Opinion issued July 25, 2013

In The

Court of Appeals 

For The 

First District of Texas 

————————————

NO. 01-12-00658-CV

———————————

SELECT SPECIALTY HOSPITAL-HOUSTON LIMITED PARTNERSHIP 

D/B/A SELECT SPECIALTY HOSPITAL HOUSTON WEST, Appellant

V.

KEITH SIMMONS AND KIRK SIMMONS, Appellees

On Appeal from the 125th District Court

Harris County, Texas

Trial Court Case No. 2012-02433

MEMORANDUM OPINION

This is an interlocutory appeal from the denial of appellant’s motion to 

dismiss appellees’ claims under Chapter 74 of the Texas Civil Practice and 

Remedies Code. We affirm. 
2

BACKGROUND

Plaintiffs/appellees Keith Simmons and Kirk Simmons (Plaintiffs) are the 

children of Willie Lee Simmons (Simmons), who is now deceased. Plaintiffs sued 

defendant/appellant Select Specialty Hospital-Houston Limited Partnership d/b/a 

Select Specialty Hospital Houston West (Select Specialty) complaining of its 

nurses’ medical care of Simmons before his death. Plaintiffs served two medical 

expert reports, one by Cheryall Sparks, RN and one by Sheila Chachere, MD. 

Select Specialty filed objections to the reports and a motion to dismiss. The trial 

court denied the motion, and Select Specialty filed this interlocutory appeal. 

A. Plaintiffs’ Allegations

The following facts are taken from Sparks’s and Chachere’s expert reports.1 

Simmons, a 69-year-old man, was transferred from Memorial Hermann City 

Medical Center to Select Specialty on July 15, 2011. Select Specialty’s admission 

database reflected a diagnosis of “Respiratory Failure, Deconditioning, Pulmonary 

Fibrosis, SOB, ARDS, and Malnutrition.” According to the Nurse Progress Notes, 

Simmons “arrived alert, on a ventilator, and with a trachcostomy, IV, foley, and 

feeding tube.” 

 

1

Throughout its brief, Select Specialty challenges the accuracy of the statements in 

Sparks’s and Chachere’s reports. For purposes of our review of the adequacy of a 

medical expert report under Chapter 74, however, we take the allegations in the 

report as true. Marino v. Wilkins, 393 S.W.3d 318, 320 n.1 (Tex. App.—Houston 

[1st Dist.] 2012, pet. denied).
3

Sparks’s report states that, when Simmons arrived at Select Specialty, there 

was “no documentation of any skin breakdowns, wounds, redness, or discoloration 

anywhere on his body.” Select Hospital’s records reflect that Simmons was rated 

as a high risk for bedsores. On August 12, 2011, he was found unresponsive by a 

nurse. On September 15, 2011, and again on September 19, 2011, he experienced 

a low heart rate and blood pressure. He died later on September 19, 2011. 

Sparks’s report contains the following synopsis of the nurses’ documentation

of treatment of Simmons’s bed sores:

On July 16, 2011, one day after Mr. Simmons’ admission to Select 

Specialty, the nurses first documented that Mr. Simmons had a Stage 

II wound on his sacrum. A Stage II wound is a wound that shows 

openings in the skin. Stage II wounds are characterized by the partial 

loss of the 1st and 2nd layers of skin. Stage II wounds are shallow 

with a red or pink ulcer bed. On July 17, 2011, the nurses also 

reported that Mr. Simmons had left and right buttock skin wounds 

with light drainage and no odor. As a result, the nurses reported that 

Mr. Simmons’ dressing was to be changed daily per orders. On July 

17, 2011 the nurses applied a santyl dressing to Mr. Simmons’ left and 

right buttock skin wounds. A santyl dressing is a collagenase enzyme 

used to help heal burns and skin ulcers, which are skin wounds. In 

normal practice, santyl is applied daily. 

On July 23 and 24, 2011, Mr. Simmons was not repositioned every 2 

hours. In addition, the nurses did not document dressing changes for 

July 24, 2011. On August 1, 2011, the nurses documented that Mr. 

Simmons developed an inner gluteal fold skin wound. On August 2, 

2011, the nurses applied a hydrocolloid dressing to Mr. Simmons’ 

inner gluteal fold skin wound. A hydrocolloid dressing is an adhesive 

wafer applied to skin ulcers, which can be changed every 3-5 days.

On August 3, 7, and 9, 2011, the nurses did not reposition Mr. 

Simmons every 2 hours and documented no dressing changes. On 
4

August 6, 2011, Mr. Simmons developed a Stage II inner thigh skin 

wound. No dressing changes were documented at the report of this 

Stage II wound. On August 10, 2011, the nurses reported that Mr. 

