Court Opinion

ID: 9963219
Source: CourtListenerOpinion
Date Created: 2024-04-24 19:06:17.231415+00
Date Added: 2024-06-11T08:24:43.046257
License: Public Domain

Felicia Robinson, et al. v. Canton Harbor Healthcare Center, Inc., No. 2169, September
Term, 2022, filed April, 24, 2024. Opinion by Beachley, J.

HEALTH CLAIMS ARBITRATION ACT – CERTIFICATE OF QUALIFYING
EXPERT – CAUSATION – PRESSURE ULCERS

        Facts: In the Circuit Court for Baltimore City, the wife and children of decedent,
Everett Robinson, filed a medical malpractice claim against Canton Harbor Healthcare
Center, a skilled nursing facility. With their complaint, the Robinsons provided a
certificate of qualifying expert (“CQE”). The CQE was authored by a registered nurse,
who opined both that Canton Harbor breached the standard of care for skilled nursing
facilities and that this breach caused Mr. Robinson to develop pressure ulcers. Canton
Harbor moved to dismiss the complaint, arguing that a registered nurse is not qualified to
provide an opinion on medical causation. The circuit court agreed and dismissed the
complaint. The Robinsons then appealed.

       Held: Reversed.

        After reviewing the statutory and regulatory framework, the Appellate Court held
that, in a case against a skilled nursing facility alleging pressure ulcer injury, a nurse with
sufficient training and experience can attest to the cause of a patient’s pressure ulcer injury
in a CQE. CJP § 3-2A-02 provides that a “health care provider” may serve as the expert
in a CQE. Registered nurses are included in the statutory definition of “health care
provider.” Various Maryland and federal statutes and regulations relating to RNs and
skilled nursing facilities indicate that the prevention and treatment of pressure ulcers are
tasks entrusted primarily to nursing staff. Furthermore, COMAR 10.27.09.02 provides that
the functions of registered nurses include nursing diagnosis, developing a plan of care that
prescribes interventions to achieve expected outcomes, and revising the plan of care based
on the effectiveness of the interventions. Together, these statutes and regulations indicate
that a sufficiently experienced and trained RN may qualify as an expert on the cause of
pressure ulcers.
Circuit Court for Baltimore City
Case No.: 24-C-22-001200
                                              REPORTED

                                     IN THE APPELLATE COURT

                                            OF MARYLAND

                                                No. 2169

                                         September Term, 2022

                                     FELICIA ROBINSON, ET AL.

                                                    v.

                                   CANTON HARBOR HEALTHCARE
                                          CENTER, INC.

                                    Arthur,
                                    Beachley,
                                    Eyler, Deborah S.
                                       (Senior Judge, Specially Assigned),

                                                   JJ.

                                         Opinion by Beachley, J.

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

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

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

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

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

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

Judicial Proceedings Article (“CJP”).

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

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

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

approximately five months following his hospitalization for a stroke. 1 Mrs. Robinson

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

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

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

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

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

       1
         Mr. Robinson’s surviving children, Sharetta Moyd, Jason Blake, and Everett B.
Robinson, III, also sued and appeal from the judgment dismissing their claims. We note,
however, that Mrs. Robinson and the surviving children later abandoned their claim for
wrongful death. See generally Spangler v. McQuitty, 449 Md. 33, 53 (2016) (“The
wrongful death statute allows the decedent’s beneficiaries or relatives to recover damages
for loss of support or other benefits that would have been provided, had the decedent not
died as a result of another’s negligence.”); CJP § 3-904(a)(1)-(b). Thus, this appeal
involves only the circuit court’s dismissal of the survival claim alleged by Mrs. Robinson
in Count One of the complaint.
care provider for damage due to a medical injury” must timely file a CQE “attesting to

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

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

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

foreclosing any further relief given the expiration of limitations.

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

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

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

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

ulcers. 2 Because Mrs. Robinson’s CQE is sufficient based on the certifying registered

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

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

                                     BACKGROUND

                    The Complaint and Certificate of Qualified Expert

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

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

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

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

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

       2
        As we explain, our holding is narrow. Although we conclude that the registered
nurse in this case may certify that a breach in the standard of care caused ulcer injury to
Mr. Robinson, we express no opinion concerning a nurse’s qualifications to attest to the
causation of other injuries, including death.
                                                  2
the facility in which [he] should have been properly treated and care[d] for.” Yet “[t]he

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

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

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

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

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

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

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

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

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

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

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

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

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

abandoned their wrongful death claim.

