions on bei n g fo u n d i n an injured state.” D r. Ga

rre tt a lso me ntions the possibili ty that Craig could have been le ft unattende d during “toileting” beca

use the patient history in the hospitals’ rec ords wher e Craig was take n for e merg ency tr e a tme nt c on ta in “ se ve ra l no ta tio ns of the patie nt h a vin g be e n ta ke n to the bathr oo m or

tr y ingto make it t o t h e b at h room in association with the circ umstances of her injury .” Reg ent Care emphasizes this statement by Dr. Ga rre tt, asserting that the re port does not contain a ny discussion of the standa

rd of c are relating to “toileting.” Howeve r, Dr. Gar rett fur ther states in his re port that if the pr op er fa ll p re c a

uti on s h a d b e e n im

ple me nte d, inj ur

y a lso c ou ld h a ve be e n avo ide d if the se
we re the a c tua l circu ms tanc e s p re c e din g Cr a ig ’s fa ll. Ag a in, Dr . G arr e tt m e nti on e d th e se po ssi bil iti e s o nly

du e to R e g e nt C are’s ina de qu a te re po rt ing . A t th e e nd of his re po rt , D r. Ga

rr e tt
re tur ns to t he mos t li ke ly

e xplanatio n o f t

he c a us e of Cr aig’s in

ju ry – th e a bs e nc e of the fa ll pr e c a uti on s – and su mma ri zes his op ini on

wi th r e g ard

to c a us a tio n a s f

oll ow s: 3
. Ca usa l c onne c ti on be twe e n fail ure to f ollow St anda r ds o f Ca r e and In juryto th e P at ie nt –

A s e xp la in e d

in d e ta il a b o v e , th e p a ti e n t sustaine d a seve re injury to her left ey e that was discove red in the e arly morning hours of September 28, 2006 at Reg ent Care . Be cause she wa s found on her rig ht side with a laceration and hematoma on the rig ht side, it is probable that she04

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- 7- str uc k o r w a s str

uc k in a fa ll or oth e r tr a

umatic e ve nt fi rs t on he r l e ft sid e in the left e y e, whe re the more seve re injury was sustained, a nd then fe ll to the fl oo r o n h e r r ig ht s ide . T he patie nt w a s ta ke n to the e me rg e nc y

de pa rtme nts of t wo hos pitals and found to have a ruptured g lobe i n the l eft ey e, a severe injury requiringemer g ency surg ery and has suffe red impairment of her sig ht in her lef t ey e that wa s obviously

cause d by

the traumatic eve n t at Reg ent Care. Had the appropr iate fall prec autions of the fac ility ’s Protocol I I , or e ve n th e lim ite d o ne s o rd e re d by Dr. Rog e r, be e n im ple me nte d o n th is patient, it is highly

unlikely if not imp o s s i b l e t h at she could have bee n in a vu lne ra ble po sit ion

in the mid dle of the nig ht su c h that sh e c ou ld e ith e r a ri se by herse lf and fa ll unattended in her room or else wher e and sustain the kind of injury to her lef t ey e that she w as found to have on Sep t em ber 28, 2006, or be othe rwise unattended such that she could suffe r a tra umatic eve nt such a s th e on e tha

t c a us e d th e se inj ur ie s. Th ere is no a de qu a te a sse ssm e nt i n Reg ent Care rec ords of the c ause of the injuries, and no information on what the patient said in answe ring questions that would have be en re lated to that issue in these circ umstances a fter she was found to have bee n injured. I n view of the foreg oing, we conclude the trial court did not abuse its discretion in finding that Dr. Ga

rre tt’s report c onstitut ed a “ g ood-fa ith effor t” to comply

with section 74.351 with reg ard to t he e le me nt o f c a

us a tio n. Dr . G arr e tt c a

us a lly linke d the fa ilure to i mpl e me nt f a ll p re c a uti on s w ith C r a i g ’ s s u

b s e qu e n tf

a l l an d i n j u r y. C ONCL US I ON The trial c ourt’s orde r is aff irmed. Catherine Stone, Chief Justice