Simmons was incontinent of urine. Incontinent of urine means that 

Mr. Simmons was incapable of controlling his urinary functions. On 

August 20, 2011, the nurses reported that Mr. Simmons was 

incontinent of feces. Incontinent of feces means that Mr. Simmons 

was incapable of controlling his bowel functions. From then, there 

are documentations stating that the nurses dressed Mr. Simmons’ skin 

wounds, including his pressure ulcers, occasionally. As the days 

progressed, Mr. Simmons’ skin wounds, including his pressure ulcers, 

became multiple in numbers.

Sparks’s report alleges that Select Specialty’s nurses breached the applicable 

standard of care in several respects related to the prevention and treatment of 

bedsores. Specifically, they (1) failed to treat Mr. Simmons’s skin wounds with 

santyl dressing on a daily basis between July 15, 2011 and August 1, 2011 (despite 

doctor’s orders to do so and despite daily changing santyl dressings being the 

“normal practices”), (2) failed to correctly administer hydrocolloid dressings 

between August 1, 2011 and September 19, 2011, and (3) failed to correctly 

reposition Mr. Simmons to address his development of bed sores.

Chachere’s report was based upon a review of Sparks’s report, and opined 

that Select Specialty’s breaches of the standard of care caused Simmons’s 

bedsores.

B. Select Specialty’s Motion to Dismiss 

Select Specialty filed a motion to dismiss, asserting that Sparks and 

Chachere were not qualified to render their opinions, and that their reports were 
5

otherwise deficient. The trial court denied Select Specialty’s motion, and it 

brought this appeal. 

ISSUES ON APPEAL

Select Specialty brings two issues on appeal: 

1. “[T]he trial court abused its discretion when it overruled 

Appellant’s Objections and denied Appellant’s Motion to 

Dismiss because Cheryall Y. Sparks, R.N. and Sheila L. 

Chachere, M.D. are not qualified to address issues of standard 

of care, breach and causation as to Select Specialty.”

2. “[T]he trial court abused its discretion when it overruled 

Appellant’s Objections and denied Appellant’s Motion to 

Dismiss because the expert reports of Cheryall Y. Sparks, R.N. 

and Sheila L. Chachere, M.D. do not adequately address the 

issues of standard of care, breach and causation as to Select 

Specialty Hospital.” 

APPLICABLE LAW

A. Standard of Review

We review a trial court’s ruling on a motion to dismiss for lack of an 

adequate medical report for an abuse of discretion. Larson v. Downing, 197 

S.W.3d 303, 304–05 (Tex. 2006) (citing Broders v. Heise, 924 S.W.2d 148, 151 

(Tex. 1996)); Strom v. Mem’l Hermann Hosp. Sys., 110 S.W.3d 216, 220 (Tex. 

App.—Houston [1st Dist.] 2003, pet. denied). A trial court abuses its discretion if 

it acts arbitrarily, unreasonably, or without reference to guiding rules or principles. 

See Lookshin v. Feldman, 127 S.W.3d 100, 103 (Tex. App.—Houston [1st Dist.] 
6

2003, pet. denied). We do not disturb the trial court’s discretion absent clear 

abuse. Larson, 197 S.W.3d at 304 (citing Broders, 924 S.W.2d at 151).

B. Chapter 74 Expert Report Requirements

Section 74.351 serves as a ‘gate-keeper’ through which no medical 

negligence causes of action may proceed until the claimant has made a good-faith 

effort to demonstrate that at least one expert believes that a breach of the 

applicable standard of care caused the claimed injury. See TEX CIV. PRAC. & REM.

CODE ANN. § 74.351 (Vernon 2011); Murphy v. Russell, 167 S.W.3d 835, 838 

(Tex. 2005). A report need not marshal all of the plaintiff’s proof, but it must 

include the expert’s opinions on the three statutory elements: standard of care, 

breach, and causation. See Am. Transitional Care Ctrs. Of Tex. Inc. v. Palacios, 

46 S.W.3d 873, 878, 880 (Tex. 2001); Spitzer v. Berry, 247 S.W.3d 747, 750 (Tex. 

App.—Tyler 2008, pet. denied) (quoting Palacios, 46 S.W.3d at 880) (stating “fair 

summary” is “something less than a full statement” of applicable standard of care, 

how it was breached, and how that breach caused injury).

To constitute a good faith effort, the report must provide enough information 

to fulfill two purposes: (1) inform the defendant of the specific conduct that the 

plaintiff has called into question; and (2) provide a basis for the trial court to 

conclude that the claims have merit. Palacios, 46 S.W.3d at 879. A report that 

merely states the expert’s conclusions as to the standard of care, breach, and 
7

causation does not fulfill these two purposes. Id. The expert must explain the basis 

for his statements and link his conclusions to the facts. Bowie Mem’l Hosp. v. 

Wright, 79 S.W.3d 48, 52 (Tex. 2002) (citing Earle v. Ratliff, 998 S.W.2d 882, 890 

(Tex. 1999)). The trial court may not draw any inferences, but must rely 

exclusively on the information contained within the report’s four corners. See 

Palacios, 46 S.W.3d at 878. 