       Canton Harbor was served with the complaint and corresponding documents,

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

   1. I am a registered nurse and am familiar with and knowledgeable of the
      standards of care applicable to the treatment and care of an individual under
      the circumstances of the treatment and care as provided to Everette [sic]
      Robinson in this matter.

       ...

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

                                                3
   4. In my opinion to a reasonable degree of medical certainty [Canton Harbor]
      breached the standard of care and the breach was the proximate cause of Mr.
      Robinson’s injuries, i[.]e., the development of his pressure ulcers.

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

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

                              Jones-Singh’s Affidavit and Report

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

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

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

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

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

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

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

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

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

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

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

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

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

ulcer.”

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

1 is least severe, and stage 4 is most severe. Syed Rafay H. Zaidi & Sandeep Sharma,
Pressure Ulcer, National Library of Medicine, https://www.ncbi.nlm.nih.gov/books/
NBK553107/ (last updated Jan. 3, 2024).
                                                   4
       Jones-Singh reviewed Canton Harbor’s records related to Mr. Robinson, which

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

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

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

“MDS.” 4    In addition, she reviewed Mr. Robinson’s medical history showing his

“admitting diagnoses” and medications.

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

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

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

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

anticipate his needs.”

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

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

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

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

       4
        The term “MDS” is an abbreviation for “Minimum Data Set,” which is a “tool for
implementing standardized assessment and for facilitating care management in nursing
homes.” See Minimum Data Set (MDS) 3.0 for Nursing Homes and Swing Bed Providers,
Centers for Medicare & Medicaid Services, https://www.cms.gov/medicare/quality/
nursing-home-improvement/minimum-data-sets-swing-bed-providers (last updated Jan.
12, 2024).
       5
         “ADL” means “activities of daily living,” and includes eating, bathing, getting
dressed, and using the bathroom. Peter F. Edemekong et al., Activities of Daily Living,
National Library of Medicine, https://www.ncbi.nlm.nih.gov/books/NBK470404/ (last
updated June 26, 2023).

                                                 5
his right buttock and left buttock, which were then merged into a sacral ulcer.”

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

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

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

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

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

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

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

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

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

to Jones-Singh,

       [i]nitially, this area was classified as Incontinence Associated Dermatitis
       (IAD). The standard of practice states that any wound noted on a pressure
       ulcer site must be classified as such. Therefore, IAD cannot be the etiology
       of a sacral ulcer. The same sacral ulcer was initially observed as a stage 2
       ulcer and had declined to a stage 3 ulcer, where it needed a topical debriding
       agent in which Santyl was ordered.

              Mr. Everett Robinson was noted with a Suspected Deep Tissue Injury
       surrounding his sacral ulcer in a weekly skin note[] dated September 28,
       2018. A suspected deep tissue injury is damage[] to underlying skin only
       caused by friction and/or shearing. Therefore, Future Care Canton Harbor
       directly caused the SDTI to the sacrum noted on Mr. Robinson as there is no
       other etiology for this type of wound.

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

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

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

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

                                                6
perfusion” that contributed to his development of pressure ulcers. By the time he began

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

According to Jones-Singh,

      [t]he standard of practice would require that a patient/resident who has
      multiple wounds or stage 3-4 wounds receive pain medication 30 minutes to
      an hour prior to dressing changes. Mr. Robinson’s wounds had declined to
      a stage 3, meeting the aforementioned criteria. Because the attending
      Physician never addressed Mr. Robinson’s wounds and failed to provide pain
      medication prior to dressing changes, it is in my professional opinion that
      Mr. Robinson suffered unnecessary pain during his dressing changes,
      which could have been prevented with the proper interventions prior to the
      treatment.

                                                7
(Emphasis added).

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

Mr. Robinson’s records:

      [I]t is my opinion to a reasonable degree of nursing certainty, that Future
      Care of Canton Harbor breached the standard of care for skilled nursing
      facilities/post-acute rehabilitation. Their failure increased the risk of
      harm, in fact harm did occur.

      The facts and clinical analysis in this report represent a deviation from the
      acceptable standard of nursing care. This includes violations of federal and
      state regulations, which are part of the acceptable standard of care and also
      their own policies and procedures, which are part of the acceptable standard
      of care.

