Supreme Court of Texas

══════════

No. 22-0317

══════════

Jesse Uriegas, as Guardian of Brandon Uriegas, 

an Incapacitated Person,

Petitioner,

v.

Kenmar Residential HCS Services, Inc.,

Respondent

═══════════════════════════════════════

On Petition for Review from the

Court of Appeals for the Seventh District of Texas

═══════════════════════════════════════

PER CURIAM

A care facility resident fell twice and sustained serious injuries. 

His guardian sued the facility for negligence and provided two expert 

reports to support the claims. The trial court ruled that the reports 

provide a fair summary of the experts’ opinions regarding the standard 

of care, breach, and the cause of injury, as the Texas Medical Liability 

Act requires. See TEX. CIV. PRAC. & REM. CODE § 74.351(a), (l), (r)(6). 

The court of appeals reversed, concluding that the reports lack sufficient 

detail about the appropriate standard of care and breach. We conclude 

that the reports sufficiently set forth a standard of care and breach 
2

linked to the underlying alleged facts, and therefore we reverse the court 

of appeals’ judgment.

I

Brandon Uriegas, a nonverbal adult, lives with severe intellectual 

disabilities, deformity of both feet, scoliosis, autism, and osteoporosis. 

In 2006, he moved into a residential care facility for people with 

developmental disabilities. Respondent Kenmar Residential HCS 

Services managed the facility.

In September 2018, Uriegas fell and hit his head while showering. 

The parties dispute whether a Kenmar staff member attended Uriegas 

at the time he fell. At the emergency room, Uriegas received three 

staples to treat lacerations to his scalp. Later that evening, Kenmar 

staff reported that Uriegas appeared “wobbly.”

The following day, Uriegas fell a second time while using the 

toilet, allegedly without staff assistance. Kenmar staff allegedly did not 

arrange for a medical evaluation.

On the morning of September 24—one day after the second fall 

and two days after the first—Kenmar staff reported that Uriegas could 

not stand and that his foot was swollen. Uriegas was taken to the 

hospital and admitted that afternoon with a fractured left hip and 

femur. He required surgery and was hospitalized for twenty-one days.

Jesse Uriegas, Uriegas’s father and legal guardian, sued Kenmar 

for negligence, gross negligence, and negligent hiring and supervision of 

its employees. He alleged that Kenmar, among other things, “fail[ed] to 

provide adequate supervision for [Uriegas] during daily activities, 
3

including the use of bathroom facilities,” “fail[ed] to provide reasonable 

and adequate care,” and “fail[ed] to timely seek medical treatment.”

Jesse Uriegas served Kenmar with an expert report by Maureen 

Hildebrandt, a certified rehabilitation registered nurse. Nurse 

Hildebrandt’s report states that the appropriate standard of care 

requires that “all injuries, regardless of severity, . . . be assessed and 

documented” because Uriegas was “incapable of verbalizing his needs” 

and “could not be relied upon to report injury-related pain/discomfort.” 

Uriegas also “was incapable of independently performing all aspects of 

personal care in the bathroom,” and thus “a staff member would need to 

be present while [Uriegas] was taking a bath/shower.” The report 

indicates that after the first fall, the standard of care required “close 

monitoring at all times, especially when [Uriegas] was walking 

anywhere.” Nurse Hildebrandt’s report identifies Kenmar’s breach as 

“failing to [e]nsure that [Uriegas]’s [individual care plan] accurately 

reflected the specific care necessary based on [Uriegas]’s specific needs” 

and “failing to properly implement the necessary interventions in 

[Uriegas]’s plan of care both before and after [the date of injury].”