In addition to setting forth the requisite criteria, a Chapter 74 report must be 

authored by a qualified “expert.” TEX. CIV. PRAC. & REM. CODE ANN. § 

74.351(r)(6). The standards governing qualifications of an expert report in support 

of a claim against a non-physician defendant are set forth in section 74.402.

§ 74.402. Qualifications of Expert Witness in Suit Against Health 

Care Provider

(a) For purposes of this section, “practicing health care” includes:

(1) training health care providers in the same field as the 

defendant health care provider at an accredited educational 

institution; or

(2) serving as a consulting health care provider and being 

licensed, certified, or registered in the same field as the 

defendant health care provider.

(b) In a suit involving a health care liability claim against a health 

care provider, a person may qualify as an expert witness on the issue of 

whether the health care provider departed from accepted standards of care 

only if the person:

(1) is practicing health care in a field of practice that 

involves the same type of care or treatment as that delivered by 

the defendant health care provider, if the defendant health care 
8

provider is an individual, at the time the testimony is given or 

was practicing that type of health care at the time the claim 

arose;

(2) has knowledge of accepted standards of care for health 

care providers for the diagnosis, care, or treatment of the 

illness, injury, or condition involved in the claim; and

(3) is qualified on the basis of training or experience to offer 

an expert opinion regarding those accepted standards of health 

care.

(c) In determining whether a witness is qualified on the basis of 

training or experience, the court shall consider whether, at the time the claim 

arose or at the time the testimony is given, the witness:

(1) is certified by a licensing agency of one or more states of 

the United States or a national professional certifying agency, 

or has other substantial training or experience, in the area of 

health care relevant to the claim; and

(2) is actively practicing health care in rendering health care 

services relevant to the claim.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.402.

QUALIFICATIONS

In its first issue, Select Specialty argues that “neither Nurse Sparks nor Dr. 

Chachere are qualified to render opinions against Select Specialty.” According to 

Select Specialty, Simmons’s “grave medical conditions” upon his admittance to 

Select Specialty, “are significant in determining whether Nurse Sparks, an 

obstetrics nurse, and/or Dr. Chachere, a pediatrician, are qualified to offer expert 

opinions as to this patient and the care this patient received at Select Specialty.” 
9

As for Nurse Sparks, Select Specialty contends that she is not qualified 

because, while she has extensive employment history in the field of obstetrics, 

“nothing in her report or her curriculum vitae demonstrate that she has ever worked 

at a long-term acute care facility such as Select Specialty or that she has ever cared 

for elderly patients suffering from the significant pulmonary and cardiac conditions 

Mr. Simmons suffered from at the time he presented to Select Specialty.” 

Moreover, “nothing in Nurse Sparks’ report or curriculum vitae evidence any 

experience whatsoever in treating patients with a tracheotomy or ventilator 

dependence, such as Mr. Simmons, in a long term acute care facility such as Select 

Specialty.”

Similarly, with regard to Dr. Chachere—a board certified pediatrician—

Select Specialty contends that “a review of her expert report and her curriculum 

vitae fail to demonstrate her qualifications to offer opinions in this case.” Select 

Specialty acknowledges that Chachere has experience treating chronically ill 

children, but argues that is not comparable to treatment of a chronically ill elderly 

person.

A. Plaintiffs’ claims 

Plaintiffs’ petition alleges Select Specialty’s nurses were negligent in the 

following specific respects related to the prevention and treatment of bedsores:

a. Failing to treat Mr, Simmons’ condition properly; 

specifically: (i) failing to treat Mr. Simmons’ skin wounds, including 
10

his pressure ulcers, with santyl dressing once per day between July 15, 

2011 and August 1, 2011; (ii) failing to treat Mr. Simmons’ skin 

wounds, including his pressure ulcers, with hydrocolloid dressing 

every 3-5 days between August 1, 2011 and September 19, 2011; and 

(iii) failing to reposition Mr. Simmons every two (2) hours to alleviate 

his pressure ulcers. 

b. Failing to provide the medical and nursing care 

reasonably required for Mr. Simmons’ condition; specifically: (i) 

failing to treat Mr. Simmons’ skin wounds, including his pressure 

ulcers, with santyl dressing once per day between July 15, 2011 and 

August 1, 2011; (ii) failing to treat Mr. Simmons’ skin wounds, 

including his pressure ulcers, with hydrocolloid dressing every 3-5 

days between August 1, 2011 and September 19, 2011; and (iii) 

failing to reposition Mr. Simmons every two (2) hours to alleviate his 

pressure ulcers.

. . . .

f. Leaving Mr. Simmons unattended for up to ten (10) 

hours at a time; and 

g. Failing to monitor Mr. Simmons’ pressure ulcers for up 

to ten (10) hours at a time.