      [Canton Harbor’s] statutory breaches include, but are not limited to
      causing the following injuries: left buttock, right buttock, sacral ulcer, and
      a suspected deep tissue injury.

      Future Care Canton Harbor breached the standard of care by:

             • Failure to prevent, monitor, document, manage and treat skin
               injury[;]

             • Failure to provide personal hygiene such that actual harm
               occurred[;]

             • Failure to train and monitor staff compliance related to: Routine
               skin and pain assessments, ITD communication and coordination
               of care, and care of blistering (lower leg extremity) skin[;]

             • Failure to provide adequate nutrition[;]

             • Failure to address abnormal labs[; and]

             • Failure to accurately complete MDS assessments driving the care
               planning process:

                    o Failing to write and maintain up to date care plan
                      interventions that support skin breakdown prevention,
                      healing[.]

                                               8
(Emphasis added).

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

regulations establishing relevant care standards for a skilled nursing facility offering long-

term care for incontinent and bed-bound patients like Mr. Robinson, then described how

Canton Harbor’s care failed to meet those standards.

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

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

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

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

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

       • “Potential for Impaired Skin integrity”: “the facility failed to implement a
         comprehensive nursing care plan that could assist and aid[] in the prevention o[f]
         pressure ulcer formation,” so that “the nursing department did not have a guide
         to assist them in these preventative measures.”

       • “Pain related to multiple wounds”: Canton Harbor “[d]id not reflect other
         reasons for pain,” meet goals to interrupt pain, or “[p]rovide pain medication 30
         mins to an hour prior to dressing change[.]”

       • Failure to develop care plans required to meet the standards of care for
         nutritional deficit, weight loss, and pain related to wounds.

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

treatment to prevent and heal pressure ulcers.

       Based on the comprehensive assessment of a resident, the facility must
       ensure that (1) A resident who enters the facility without pressure sores does
       not develop pressure sores unless the individual’s clinical condition
       demonstrates that they were unavoidable; and (2) A resident having pressure
       sores receives necessary treatment and services to promote healing, prevent
       infection and prevent new sores from developing.

                                                 9
See 42 C.F.R. § 483.25(b)(1).

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

ulcer:

         For a resident who . . . has a pressure ulcer that is not healing, or is at risk of
         developing subsequent pressure ulcers, the facility is in compliance with this
         requirement if they:

                    • Accurately or consistently assess a resident’s skin integrity on
                      admission and as indicated thereafter

                    • Recognized and assessed factors placing the resident at risk of
                      developing a new pressure ulcer or experiencing non-healing
                      or delayed healing of a current pressure ulcer, including
                      specific conditions, causes and/or problems, needs and
                      behaviors

                    • Defined and implemented interventions for pressure ulcer
                      prevention and treatment in accordance with resident needs,
                      goals, and recognized standards of practice

                    • Address the potential for infection management

                    • Revised approaches.

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

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

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

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

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

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

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

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

                                                    10
[t]he standard of care and duty of Future Care Canton Harbor called for the following:

   √ Routine (daily) skin inspections, reporting to the charge nurse an[y] changes
     to the skin during showers and/or peri-care

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

           o Care plan interventions and physician orders identified from risk
             assessment findings

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

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

   √ Interventions to address complications related to immobility (i.e.,
     repositioning, off-loading, foot cradles and air loss mattress function)

   √ Shear and friction considerations (i.e., head of bed elevation < to 30 degrees,
     OT seating and positioning modifications, off-loading)

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

   √ Family education

           o Skin safety interventions related to non-adherence

   √ Following physician’s orders.

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

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

skilled nursing facilities,

       [t]he facts and clinical analysis in [her] report represent a deviation from the
       acceptable nursing standard of care. This includes violations of federal and
       state regulations, which are part of the acceptable standard of care and also
       their own policies and procedures, which are part of the acceptable standard
       of care.

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

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

                                                 11
in substandard care.” In turn, “[t]hese actions resulted in avoidable pressure ulcers to Mr.

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

                                      Motion to Dismiss

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

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

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

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

knowledge, skill, experience, training, or education,” Canton Harbor argued that Jones-

Singh’s CQE did not comply because “a registered nurse cannot provide expert testimony

[on] the issue of proximate causation.”

