Court Opinion

ID: 4073147
Source: CourtListenerOpinion
Date Created: 2016-09-30 03:28:47.875689+00
Date Added: 2024-06-11T14:32:41.937274
License: Public Domain

ACCEPTED
                                                                                    01-05-00793-CV
                                                                         FIRST COURT OF APPEALS
                                                                                 HOUSTON, TEXAS
                                                                              11/10/2015 3:30:30 PM
                                                                              CHRISTOPHER PRINE
                                                                                             CLERK

                           01-15-00793-CV

                        In the Court of Appeals                    FILED IN
                                                            1st COURT OF APPEALS
               For the First District of Texas at Houston       HOUSTON, TEXAS
                                                            11/10/2015 3:30:30 PM
                                                            CHRISTOPHER A. PRINE
      Nexion Health at Beechnut, Inc. d/b/a Beechnut        Manor, Clerk
                                 Appellant,

                                   v.

       Maria Moreno, Individually and as Representative of
                 the Estate of Mario Moreno,
                               Appellee.

                         On Appeal from the
         133rd Judicial District Court of Harris County, Texas
                     Cause Number: 2015-01975
         The Honorable Jaclanel McFarland, Presiding Judge

                      APPELLANT’S BRIEF

                      Attorneys for Appellant

       MACDONALD DEVIN, PC              Gregory N. Ziegler
       3800 Renaissance Tower           Texas Bar No. 00791985
           Dallas, Texas 75270          GZiegler@MacdonaldDevin.com
        214.744.3300 telephone          Weston M. Davis
         214.747.0942 facsimile         Texas Bar No. 24065126
                                        WDavis@MacdonaldDevin.com
ORAL ARGUMENT REQUESTED
                      IDENTITY OF PARTIES AND COUNSEL

Defendant/Appellant

      Nexion Health at Beechnut, Inc. d/b/a Beechnut Manor

Counsel for Defendant/Appellant

      Gregory N. Ziegler
      Texas Bar No. 00791985
      Weston M. Davis
      Texas Bar No. 24065126
      MACDONALD DEVIN, PC
      1201 Elm Street
      3800 Renaissance Tower
      Dallas, Texas 75270
      214.744.3300 Telephone
      214.747.0942 Facsimile

Counsel for Plaintiff/Appellee

      Maria Moreno, Individually and as Representative of the Estate of Mario
      Moreno, represented by
      Jason A. Gibson
      THE GIBSON LAW FIRM
      440 Louisiana, Suite 2400
      Houston, Texas 77002
      713.650.1010 Telephone
      713.650.1011 Facsimile

                                        i
              STATEMENT REGARDING ORAL ARGUMENT

     Pursuant to Texas Rule of Appellate Procedure 39.1, Appellant

requests oral argument in this case. This case presents an issue regarding

the expert report requirement of Civil Practice and Remedies Code Chapter

74, which is a developing area of the law.       For this reason, Appellant

respectfully submits that argument would significantly aid the Court in

determining the legal and factual issues presented in this appeal.1

1    See TEX. R. APP. P. 39.8.

                                      ii
                                       TABLE OF CONTENTS

Identity of Parties and Counsel ............................................................. i

Statement on Oral Argument ................................................................ ii

Table of Contents .................................................................................... iii

Index of Authorities ................................................................................ v

Statement of the Case ............................................................................ 2

Statement of Jurisdiction ...................................................................... 3

Issues Presented ..................................................................................... 3

Statement of Facts ................................................................................. 4

Summary of the Argument .................................................................... 5

Argument .................................................................................................... 6

        I.       Standard of Review ............................................................... 6

        II.      First Issue: Trial court abused its discretion in
                 denying Appellant’s motion to dismiss because Dr.
                 Marks’ report does not sufficiently identify causation. ............ 7

        III. Second issue: Trial court abused its discretion in
             denying Appellant’s motion to dismiss because Dr.
             Marks’ report and CV do not evidence adequate
             qualifications ............................................................................. 9

        IV.      Third Issue: The trial court abused its discretion in
                 failing to dismiss Appellee’s claims. ....................................... 10

Prayer ....................................................................................................... 11

Certificate of Service ............................................................................. 12

                                                       iii
Certificate of Compliance .................................................................... 13

Appendix Contents ................................................................................ 13

                                                 iv
                               INDEX OF AUTHORITIES

Cases

Baker v. Gomez,
     276 S.W.3d 1, 8 (Tex. App.–El Paso 2008, pet. denied) .................... 6

Bowie Memorial Hosp. v. Wright,
     79 S.W.3d 48, 53 (Tex. 2002) ......................................................... 6, 9

Buck v. Blum,
     130 S.W.3d 285 (Tex. App.–Houston [14th Dist.] 2004, no pet.) ..... 6

Cayton v. