COURT OF APPEALS

SECOND DISTRICT OF TEXAS

FORT WORTH

NO. 02-15-00047-CV

NEXION HEALTH AT NORTH 

RICHLAND HILLS, INC. D/B/A 

GREEN VALLEY HEALTHCARE 

AND REHABILITATION CENTER 

AND NEXION HEALTH 

MANAGEMENT, INC. D/B/A GREEN 

VALLEY HEALTHCARE AND 

REHABILITATION CENTER

APPELLANTS

V.

STEPHANIE STREET-LARSON, 

INDIVIDUALLY AND AS 

REPRESENTATIVE OF THE 

ESTATE OF ALVIA BLEDSOE, 

DECEASED

APPELLEE

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FROM THE 67TH DISTRICT COURT OF TARRANT COUNTY

TRIAL COURT NO. 067-271867-14

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MEMORANDUM OPINION1

 1

See Tex. R. App. P. 47.4.
2

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This is a health care liability suit. Appellee Stephanie Street-Larson, 

Individually and as Representative of the Estate of Alvia Bledsoe, Deceased,

sued two entities: Appellant Nexion Health at North Richland Hills, Inc. d/b/a 

Green Valley Healthcare and Rehabilitation Center (Health) and Appellant 

Nexion Health Management, Inc. d/b/a Green Valley Healthcare and 

Rehabilitation Center (Management) (collectively the Nexion entities). Her claims 

were based on allegations of abuse and neglect of her father, Alvia Bledsoe, 

while he was in the care of a nursing facility owned and operated by the Nexion 

entities. The trial court denied the motion to dismiss filed by the Nexion entities

under section 74.351 of the civil practice and remedies code.2

 In three issues, 

the Nexion entities argue that the trial court abused its discretion by denying their 

motion. Because we hold that the expert report served on the entities by StreetLarson was adequate, we affirm the trial court’s order.

Background

Street-Larson alleged that Bledsoe had been a resident of the facility from 

May 1, 2011, through June 9, 2012, and that he died on June 15, 2012, due to 

the negligent acts and omissions of the Nexion entities. She further alleged, 

however, that Bledsoe was discharged from the facility on April 29, 2012, and 

was then admitted to a hospital.

 2

Tex. Civ. Prac. & Rem. Code Ann. § 74.351 (West 2011 & Supp. 2014).
3

Upon Bledsoe’s admission to the hospital, physicians discovered four 

pressure ulcers on his body. Street-Larson alleged that doctors also diagnosed 

him with a severe urinary tract infection, sepsis, malnutrition, bronchitis, and 

acute renal failure. Bledsoe died on June 15, 2012. Street-Larson sued and 

served the Nexion entities with the expert report of Dr. Lige B. Rushing.

Dr. Rushing specializes in internal medicine and rheumatology. In his 

report, Dr. Rushing discussed the care and treatment provided by “Green Valley 

Healthcare and Rehabilitation and its staff (hereinafter referred to collectively as 

‘Defendants’)”. His report did not use the names Nexion Health at North 

Richland Hills, Inc. or Nexion Health Management, Inc.; he referred only to 

“Green Valley Healthcare and Rehabilitation,” “Green Valley,” “the facility,” and 

“Defendants.” Dr. Rushing described the standard of care for the facility, stated 

that none of these standards were met, and described how pressure ulcers 

formed on Bledsoe as a result of the facility’s failure to meet the standard of care. 

Dr. Rushing stated that Bledsoe was a resident of the facility through June 9, 

2012, but also stated that Bledsoe was transferred from the facility on April 29, 

2012.

The Nexion entities filed a motion to dismiss. They asserted that the report 

“fail[ed] to implicate any conduct of” Management and failed to explain the causal 

relationship between Health’s acts and Bledsoe’s injuries and death. In 

response, Street-Larson argued that the report was adequate as to causation 

and that the expert report implicated the conduct of both defendants.
4

The trial court denied the motion to dismiss. Management and Health then 

brought this interlocutory appeal.3

Standard of Review

We review for an abuse of discretion a trial court’s denial of a motion to 

dismiss under section 74.351.4

 A trial court abuses its discretion if the court acts 

without reference to any guiding rules or principles, that is, if the act is arbitrary or 

unreasonable.5

Discussion

In their first issue, the Nexion entities argue that the trial court abused its 

discretion by denying the motion to dismiss as to Health because Dr. Rushing’s 

report fails to establish the causal relationship between the alleged harm and 

Health’s conduct.

A plaintiff in a health care liability claim must provide an expert report in 

support of the claim.6

 For an expert report to be sufficient, it must fairly 

summarize the standard of care applicable to the health care provider; it must 

 3

See Tex. Civ. Prac. & Rem. Code Ann. § 51.014(a)(9) (West 2015) 

(providing that a person may appeal from an interlocutory order denying a motion 

to dismiss under section 74.351).

4

Jernigan v. Langley, 195 S.W.3d 91, 93 (Tex. 2006); Granbury Minor 

Emergency Clinic v. Thiel, 296 S.W.3d 261, 266 (Tex. App.—Fort Worth 2009, 

no pet.).

5

Low v. Henry, 221 S.W.3d 609, 614 (Tex. 2007).

6

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(a).
5

explain how the health care provider failed to meet that standard; and it must 

establish the causal relationship between the failure and the harm alleged.7

 

Regarding the causation element, the expert report must discuss causation with 

sufficient specificity (1) to inform the defendant health care provider of the 

conduct that the plaintiff has called into question and (2) to provide a basis for the 

trial court to conclude that the claims have merit.8

 Within the report, ‘“the expert 

must explain the basis of his [or her] statements to link his [or her] conclusions to 

the facts.”’

9

Street-Larson alleged in her petition that due to the Nexion entities’

negligence, her father “suffered substantial injury and damages including . . . 

Bledsoe’s pain and suffering leading up to his untimely death.” She more 

specifically alleged that their negligence led to her father developing four 

pressure ulcers, as well as “a severe urinary tract infection, sepsis, malnutrition, 

bronchitis[,] and acute renal failure.”

The main focus of Dr. Rushing’s report was the pressure ulcers. 

Describing the standard of care and the breach of that standard by the Nexion 

entities’ operators and staff, he stated,

 7

Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 630 (Tex. 2013) (construing 

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6)).

8

Jelinek v. Casas, 328 S.W.3d 526, 539 (Tex. 2010).

9

Id. (citation omitted).
6

The standard of care for a skilled nursing care facility requires 

that they neither accept nor retain a resident whose needs they 

cannot meet. One of Mr. Bledsoe’s needs was the prevention of the 

development of decubitus ulcers. He clearly developed decubitus

ulcers while he was a resident at Green Valley. . . . [T]hey knew or 

should have known that he was at high risk for the development of 

pressure ulcers and infections because of his limited mobility and 

advanced age. In order to meet the standard of care, Green Valley 

Healthcare and Rehabilitation should have provided an appropriate 

pressure ulcer prevention program. This would consist of but not be 

limited to a special mattress surface such as a low air loss mattress 

or equivalent, [and] a regular turning and repositioning program 

every two hours with documentation each time he was turned and 

repositioned. There should have been regular[ly] scheduled and 

documented head to toe skin assessments at least once a week. 

There is an occasional note in the chart that he was turned and 

repositioned but this does not meet the standard of care. It should 

have been abundantly clear to all of his caregivers that his needs 

were not being met when he developed pressure ulcers. The 

standard of care required that his caregivers notify his treating 

physician and the family that they are unable to meet his needs and 

that he should be transferred to another facility or receive care from 

another health agency that could indeed meet his needs[,] i.e.[,]

proper management for the prevention and treatment of pressure 

ulcers. In Mr. Bledsoe’s case, based on the comprehensive 

assessment of the resident, the facility and health agencies must 

insure that a resident who enters the facility without pressure ulcers 

does not develop pressure ulcers unless the individual’s clinical 

condition demonstrates that they were unavoidable and a resident 

having pressure ulcers receive the necessary treatment and services 

to promote healing, prevent infection, and prevent new sores from 

developing. There is nothing in Mr. Bledsoe’s clinical condition to 

indicate that his pressure ulcers were unavoidable.

. . . .

In summary, the care and treatment rendered to Mr. Bledsoe 

by Green Valley Healthcare and Rehabilitation fell below the

accepted standard care the following ways:

1. Accepted and retained a patient whose needs they could 

not meet.
7

2. Failed to have appropriate pressure ulcer prevention 

program.

3. Failed to properly treat Mr. Bledsoe’s pressure ulcer.

4. Failed to keep appropriate records.

5. Failed to prevent Mr. Bledsoe’s pressure ulcer.

The report, then, described the standard of care applicable to the Nexion 

entities and its staff for preventing pressure ulcers from developing and for 

preventing any existing pressure ulcers from becoming infected. The report 

further described how the facility and its staff failed to meet that standard. Dr. 

Rushing then went on to describe how this failure caused Bledsoe to develop 

pressure ulcers. He stated,

When prolonged pressure, i.e.[,] longer than two hours is 

present [on a] body part and this pressure exceeds approximately 32 

mmHg, the capillaries are compressed and the blood flow to the 

affected part is shut off. Capillaries are the smallest vessels that 

connect the arteries and the veins. Capillaries have very thin walls 

and it is through the walls of these tiny blood vessels that oxygen 

and nutrients pass into the surrounding tissue to be utilized. All 

living tissue in the body requires oxygen and nutrients to stay alive 

and to function. When the tissues are deprived of blood flow, 

oxygen and nutrients, then the death of tissue occurs, the medical 

term for this is necrosis, and in layman’s terms, the tissue simply 

dies and decays. This is precisely what happened in this case. 

Unrelieved pressure on a capillary is just like placing one’s foot on a 

garden hose, compressing it, and shutting off the flow. This is what 

happened in Mr. Bledsoe’s case: his capillaries were compressed; 

the blood flow was shut off from the tissues; the tissues died and 

became necrotic or decayed. It is in this decayed necrotic material 

that bacteria or germs set up housekeeping. This decayed tissue is 

an ideal culture medium for bacteria. It is rich in nutrients upon 

which bacteria thrive. Bacteria from the skin invade the necrotic 

tissue and multiply virtually unopposed. There is no blood supply to 

the necrotic tissue and therefore oxygen, nutrients, and white blood 

cells cannot be delivered to affected area to fight the infection. The 

infection by germs causes inflammation via toxins released by the 

bacteria. These toxins cause the production of chemical mediators, 
8

two examples of which are tumor necrosis factor alpha and 

interleukin-6. These chemical mediators themselves cause tissue 

destruction when unregulated which in turn generates more 

chemical mediators (called cytokines). This process may become a 

self-perpetuating, unregulated, and a malignant process. In 

addition, Mr. Bledsoe had known low hemoglobin levels. This is one 

process by which pressure ulcers become larger and this is what 

happened in this case. [Emphasis added.]

. . . .

. . . It is my opinion that the events and failures set forth in this 

report proximately caused Mr. Bledsoe’s injuries. Specifically, as a 

result of Defendants’ tortious misconduct described above, Mr. 

Bledsoe had prolonged, unrelieved pressure on his left hip, coccyx, 

right lateral foot and right heel. This pressure shut off the blood flow. 

When the blood flow was shut off, the tissue/skin died and decayed. 

Bacteria invaded the dead tissue and multiplied. These bacteria 

then invaded the surrounding normal tissue causing more dead and 

decayed tissue to form with more infection. This became a selfperpetuating event which caused progressive deterioration of his 

infections, which left untreated resulted in Mr. Bledsoe’s untimely 

death.

The malnutrition, pneumonia and failure to monitor also 

complicated Mr. Bledsoe’s infection and contributed to his overall 

untimely decline in condition and death. Had reasonable steps been 

taken to treat his infection and provide appropriate monitoring, to a 

reasonable degree of medical probability, Mr. Bledsoe’s life could 

have been prolonged and his pain and suffering reduced.

Dr. Rushing also stated that Bledsoe’s records noted no pressure ulcers or 

skin breakdowns at the time he entered the facility. This report describes how 

the breach of the standard of care led to Bledsoe developing pressure ulcers and 

how the ulcers became infected. The report thus explains the causal link 

between breaches of the standard of care by the facility and employees of the 

Nexion entities and the injury (pressure ulcers) suffered by Bledsoe as alleged by 
9

Street-Larson. The report therefore discusses causation with sufficient specificity 

to meet the requirements of an expert report.