       Although Canton Harbor acknowledged that “there are no reported Maryland

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

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

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

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

defined to

       mean[] the performance of acts requiring substantial specialized
       knowledge, judgment, and skill based on the biological, physiological,
       behavioral, or sociological sciences as the basis for assessment, nursing
       diagnosis, planning, implementation, and evaluation of the practice of
       nursing in order to:

       (i) Maintain health;

       (ii) Prevent illness; or

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

                                                  12
Md. Code, (1981, 2021 Repl. Vol.), § 8-101(o)(1) of the Health Occupations Article

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(last updated March 18, 2024).

       According to Canton Harbor, because

       the term “medical diagnosis” is used in its definition of “practice medicine”
       and “nursing diagnosis” is used in its definition of “practice registered
       nursing,” the Maryland legislature made clear that registered nurses are not
       permitted to make a medical diagnosis; they are only permitted to make a
       nursing diagnosis which is limited to providing a description of a health
       problem. With that in mind, a nurse cannot provide medical causation
       testimony because, by its very nature, such testimony requires the nurse to
       opine as to whether the tortfeasor’s breach of the standards of care caused

                                                13
       the plaintiff’s injuries and/or damages. It requires more than providing a
       mere “description” of the plaintiff’s health problem.

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

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

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

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

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

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

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

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

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

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

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

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

added)).

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

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

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

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

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

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

pressure ulcers.”

                                                 14
        Because the complaint alleges claims against a skilled nursing facility, Mrs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

opine as to medical causation.”

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

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

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

                                                15
connection” between the breach in the standard of care and Mr. Robinson’s death. Any

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

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

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

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

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

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

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

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

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

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

causation,” argued that

       a nurse evaluates the patient, provides a description of the medical condition
       for the doctor, and then the doctor is left to make the decision as to what
       caused that condition, what the condition is and what treatment to provide.
       A nurse cannot stand in the shoes of a doctor in the course of her practice and
       diagnose and treat medical conditions without consulting a doctor. If she did
       that, she would lose her license. And so . . . a nurse should not be able to
       stand in the shoes of a doctor in . . . a CQE or frankly testify at trial that a
       particular condition was proximately caused by any breach in the standard of
       care because, again, that is going outside the scope of her practice.

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

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

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

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

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

                                                 16
       asking [the court] to create a bright-line rule in decubitus ulcer cases that
       there’s going to be a mandatory requirement of two certificates: One by a
       nurse who judges the standard of care as to whether it’s been breached in
       long-term healthcare facilities such as the one in the settings we’re in; and
       second, a physician’s certificate of qualified expert which then discusses the
       issue of causation. That is simply not in the statute. That is simply not in the
       case law. . . .

              We dealt with the issue and looked at it from different states, and
       under item 5 of our reply provided to the [c]ourt, at least six cases that have
       concluded the other way. Understanding that the nature of the claims deals
       with bedsores. And, particularly, one of the cases from Missouri states that
       nurses were qualified to give expert testimony regarding bedsores, their
       cause and treatment. One of the important function[s] of nurses is to prevent
       the formation of decubitus ulcers in bedridden patients.

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

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

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

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

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

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

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

issue and the medical expenses associated with that.”

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

amend, explaining:

              The issue involved in this matter is whether a registered nurse can
       serve as a qualified expert under Maryland Code Courts and Judicial
       Proceedings section 3-2A-04(b)(1)(1). The [c]ourt finds that the Plaintiff’s
       designated expert Ms. Jones-Sing[h] is a healthcare provider as -- that’s
       defined under Courts and Judicial Proceedings section 3-2A-01(f)(1). The
       [c]ourt further finds that she is qualified to attest to the standard of care and
       deviation there[from] for nurses.

                                                  17
              However, when considering Maryland Code Health Occupations 14-
      101(o) and 8-101(o) as well as COMAR section 10.27.09.01.B(16), the
      [c]ourt finds that a registered nurse cannot make a medical diagnosis, and
      therefore, cannot determine a medical condition nor the cause of a
      condition. Therefore, the [c]ourt concludes that a registered nurse cannot
      attest that there was a departure from the standard of care that’s the
      proximate cause of the alleged injury as required by Courts and Judicial
      Proceedings section 3-2A-04(b)(1)(1).

             As such, the [c]ourt finds that the certificate of qualified expert is
      defective. And Courts and Judicial Proceedings section 3-2A-04(b)(1)(1)
      mandates dismissal. Furthermore, the [c]ourt finds that . . . there has been
      no showing of good cause for an extension of time. And, therefore, the
      [c]ourt will not grant such. So the [c]ourt is going to enter an order of
      dismissal of this matter for those reasons.

(Emphasis added).

                                         Appeal

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

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

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

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

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

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

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

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

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

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

One of the complaint.

                                               18
                        STANDARDS GOVERNING REVIEW

       Maryland’s Health Care Malpractice Claims Act establishes the statutory

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

§ 3-2A-04 provides:

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

          (1)(i)1. Except as provided in item (ii) of this paragraph, a claim or action
          filed after July 1, 1986, shall be dismissed, without prejudice, if the
          claimant or plaintiff fails to file a certificate of a qualified expert with
          the Director attesting to departure from standards of care, and that the
          departure from standards of care is the proximate cause of the alleged
          injury, within 90 days from the date of the complaint . . . .

(Emphasis added).

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

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

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

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

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

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

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

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

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

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

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

negligence claim for failing to satisfy the CQE requirement:

                                                 19
               The sufficiency of a CQE is a question of law, and the standard “is the
       same as determining whether a complaint is legally sufficient”—that is, after
       assuming the truth of all assertions in the CQE and taking all permissible
       inferences in favor of its validity, we ask whether the CQE meets the
       requirements set forth in the HCMCA. See Carroll v. Konits, 400 Md. 167,
       179-80 & n.11 (2007). As with other questions of law, our review is de novo.
       In interpreting statutory language, we bear in mind that the “cardinal rule” of
       statutory construction is to ascertain and give effect to the General
       Assembly’s intent. As such, we first assess whether the statutory language
       is clear and unambiguous. If it is, we will not add or delete words or force a
       particular interpretation; we will simply interpret the language as written and
       end our inquiry . . . .

               If the statutory language is ambiguous, however, we engage in a
       broader inquiry by resolving the ambiguity “in light of the legislative intent,
       using all the resources and tools of statutory construction at our disposal.” In
       that case, we may consider “not only the literal or usual meaning of the
       words, but their meaning and effect in light of the setting, the objectives[,]
       and [the] purpose of the enactment[.]” And we may interpret the language
       with regard to various indicia of legislative intent, including “the structure of
       the statute, including its title; how the statute relates to other laws; the
       legislative history[;] . . . the general purpose behind the statute; and the
       relative rationality and legal effect of various competing constructions.”

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

                                       DISCUSSION

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

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

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

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

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

injuries alleged in Mrs. Robinson’s complaint.

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

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

                                                 20
not have. In support, Canton Harbor points to the relevant portion of the statutory

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

                                                   21
definition of “health care provider.” CJP § 3-2A-01(f). Canton Harbor concedes that

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

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

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

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

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

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

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

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

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

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

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

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

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

       6
         Although no reported Maryland case has addressed whether a registered nurse may
satisfy the proximate cause requirement for a CQE in a medical negligence case, our
Supreme Court has rejected a related contention that a pharmacist is per se disqualified
from giving an expert opinion in an informed consent case. In Shannon v. Fusco, 438 Md.
24 (2014), the family of a patient who died after taking a medication prescribed by his
oncologist sued for lack of informed consent regarding the risks of taking the drug while
undergoing radiation therapy. The Court “reject[ed] [the defendant physician’s] argument
that a pharmacist is per se unqualified to testify in an informed consent action when a
physician has been sued.” Id. at 55. Even though that pharmacist “had the requisite
expertise to testify about the material risks of the administration of” that particular drug,
the Court concluded that his proffered testimony did not in fact address the material risks
at issue in that case. Id. at 56.

                                                 22
a manner and in such an environment as will promote maintenance or enhancement of the

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

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

physical, mental, and psychosocial well-being of each resident[,]” 42 U.S.C. § 1395i-

3(b)(4)(A)(i).

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

Article (“HG”), a “nursing home” is

       a facility that offers nonacute inpatient care to patients suffering from a
       disease, chronic illness, condition, disability of advanced age, or terminal
       disease requiring maximal nursing care without continuous hospital
       services and who require medical services and nursing services rendered by
       or under the supervision of a licensed nurse together with convalescent,
       restorative, or rehabilitative services.

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

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

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

       (o)(1) “Practice registered nursing” means the performance of acts
       requiring substantial specialized knowledge, judgment, and skill based on
       the biological, physiological, behavioral, or sociological sciences as the
       basis for assessment, nursing diagnosis, planning, implementation, and
       evaluation of the practice of nursing in order to:

                 (i) Maintain health;

                 (ii) Prevent illness; or

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

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

                 (i) Administration;

                 (ii) Teaching;
                                                    23
              (iii) Counseling;

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

              (v) Execution of therapeutic regimen, including the administration
              of medication and treatment;

              (vi) Independent nursing functions and delegated medical
              functions; and

              (vii) Performance of additional acts authorized by the Board under §
              8-205 of this title.

(Emphasis added).

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

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

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

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

of a registered nurse, which requires that registered nurses:

       1) “collect client health data” “using appropriate assessment techniques[,]”
          COMAR 10.27.09.02A(1), (4);

       2) “analyze the assessment data in determining nursing diagnoses[,]” COMAR
          10.27.09.02B(1);

       3) “identify expected outcomes”           based    on    the   diagnoses,   COMAR
          10.27.09.02C(1), (2)(a)(i);

       4) “develop a plan of care that prescribes interventions to attain expected
          outcomes[,]” COMAR 10.27.09.02D(1);

       5) “implement the interventions identified in the plan of care[,]” COMAR
          10.27.09.02E(1);

       6) “evaluate the client’s progress toward attainment of outcomes[,]” COMAR
          10.27.09.02F(1); and

                                                24
       7) “revise the nursing diagnosis, outcomes, and the plan of care” based on
          “effectiveness of interventions,” COMAR 10.27.09.02F(2)(c), (e).

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

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

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

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

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

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

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

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

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

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

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

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

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

(emphasis added). 7 Consistent with federal regulations, a Maryland statute mandating

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

following:

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

       (2) Enteral feeding that comprises at least 26 per cent of daily calorie
       requirements and provides at least 501 milliliters of fluid per day[;]

       (3) Nasopharyngeal and tracheostomy aspiration;

                                                25
quality assurance programs in nursing homes lists “prevention of decubitus ulcers” as

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

       Maryland nursing home regulations similarly identify the scope of services that

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

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

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

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

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

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

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

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

the expertise of a physician.

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

       (5) Application of dressings involving prescription medications and aseptic
       techniques;

       ...

       (7) Heat treatments which have been specifically ordered by a physician as
       part of active treatment and which require observation by nurses to
       adequately evaluate the patient’s progress;

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

       (9) Rehabilitation nursing procedures, including the related teaching and
       adaptive aspects of nursing, that are part of active treatment, e.g., the
       institution and supervision of bowel and bladder training programs.

                                                  26
       We note that in 2010 the president of the American Nurses Association issued a

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

              RNs would not be practicing outside their scope of practice if the
       nurse identifies the alteration in skin integrity as a pressure ulcer and stages
       it before the admitting provider. On the contrary, it is the expectation that
       the RN actually does that. Anything less does not fulfill our professional
       standard and commitment to the patient.

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

American Nurse (Jan. 11, 2010), https://www.myamericannurse.com/is-diagnosis-of-

pressure-ulcers-within-an-rns-scope-of-practice/.

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

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

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

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

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

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

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

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

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

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

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

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

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

pressure ulcers by predicating their proximate cause opinions on impermissible medical

                                                 27
diagnoses. If and when that happens in a particular case, the same remedy at issue here—

dismissal—will be available to court and counsel.

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

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

has already happened in this case. As we detailed, this CQE was predicated on Jones-

Singh’s attestation that breaches in the standards of nursing care for preventing and treating

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

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

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

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

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

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

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

       8
         “Maryland’s wrongful death statute allows the maintenance of an action ‘against
a person whose wrongful act causes the death of another.’” Spangler, 449 Md. at 47-48
(quoting CJP § 3-902(a)). “The primary beneficiaries of a wrongful death action are the
spouse, parent, and child of the decedent.” Id. at 48 (citing CJP § 3-904(a)(1)). “Where
the decedent is a spouse, . . . the wrongful death statute provides damages for ‘pecuniary
losses,’ if any, in addition to damages for ‘mental anguish, emotional pain and suffering,
loss of society, companionship, comfort, protection, marital care, parental care, filial care,
attention, advice, counsel, training, guidance, or education where applicable[.]’” Id.
(quoting CJP § 3-904(c)-(d)).
       9
         In light of Mrs. Robinson’s concession that the CQE would be insufficient to attest
to the proximate cause of Mr. Robinson’s death, we surmise that Mrs. Robinson likewise
abandons the Estate’s claim for funeral expenses.
                                                 28
       For these reasons, the circuit court erred in construing Maryland’s statutory scheme