Kenmar objected to Nurse Hildebrandt’s report on several 

grounds. The trial court sustained Kenmar’s objection to Nurse 

Hildebrandt’s qualifications to opine on causation; it overruled 

Kenmar’s other objections and permitted supplementation with an 

expert report by Dr. Brett Cascio, an orthopedic surgeon. In his report, 

Dr. Cascio opined that the standard of care included “significant 

monitoring and assistance when moving” to prevent falls, “frequent and 

thorough evaluations for injury,” and, after a fall, “a complete and 
4

thorough medical evaluation . . . to ensure that [Uriegas] did not sustain 

a serious injury that he is unable to relay to caretakers.” Dr. Cascio 

identified Kenmar’s breach: “there was not any staff to assist [Uriegas] 

getting in and out from the bathroom”; “Kenmar failed to provide 

assistive care personnel and equipment”; “[a]fter the falls, Kenmar did 

not properly assess [Uriegas] for injuries”; and “Kenmar and employees 

failed to provide the appropriate monitoring and assistance.”

Kenmar objected to this report as well. The trial court overruled 

Kenmar’s objections and denied its motion to dismiss. Kenmar 

appealed.

The court of appeals reversed, holding that the reports failed to 

provide a fair summary of the standard of care and the alleged breach 

of that standard. ___ S.W.3d ___, 2022 WL 843890, at *1 (Tex. App.—

Amarillo Mar. 11, 2022). One justice would have held that Dr. Cascio’s 

report provided a fair summary. Id. at *6 (Quinn, C.J., concurring and 

dissenting). 

II

The Texas Medical Liability Act requires healthcare liability 

claimants to timely serve a defendant healthcare provider with an 

adequate expert report. TEX. CIV. PRAC. & REM. CODE § 74.351(a), (l). 

An expert report is adequate if it “represent[s] an objective good faith 

effort” to provide a “fair summary of the expert’s opinions . . . regarding 

applicable standards of care, the manner in which the care rendered by 

the physician or health care provider failed to meet the standards, and 

the causal relationship between that failure and the injury, harm, or 

damages claimed.” Id. § 74.351(l), (r)(6). An expert report demonstrates 
5

a good faith effort and thus satisfies the statute’s requirements when it 

“(1) inform[s] the defendant of the specific conduct called into question 

and (2) provid[es] a basis for the trial court to conclude the claims have 

merit.” Baty v. Futrell, 543 S.W.3d 689, 693-94 (Tex. 2018). In 

articulating the standard of care and breach, an expert report “must set 

forth ‘specific information about what the defendant should have done 

differently’”; that is, “‘what care was expected, but not given.’” Abshire 

v. Christus Health Se. Tex., 563 S.W.3d 219, 226 (Tex. 2018) (quoting 

Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 880 

(Tex. 2001)).

The Act permits a claimant to satisfy the requirement with 

multiple reports “by serving reports of separate experts regarding 

different physicians or health care providers or regarding different 

issues arising from the conduct of a physician or health care provider.” 

TEX. CIV. PRAC. & REM. CODE § 74.351(i). Thus, we review the adequacy 

of reports in the aggregate. See Abshire, 563 S.W.3d at 223 (“[O]ne 

expert need not address the standard of care, breach, and causation; 

multiple expert reports may be read together to determine whether 

these requirements have been met.”).

In this case, the trial court properly sustained Kenmar’s objection 

to Nurse Hildebrandt’s report because she was not qualified to opine on 

causation. See TEX. CIV. PRAC. & REM. CODE § 74.351(r)(5)(C) (requiring 

that a qualified physician opine on causation). The trial court granted

an extension to file Dr. Cascio’s report and, after receiving the second 

report, viewed both reports together and permitted the suit to proceed. 

In denying Kenmar’s motion to dismiss, the trial court necessarily found 
6

that the two reports together provide a fair summary of the alleged 

standard of care, breach, and causation, as the Act requires.

In Nurse Hildebrandt’s report, she opines that the standard of 

care required “a staff member . . . to be present while [Uriegas] was 

taking a bath/shower” because Uriegas “was incapable of independently 

performing all aspects of personal care in the bathroom.” His diagnoses 

of osteoporosis and bilateral pedal deformity “increas[ed] the risk of 

falls” and “placed [him] at a higher risk for injury in the event of a fall.”