B. Nurse Sparks’s Qualifications

Sparks’s curriculum vitae reflects that she is a nurse who currently practices 

and teaches in the field of obstetrics, and that she currently works as a nurse 

consultant. She has also worked as nurse manager in the field of oncology, as well 

as held positions as a labor-and-delivery nurse, recovery-room nurse, clinical 

nurse, cardio-vascular intermediate-care nurse, urology nurse, and medical-surgery 

nurse. 
11

Her report states that she “is currently a registered nurse in the State of 

Texas with over 30 years of experience,” and describes her qualifications as 

follows:

My nursing experience includes caring for cardiovascular, internal 

medicine, surgical, urology, obstetrical, oncology and radiology 

patients. During my nursing practice, I cared for many elderly 

patients and prevented, dressed, and treated skin wounds including 

pressure ulcers. . . .

I also managed a nursing staff at Jefferson Davis Hospital and at M.D. 

Anderson Hospital. In that capacity, I was involved in writing patient 

policies and procedures for nurses. I also served on the Peer Review 

Committee at Kelsey Seybold Clinic for two years. While serving on 

the committee, I determined whether nurses fell below the standard of 

care for nurses.

I currently consult practicing registered nurses on many subjects, 

including how to prevent, treat, and dress patient skin wounds, 

including pressure ulcers, which are the same skin wounds 

complained of by Mr. Willie Lee Simmons. Based upon my 

knowledge, skill, experience, training, and education, I am familiar 

with the applicable standard of care required for nurses to prevent, 

treat, and dress skin wounds, including pressure ulcers.

Finally, her report states that it is applicable to actions “taken or not taken by 

Select Specialty, by and through its registered nurses . . . . during Mr. Simmons’ 

stay at the hospital.”

The trial court did not abuse its discretion in concluding that Sparks was 

qualified to opine as to whether the Select Specialty’s nurses departed from the 

accepted standards of care in preventing and treating pressure ulcers. Sparks’s 

curriculum vitae and report reflect that she is currently practicing as a registered 
12

nurse, and currently consults with practicing nurses on the prevention and 

treatment of pressure ulcers like those suffered by Simmons. TEX. CIV. PRAC. &

REM. CODE Ann. § 74.402(b)(1), (a)(2).2 Her report details her knowledge of the 

accepted standards of care and experience in treating both the complained of 

condition—i.e., pressure ulcers—and specifically treating them in elderly patients. 

While Select Specialty correctly points out that Sparks does not profess to 

have experience caring for “ventilator dependent patients with co-morbidities of 

respiratory failure, deconditioning, pulmonary fibrosis, shortness of breath, acute 

respiratory distress syndrome and malnutrition at a long term acute care facility,” 

section 74.402 of the Texas Civil Practice and Remedies Code does not require 

such specific experience to qualify Sparks as an expert in the prevention and 

treatment of pressure ulcers—the subject of Plaintiffs’ claims. See, e.g., Mem’l 

Hermann Healthcare Sys. v. Burrell, 230 S.W.3d 755, 759 (Tex. App.—Houston 

[14th Dist.] 2007, no pet.) (holding physician qualified to opine about standard of 

care for preventing bedsores based on report stating, “I am familiar with the 

 

2

Select Specialty contends that Sparks is not “practicing health care in a field of 

practice that involves the same type of care or treatment as that delivered by the 

defendant health care provider,” as required by section 74.702(b). That argument, 

however, does not take into account section 74.702(a), which provides “practicing 

health care includes . . . serving as a consulting health care provider and being 

licensed, certified, or registered in the same field as the defendant health care 

provider.” Nurse Sparks’ curriculum vitae reflects that she is a licensed, registered 

nurse, and that she currently works as a nurse consultant. Her report states that 

she currently “consult[s] practicing registered nurses on many subjects, including 

how to prevent, treat, and dress patient skin wounds, including pressure ulcers, 

which are the same skin wounds complained of by Mr. Willie Lee Simmons.”
13

standard of care as it pertains to prevention and treatment of decubitus ulcers. I 

have experience in instructing nurses and other personnel in the proper techniques 

to prevent decubitus ulcers and I have treated patients with decubitus ulcers over 

the course of my practice as an infectious disease internist and occupational 

doctor.”); Esquivel v. El Paso Healthcare Sys. Ltd, 225 S.W.3d 83, 89–90 (Tex. 

App.—El Paso 2005, no pet.) (holding that professor of nursing, who also “served 

in various capacities at a 450-bed hospital, including assistant administrator for 

nursing services, acting director, director of nursing services, director of staff 

education, and nursing supervisor,” whose report states that she was “familiar with 

the standard of care for skin care and prevention of decubitus ulcers as well as 

documentation, observation, assessment ,and intervention required,” was qualified 

as expert as to the standard of care and breach, but not causation). 