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

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

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

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

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

       10
           The parties rely extensively on out-of-state caselaw to support their respective
positions. Our review of the relevant caselaw reveals that most of the cases are
distinguishable from the present case. Nevertheless, it appears the weight of authority
supports our conclusion that qualified nurses may give expert testimony regarding the
treatment and cause of decubitus ulcers. See, e.g., Gaines v. Comanche Cnty. Med. Hosp.,
143 P.3d 203, 206 n.10 (Okla. 2006) (collecting extrajurisdictional cases holding that
“nurses may offer expert testimony concerning the development or prevention of decubitus
ulcers”); Mellies v. Nat’l Heritage, Inc., 636 P.2d 215, 224 (Kan. Ct. App. 1981) (ruling
that “if a proper foundation is laid as to the nurse’s experience with decubitus ulcers, she
or he can qualify as an expert as to causation”); Parris v. Uni Med, Inc., 861 S.W.2d 694,
699 (Mo. Ct. App. 1993) (holding no abuse of discretion in allowing nurses to give expert
testimony regarding cause and treatment of bedsores because they “had extensive
experience” given that “[o]ne of the important functions of nurses is to prevent the
formation of decubitus ulcers in bed-ridden patients”); Freed v. Geisinger Med. Ctr., 971
A.2d 1202, 1212 (Pa. 2009) (overruling Flanagan v. Labe, 690 A.2d 183 (Pa. 1997), “to
the extent it prohibits an otherwise competent and properly qualified nurse from giving
expert opinion testimony regarding medical causation” in case alleging negligence in
preventing and caring for pressure wounds), aff’d on reargument, 5 A.3d 212 (2010); cf.
Rasor v. Nw. Hosp., LLC, 419 P.3d 956, 963 (Ariz. Ct. App. 2018) (noting that under
Arizona law, a registered nurse may establish a “‘nursing diagnosis,’ which includes
determining the ‘etiology’ or cause of a disorder” (citations omitted)). We recognize that
there is contrary authority. Vaughn v. Miss. Baptist Med. Ctr., 20 So. 3d 645, 652 (Miss.
2009) (“We now explicitly hold that nurses cannot testify as to medical causation.”);
Esquivel v. El Paso Healthcare Sys., Ltd., 225 S.W.3d 83, 90-91 (Tex. App. 2005) (holding
that nurse could not express opinion as to “causal link” related to alleged decubitus ulcer
injuries); Kent v. Pioneer Valley Hosp., 930 P.2d 904, 907 (Utah Ct. App. 1997) (holding
that nurse was not qualified “to opine as to nerve damage caused by an allegedly improper
injection”). In our view, the relevant caselaw generally reflects what the medical and
                                                29
                                  Sufficiency of This CQE

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

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

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

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

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

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

proximate cause attestations.

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

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

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

documenting the appearance and progression of multiple pressure ulcers and other

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

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

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

responsibilities undertaken by Canton Harbor’s registered nurses.

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

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

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

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

nursing communities already know—that nurses routinely engage in the prevention and
treatment of decubitus ulcers.
                                                30
patients at a skilled nursing facility providing long term care, based on records relating to

the care rendered to that patient.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

proximately caused Mr. Robinson’s pressure ulcer injury.

                                     CONCLUSION

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

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

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

                                                31
nursing standards proximately caused a patient’s ulcer injury. See CJP § 3-2A-04(b)(1).

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

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

remand for further proceedings. 11

                                         JUDGMENT OF THE CIRCUIT COURT
                                         FOR BALTIMORE CITY VACATED AND
                                         CASE REMANDED FOR FURTHER
                                         PROCEEDINGS CONSISTENT WITH
                                         THIS OPINION. COSTS TO BE PAID BY
                                         APPELLEE.

       11
         Because we hold that Mrs. Robinson’s CQE was sufficient, we need not address
her argument that the circuit court erred by denying her an extension of time to file a
corrected CQE.
                                              32