Leaving aside Uriegas’s general increased risk of falling, Nurse 

Hildebrandt further explains that a fall placed Uriegas at an increased 

risk of an undetected injury because he was “incapable of verbalizing his 

needs” and “could not be relied upon to report injury-related 

pain/discomfort.” Given his limited ability to self-report injury, the 

standard of care in Uriegas’s case required that “all injuries, regardless 

of severity, . . . be assessed and documented.” After the first fall, the 

report indicates that it was “clearly and undeniably the responsibility of 

the nursing staff” to modify Uriegas’s care to include “close monitoring 

at all times, especially when [Uriegas] was walking anywhere.”

In further support of the alleged standard of care, Dr. Cascio 

explains in his report that the care plan for someone with Uriegas’s 

diagnoses should include “significant monitoring and assistance when 

moving” to prevent falls, “frequent and thorough evaluations for injury,” 

and, after a fall, “a complete and thorough medical evaluation . . . to 

ensure that [Uriegas] did not sustain a serious injury that he is unable 

to relay to caretakers.”
7

Dr. Cascio opines that “the proper standard of care [was] to fully 

examine [Uriegas] for injury and evaluate the existing care plan to 

determine if a change or correction is needed.” Kenmar “should have 

conducted a thorough evaluation for injury considering that [Uriegas] is 

essentially nonverbal and cannot convey injuries himself.”

Kenmar contends that the reports do not provide a fair summary 

of the standard of care. In its view, Nurse Hildebrandt’s report is

impermissibly vague. For example, the report recommends updating 

the care plan after a “change in status” but does not define what a 

“change in status” means; she suggests that “immediate interventions” 

were required after Uriegas’s fall but fails to describe those 

interventions; and she prescribes training for staff without explaining 

what instruction should have been given to train them in “how to 

properly monitor and care for the client.” Kenmar further contends that

Dr. Cascio should have addressed the number of people Kenmar should 

have placed in the position of monitoring Uriegas, their schedule, and 

the type of assistance they should have provided. Agreeing with 

Kenmar, the court of appeals concluded that Nurse Hildebrandt 

provided “conclusory statements that fail[ed] to inform Kenmar of what 

it should have done differently.” 2022 WL 843890, at *4. The court of 

appeals similarly rejected Dr. Cascio’s report because it “provide[d] no 

details regarding what constitutes ‘appropriate’ or ‘significant’ 

monitoring and assistance,” did not “explain who was responsible for 

administering an examination or what an examination should have 

encompassed,” and did not “explain what specific action Kenmar should 

have taken but did not.” Id. at *5.
8

While the two reports may lack sufficient specificity with respect 

to initial monitoring and fall protection, when viewed together, they

sufficiently describe the standard of care for someone with Uriegas’s 

diagnoses as requiring a thorough evaluation for injuries after a fall and 

increased staff monitoring after a fall takes place to ensure that the

patient does not attempt to use the toilet without assistance. According 

to the alleged underlying facts, Uriegas received no medical evaluation 

or treatment after his second, unmonitored fall until the next day. With 

respect to Kenmar’s alleged lack of post-fall monitoring, evaluation for 

injury, and treatment, Dr. Cascio’s report sufficiently sets forth the 

standard of care and breach. Dr. Cascio’s report calls for monitoring 

Uriegas “when moving” after the first fall. While the reports lack 

specifics in some instances, they provide a fair summary of the standard 

of care for the claim of failure to appropriately monitor Uriegas after his 

two falls. Further, the reports are based on the underlying factual 

allegations that Kenmar failed to monitor according to an appropriate 

care plan after a fall. In Dr. Cascio’s view, Kenmar failed to increase 

monitoring, evaluate Uriegas for injuries, or seek evaluation before and 

after his second fall, as he states the appropriate standard of care 

requires.