C. Dr. Chachere’s Qualifications

Chachere’s curriculum vitae reflects that she currently works in the field of 

pediatrics, caring for “well and chronically ill children and adolescents.” She has 

practiced and taught in the field of pediatrics in several capacities for different 

employers. Her report elaborates about how her current practice and experience 

relates to Select Specialty’s treatment of Simmons:

My medical knowledge, skill, experience, training, and education 

includes, but is not limited to, caring for and teaching medical 

students how to care for hundreds of children with chronic healthcare 

needs. For example, many of my chronically ill patients included 
14

children with spina bifida, which means that the patient’s spine failed 

to form correctly. Due to spina bifida, the children were highly 

immobile and incontinent of feces and urine. Incontinence of feces 

means that the children were incapable of controlling their bowel 

functions similar to Mr. Willie Lee Simmons’ condition during his 

treatment by [Select Specialty] nurses. Many of my hospice patients 

exhibited identical conditions.

Due to my patients’ medical conditions, I have to prevent, treat, and 

dress their skin wounds, including pressure ulcers. I also had to teach 

my students how to perform the same acts. Pressure ulcers, also 

known as decubitus ulcers, are open wounds that form whenever 

prolonged pressure is applied to skin covering bony outcrops of the 

body. Patients who are bedridden like many of my patients and Mr. 

Simmons are at high risk of developing pressure ulcers . . . .

Even though Mr. Simmons was a 69 year old elderly man, his injuries, 

namely skin wounds, including pressure ulcers, are common to and 

equally developed in the field of pediatrics. I also have practical 

knowledge of what is usually and customarily done by nurses 

confronted with a patient suffering from skin wounds, including 

pressure ulcers. As a professor at Baylor College of Medicine, I had 

to train nurses on how to prevent, treat, and dress patient skin wounds, 

including pressure ulcers, during nursing in-service.

Patients exhibiting a high risk to pressure ulcers include those who are 

obese, elderly; or suffering from chronic diseases, infections, injuries; 

or in a poor nutritional state. Many of my pediatric patients were 

chronically ill, which put them at a high risk for pressure ulcers 

similar to how Mr. Simmons was at a high risk for pressure ulcers 

because he was an elderly, chronically ill man. In addition, I have 

read medical literature, and reviewed case studies on what causes skin 

wounds, including skin ulcers, in both young and elderly patients. 

I currently monitor and prevent skin wounds, including pressure 

ulcers, from developing on my patients with spina bifida and other 

chronic illnesses as a private practitioner at Porter Pediatrics and did 

so during the time that Select Specialty’s nurses treated Mr. Simmons. 

The trial court did not abuse its discretion in concluding that Chachere is 

qualified to render an opinion as to causation. Select Specialty argues that she 
15

Chachere is not qualified because “[n]either her expert report nor her curriculum 

vitae demonstrate any experience or training whatsoever in the field of geriatrics or 

in caring for chronically ill elderly patients who are ventilator dependent with the 

same multiple co-morbidities Mr. Simmons had at the time he was a patient at 

Select Specialty.” But her report explains that the causes and treatment of pressure 

ulcers in an elderly patient like Simmons are similar to the causes and treatment of 

chronically ill pediatric patients that she currently treats.3 Thus, she “is practicing 

health care in a field of practice that involves the same type of care or treatment” 

as Select Specialty’s nurses. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.402 

(b)(1). Her report demonstrates that she has knowledge of the acceptable standards 

of care for the diagnosis, care, and treatment of pressure ulcers, and that she is 

qualified on through experience to offer an expert opinion. TEX. CIV. PRAC. &

REM. CODE ANN. § 74.402(b)(2)–(3). 

Moreover physicians with qualifications similar to Chachere’s have 

consistently been held qualified as experts to opine on the standard of care, breach, 

and causation related to the prevention and treatment of pressure ulcers. For 

 

3 Her report specifically states that Simmons’s injuries, namely “skin wounds, 

including pressure ulcers, are common to and equally developed in the field of 

pediatrics.” See Newman v. Graham, 316 S.W.3d 197, 200–201 (Tex. App.—

Dallas 2010, no pet.) (“A medical expert with a different specialty than the 

defendant physician may testify ‘so long as the subject of the inquiry is common 

to and equally recognized and developed in both fields” (quoting Broders, 924 

S.W.2d at 152)). 
16

example, in San Jacinto Methodist Hosp. v. Bennett, the Fourteenth Court of 

Appeals summarized the expert physician’s qualifications as follows, and affirmed 

the trial court’s determination that the expert was qualified:

In his report, Dr. Hammond stated he was practicing medicine at all 

times relevant to the claims made in the case and was actively 

practicing at the time of his opinion. He is board certified in internal 

medicine and had been board certified in nephrology from 1996 to 

2006, i.e., a period overlapping the time Taylor’s injury allegedly 

occurred. Dr. Hammond stated that the two certifications “directly 

address the subject matter of this claim, as the claim relates to 

management of decubitus ulcers.” Dr. Hammond indicated, because 

he had either trained, served as a consultant to, or observed health care 

providers in the same fields as the defendants, he has knowledge of 

the accepted standards of medical care for the diagnosis, care, and 

treatment related to the prevention and management of decubitus 

ulcers. He further stated he is “familiar with the standard of care for 

both nurses and physicians for the prevention and treatment of 

decubitus ulcers.” Finally, Dr. Hammond explained, “I give direct 

care to patients with decubitus ulcers and was doing so at all times 

relevant to this case. As such, I am also familiar with the 

consequences of improper management of decubitus ulcers that is not 

within the standard of care.” 