The Nexion entities further challenge the report based on conflicting dates 

listed in the report. As noted, Dr. Rushing states in the report that Bledsoe “was 

a resident at the Green Valley Healthcare and Rehabilitation facility from on or 

about September 3, 2011, until June 9, 2012,” but he also states that “[o]n or 

about April 29, 2012, Mr. Bledsoe was transferred to Texas Health Harris HEB 

[hospital] after experiencing altered mental state.” The Nexion entities argue that

“that Dr. Rushing’s report is unclear regarding the date that Mr. Bledsoe actually 

left the facility, precluding any definitive determination of when or where Mr. 

Bledsoe’s injuries occurred.” We disagree.

Taking Dr. Rushing’s entire report in context, he reports that Bledsoe was 

taken from Green Valley to a hospital and that the pressure ulcers were 

discovered upon Bledsoe’s admission there. The report creates no confusion 

about Bledsoe’s developing the pressure ulcers while at the facility operated by 

the Nexion entities. Regardless of the date that Bledsoe left the facility for the 

hospital or was officially discharged from it, the report makes clear that Bledsoe 

had no pressure ulcers when he entered the facility and that he had them upon 

his admission to the hospital. And we observe that the purpose of the report is, 

in part, to inform the defendant health care provider of the conduct that the 

plaintiff has called into question, that the Nexion entities know from their own
10

records what date Bledsoe was discharged from their facility, and that this report 

informs them of the conduct that Street-Larson is challenging.

We hold that the expert report was sufficient as to causation. We overrule 

the Nexion entities’ first issue.

The Nexion entities assert in their second issue that the trial court abused 

its discretion when it denied the motion to dismiss as to Management because 

the report does not address Management’s conduct. We disagree.

When a health care liability claim against a health care provider involves a 

vicarious liability theory, an expert report need only meet the statutory standards 

as to the health care provider’s employee in order to satisfy the expert report 

requirement.10 A report that does so is sufficient to implicate the employer’s 

conduct under the vicarious liability theory.11 When the employer is sued under a 

vicarious liability theory and an expert report is served on the employer that 

meets the expert report requirements as to an employee, the employer has been 

made aware of the conduct that is at issue.12

 10Potts, 392 S.W.3d at 632.

11Id.; see also Gardner v. U.S. Imaging, Inc., 274 S.W.3d 669, 671–72 

(Tex. 2008).

12See Potts, 392 S.W.3d at 630 (stating that one purpose of the expert 

report is to inform the defendant of the specific conduct that the plaintiff has 

called into question).
11

In her petition, Street-Larson referred to both Nexion entities as doing 

business as “Green Valley Healthcare and Rehabilitation Center.”13 She referred 

to the center as “the Facility.” She then referred to the entities collectively as 

“Defendants,” and she alleged that each “Defendant” “owned, managed, 

operated, supervised, and/or staffed the nursing facility.” As noted, Dr. Rushing’s 

report did not refer to either Nexion entity and instead used the names “Green 

Valley Healthcare and Rehabilitation,” “Green Valley,” “the facility,” and 

“Defendants.”

Dr. Rushing’s report described the standard of care applicable to the 

facility and its staff, including the nurses and nursing assistants who provided 

care to Bledsoe, described how the care and treatment provided by them fell 

short of that standard, and explained how that breach caused the alleged injuries 

to Bledsoe. The report therefore meets the standard of care as to Management’s 

employees, and, accordingly, the report was sufficient as to Management. We 

overrule the Nexion entities’ second issue.

In their third issue, the Nexion entities argue that the trial court abused its 

discretion by denying their motion to dismiss because Street-Larson failed to 

submit any report addressing Management’s conduct and because, regarding 

Health, Dr. Rushing failed to provide adequate opinions on causation. Their only 

 13Management, however, referred to itself in its answer and motion to 

dismiss, as well as in its notice of appeal, as simply “Nexion Health Management, 

Inc.”
12

new argument under this issue is an argument that Street-Larson should not be 

given an opportunity to cure the deficiencies in Dr. Rushing’s report.

14 Because 

we have held that the expert report was sufficient, we overrule this issue.

Conclusion

Having overruled each of the Nexion entities’ three issues, we affirm the 

trial court’s order denying the motion to dismiss.

/s/ Lee Ann Dauphinot

LEE ANN DAUPHINOT

JUSTICE

PANEL: DAUPHINOT, WALKER, and MEIER, JJ.

DELIVERED: June 18, 2015

 14See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(c) (providing that if an 

expert report is found deficient, “the court may grant one 30-day extension to the 

claimant in order to cure the deficiency”).