In Miller v. JSC Lake Highlands Operations, LP, a nursing home 

resident died after aspirating on her dental bridge. 536 S.W.3d 510, 512

(Tex. 2017). The expert reports explained that the nursing home staff 

knew her dental bridge was missing and that her voice sounded raspy; 

under those circumstances, the standard of care required staff to check 

the resident’s throat for the missing bridge and take her to the 
9

emergency room. Id. at 517. The staff’s failure to do so contributed to 

the delay that ultimately, in the experts’ opinion, caused her death. Id. 

In this case, as in Miller, the standard of care depends on the facility 

staff’s alleged knowledge: that Kenmar staff knew that Uriegas was at 

increased risk of injury from falls due to his diagnoses and he could not 

verbalize his complaints. In Miller, the standard of care required

looking in the patient’s throat; according to the experts in this case, it 

required additional monitoring and evaluation of symptoms, like 

appearing “wobbly” after a fall. 

Kenmar further challenges the reports as lacking specificity 

about breach of the standard of care. Kenmar observes that it brought 

Uriegas to the hospital after his first fall, which, it contends, disproves

that it breached the standard of care. Without more, a health care 

provider’s disagreement with the expert’s opinion in a Chapter 74 report

does not render the report insufficient. See, e.g., Miller, 536 S.W.3d at 

516-17 (“At this preliminary stage, whether [the expert’s articulated 

standards] appear reasonable is not relevant to the analysis of whether 

the expert’s opinion constitutes a good-faith effort.”). Even so, Dr. Cascio 

faults Kenmar for failing to monitor Uriegas upon his return to the 

facility, which he notes resulted in delayed medical evaluation, and for 

its failure to properly treat Uriegas’s injuries after the second fall. The 

first trip to the hospital does not address these alleged breaches. We 

conclude that Dr. Cascio’s opinion as to breach provides a fair summary 

of the claims against Kenmar.

The court of appeals likened Dr. Cascio’s report to one that 

improperly “infer[red] breach of a standard of care from the fact that an 
10

injury exists that normally should not.” 2022 WL 843890, at *6 (quoting 

Hoelscher v. San Angelo Cmty. Med. Ctr., No. 03-03-00236-CV, 2004 WL 

2731967, at *3 (Tex. App.—Austin Dec. 2, 2004, no pet.)). But the report 

notes that Uriegas required a thorough examination after a fall and 

additional monitoring because Uriegas’s condition prevents him from 

communicating his personal needs and injuries to a caregiver. Dr. 

Cascio recites specific facts to support his opinions: Kenmar allegedly 

knew of Uriegas’s diagnoses, knew that he was at risk for falling again

without assistance, and knew that because Uriegas could not report 

injuries to staff, he required a thorough evaluation after a fall. In Dr. 

Cascio’s opinion, Kenmar did not provide the required assistance and 

evaluation.

Finally, the court of appeals faulted Nurse Hildebrandt’s report 

for “not explain[ing] how the outcome would have changed” had Kenmar 

complied with the alleged standard of care and for “not assert[ing] that 

the failure to have a nurse assess [Uriegas] after this fall was the 

proximate cause of his injuries.” 2022 WL 843890, at *5. Dr. Cascio 

opines, however, that a proper assessment would have led to earlier 

medical intervention and treatment and the thirty-hour delay 

contributed to Uriegas’s injuries. Only physicians are qualified to opine 

on causation, and Kenmar does not challenge Dr. Cascio’s opinion as to 

causation. See TEX. CIV. PRAC. & REM. CODE § 74.351(r)(5)(C).

* * *
11

We hold that the trial court did not abuse its discretion in denying 

Kenmar’s motion to dismiss under Chapter 74. The proffered reports

provide a fair summary of the experts’ opinions as to the appropriate 

standard of care and breach of that standard. Accordingly, without 

hearing oral argument, we reverse the court of appeals’ judgment and 

remand the cause to the trial court for further proceedings. See TEX. R.

APP. P. 59.1.

OPINION DELIVERED: September 15, 2023