256 S.W.3d 806, 813 (Tex. App.—Houston [14th Dist.] 2008, no pet.). In holding 

the physician’s report sufficiently established his qualifications, the Bennett court 

noted that his statement “compares favorably to that held sufficient in Burrell”: 

I completed a fellowship in infectious disease and have practiced for 

over 25 years in infectious disease. I am a frequent speaker at various 

regional and national medical conferences and have been a consultant 

for the Massachusetts Department of Health. I have reviewed various 

medical records concerning Katie Whitfield and I am familiar with the 

standard of care as it pertains to prevention and treatment of decubitus 

ulcers. I have experience in instructing nurses and other personnel in 

the proper techniques to prevent decubitus ulcers and I have treated 
17

patients with decubitus ulcers over the course of my practice as an 

infectious disease, internist and occupational doctor.

Id. (quoting Burrell, 230 S.W.3d at 759).

Similar to the experts in Bennett and Burrell, Chachere states that she has 

treated patients with pressure ulcers, and instructed students how to prevent, treat,

and dress pressure ulcers. She has read medical literature, and reviewed case 

studies on what causes skin wounds, including skin ulcers, in both young and 

elderly patients. At the time of Simmons’s care, part of Chachere’s practice was to 

monitor and prevent pressure ulcers from developing on patients suffering from 

chronic illnesses. Finally, she explains how her knowledge and experience related 

to pressure ulcers are applicable to patients like Mr. Simmons. 

Because we conclude that the trial court did not abuse its discretion in 

concluding that Sparks and Chachere were qualified, we overrule appellants’ first 

issue.

REPORTS

 In its second issue, Select Specialty contends that the “expert reports of 

Nurse Sparks and Dr. Chachere are insufficient on the elements of standard of care, 

breach and causation as to Select Specialty.” Specifically, it argues that “neither 

Nurse Sparks nor Dr. Chachere are qualified by education, training or experience 

to offer opinions on the standard of care, breach or causation as to Select 

Specialty.” 
18

With regard to Sparks’s report, Select Specialty relies primarily on American 

Transitional Care Centers of Texas v. Palacios, 46 S.W.3d 873, 880 (Tex. 2001) to 

argue that her articulation of the standard of care and breach is insufficient. In 

Palacios, the supreme court held that a single statement in an expert report “that 

precautions to prevent [plaintiff’s] fall were not properly utilized” was not a 

sufficient statement of the standard of care applicable to the defendant hospital. Id.

at 879–80. The court explained that “the standard of care for a hospital is what an 

ordinary prudent hospital would do under the same or similar circumstances,” and 

that “[w]hether a defendant breached his or her duty to a patient cannot be 

determined absent specific information about what the defendant should have done 

differently.” Id. at 880. According to Select Specialty, Nurse Sparks’ report “fares 

no better” because it contains only “generalized statements regarding standard of 

care . . . and breach.”

With regard to Dr. Chachere’s report, Select Specialty argues that it does not 

describe, with sufficient specificity, “how the alleged breach of the standard of 

care caused the complained of results.” Rather, Select Specialty argues, 

Chachere’s report is impermissibly conclusory.

A. Nurse Sparks’s Report

With regard to bedsores, Sparks’s report states that she is “familiar with the 

applicable standard of care required for nurses to prevent, treat, and dress skin 
19

wounds, including pressure ulcers.” The report further states that the applicable 

standard of care in found in the Texas Standards of Nursing Practice, and provides 

in part that: (1) “A nurse shall know the rationale for and the effects of medications 

and treatments and shall correctly administer the same,” and (2) “A nurse shall 

implement measures to promote a safe environment for clients and others.” 

Under the heading of “Breach of Standard of Care,” Sparks’s report 

discusses the standards of care for the prevention and treatment of bedsores, and 

opines that Select Specialty’s nurses breached those standards:

The nurses breached the standard of care applicable to nurses by 

failing to correctly administer santyl dressings. More specifically, the 

nurses failed to treat Mr Simmons’ skin wounds, including his 

pressure ulcers, with santyle dressing on a daily basis between July 

15, 2011 and August 1, 2011. In normal practice, santyle dressing is 

applied daily to help heal burns and skin ulcers. Further, the nurses 

received orders to change Mr. Simmons’ santyl dressing daily and 

failed to do so, which a nurse of ordinary prudence would not have 

done under the same or similar circumstances. Since the nurses failed 

to treat Mr. Simmons’ skin wounds, including his pressure ulcers, 

with santyl dressing once per day, they breached the standard of care 

applicable to nurses that states that a nurse shall correctly administer 

treatments and medications.

In addition, the nurses breached the standard of care applicable to 

nurses by failing to correctly administer hydrolloid dressings. More 

specifically, the nurses failed to treat Mr. Simmons’ skin wounds, 

including his pressure ulcers, with hydrocolloid dressing between 

August 1, 2011 and September 19, 2011. A hydrocolloid dressing an 

adhesive wafer applied to skin ulcers every 3-5 days, The nurses’ 

failure to apply hydrocolloid dressing every 3-5 days to Mr. 

Simmons’ skin wounds, including his pressure ulcers, was an act that 

a nurse of ordinary prudence would not have done under the same or 

similar circumstances. Since the nurses failed to treat Mr. Simmons’ 
20

skin wounds, including his pressure ulcers, with hydrocolloid dressing 

every 3-5 days, they breached the standard of care applicable to nurses 

that states that a nurse shall correctly administer treatment and 

medications. 

Moreover, the nurses breached the standard of care applicable to

nurses by failing to correctly reposition Mr. Simmons. More 

specifically, when Mr. Simmons arrived at Select Specialty on July 

15, 2011, his Braden Scale for Predicting Pressure Sore Risk totaled 

10, which placed him at a high risk for skin breakdown. On July 22, 

1011, Mr. Simmons developed gluteal skin wounds. On August 1, 

2011, Mr. Simmons developed an inner gluteal fold skin wound. On 

August 6, 2011, Mr. Simmons developed a Stage II inner thigh skin 

wound. On August 8, 2011, Mr. Simmons developed another gluteal 

fold wound. On August 9, 2011, Mr. Simmons developed a right 

inner thigh wound. On August 3, 7, and 9, 2011 the nurses failed to 

reposition Mr. Simmons every two hours, which is not what a nurse of 

ordinary prudence would have done under the same or similar 

circumstances. In addition, on August 2 and 3, 2011, the nurses 

decided not to reposition Mr. Simmons for up to ten (10) hours at a 

time. Since the nurses failed to reposition Mr. Simmons every two 

hours, the nurses breached the standard of care applicable to nurses to 

correctly administer treatment and medications. 

The trial court did not abuse its discretion in concluding that Sparks’s report 

adequately addressed the elements of standard of care and breach against Select 

Specialty as it relates to Simmons’s development of bedsores. An expert report 

must “provide[] a fair summary of the expert’s opinions as of the date of the report 

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

the physician or health care provider failed to meet the standards.” TEX. CIV.

PRAC. & REM. CODE ANN. § 74.351(r)(6). “[A] fair summary must set out what 

care was expected, but not given, and how that caused the injury.” Spitzer v. 

Berry, 247 S.W.3d at 750 (quoting Palacios, 46 S.W.3d at 880). 
21

Unlike the one-sentence standard-of-care statement in Palacios “that 

precautions to prevent [plaintiff’s] fall were not properly utilized,” which the 

supreme court found insufficient, 46 S.W.3d at 880, Sparks’s report provides a fair 

summary of what the Select Specialty’s nurses should have done, and how they 

failed to meet the applicable standard. Specifically, Sparks’s report specifically 

identifies what should have been done and what was not done in relation to (1) 

correctly and timely administering santyl dressing, (2) correctly and timely 

administering hydrocolloid dressing, and (3) timely and correctly repositioning

Simmons. E.g., Columbia N. Hills Hosp. Subsidiary, L.P. v. Alvarez, 382 S.W.3d 

619, 629 (Tex. App.—Fort Worth 2012, no pet.) (expert reports sufficient because 

they “put the hospital on notice of what care [experts] opined was required but not 

given”); Carrillo v. Palacios, No. 13-08-00418-CV, 2008 WL 4981558, at *7 

(Tex. App.—Corpus Christi Nov. 25, 2008, no pet.) (holding report was specific 

enough to put defendant on notice of what care nurses should have provided, how 

nurses breached standard of care, and how that breach caused decubitus ulcers, and 

provided the trial court with a basis to determine if claims had merit). 

B. Dr. Chachere’s Report 

With regard to causation, Chachere’s report provides the following opinion 

of how the breaches of the standard of care identified by Sparks’s report 

contributed to Simmons’s development of bedsores:
22

Santyl dressing is applied daily to skin wounds to help heal burns and 

skin ulcers. So the nurses’ failure to treat Mr. Simmons’ sacrum, 

buttocks (gluteal), and though with santyl dressing once per day 

between July 15, 2011 and August 1, 2011 even after being ordered to 

do so, more likely than not, in reasonable medical probability, directly 

caused skin wounds, including pressure ulcers, to develop on Mr. 

Simmons’ sacrum, buttocks, and thigh. Santyl dressing is used to 

treat skin ulcers, so the nurses’ failure to apply the santyl dressing to 

Mr. Simmons skin wounds once per day could only result in Mr. 

Simmons developing skin ulcers on his sacrum, buttocks, and thigh.

Hydrocolloid dressing is applied every 3-5 days to skin wounds to 

help heal burns and skin ulcers. As a result, the nurses’ failure to treat 

Mr. Simmons’ sacrum, buttocks, and thigh with hydrocolloid dressing 

every 3-5 days between August 1, 2011 and September 19, 2011 more 

likely than not, in reasonable medical probability, directly caused skin 

wounds, including ulcers, to develop on Mr. Simmons’ sacrum, 

buttocks, and thigh. Hydrocolloid dressing is used to treat skin ulcers 

so the nurses’ failure to apply the hydrocolloid dressing every 3-5 

days to Mr. Simmons could only result in Mr. Simmons developing 

skin ulcers on his sacrum, buttocks, and thigh. When Mr. Simmons 

arrived at Select Specialty on July 15, 2011, he had no skin 

breakdowns, wounds, redness, or discoloration anywhere on his body. 

Mr. Simmons, however, being a 69 year old elderly and chronically ill 

patient was at a high risk for developing pressure ulcers because he 

laid immobile in this bed during his treatment at Select Specialty. 

One of the major factors in the development of pressure ulcers is a 

prolonged pressure on a part due to the weight of the body or a limb. 

So the nurses’ failure to reposition Mr. Simmons every two hours 

caused prolonged pressure on Mr. Simmons’ sacrum, buttocks, and 

thigh, which more likely than not, in reasonable medical probability, 

caused skin wounds, including pressure ulcers, to develop on Mr.

Simmons’ sacrum, buttocks, and thigh. The nurses’ failure to 

reposition Mr. Simmons every two hours, and in some cases 

reposition him only every ten hours, combined with the accumulation 

of urine and feces, which causes skin breakdown, more likely than 

not, in reasonable medical probability, directly caused skin wounds, 

including ulcers, to develop on Mr. Simmons’ sacrum, buttocks, and 

thigh. 
23

The trial court did not abuse its discretion in determining that Chachere’s 

report adequately addressed the element of causation as it relates to bedsores. An 

expert is required to link his or her conclusions to the facts, but no “magical 

words” are required. Bowie Mem’l Hosp., 79 S.W.3d at 53. While Select 

Specialty argues that Chachere’s causation opinions are impermissibly conclusory, 

we conclude that her opinions are as, or more, specific than causation statements 

found to be adequate in other cases. Her report specifically identifies and links 

each alleged breach of the standard of care related to failure to treat Simmons with 

santyl dressings, failure to treat Simons with hydrocolloid dressing, and failure to 

reposition Simmons to his development of bedsores. E.g., Bennett, 256 S.W.3d at 

817 (expert report was not impermissibly conclusory with regard to causation 

because it set “forth the mechanism of [patient’s] injury, specifically (1) failure to 

provide adequate initial skin assessment, hydration, and nutrition led to the 

formation of ulcers, and (2) failure to provide skin care nursing and protocol 

interventions when decubitus ulcers were detected, as well as failing to optimize 

[patient’s] nutrition and hydration led to formation of new ulcers and prevented 

healing of existing ulcers”); Gallardo v. Ugarte, 145 S.W.3d 272, 280 (Tex. 

App.—El Paso 2004, pet. denied) (report’s giving examples of things that should 

have been done to prevent and treat decubitus ulcers—including more frequent 

repositioning—adequately addressed causation “by indicating that if the proper 
24

steps had been taken the decubitus ulcers could have been prevented or at least 

prevented from progressing to stage IV”).

Because we conclude that the trial court did not abuse its discretion in 

concluding that Sparks’s and Chachere’s adequately addressed standard of care, 

breach, and causation as to plaintiffs’ claims related to bedsores, we overrule 

Select Specialty’s second issue.4 

CONCLUSION

 We affirm the trial court’s judgment. 

Sherry Radack

Chief Justice 

Panel consists of Chief Justice Radack and Justices Sharp and Massengale.

 

4

Select Specialty also challenges the sufficiency of the expert reports as they relate 

to claims that Simmons was left unattended in unsanitary conditions such that ants 

and gnats accumulated in his trachea tube. Because we have concluded that the 

reports are sufficient as to the claims related to bedsores, we need not reach Select 

Specialty’s arguments about plaintiffs’ other claims. Certified EMS, Inc. v. Potts, 

392 S.W.3d 625, 630 (Tex. 2013) (case should proceed so long as expert reports 

are adequate as to one theory of liability).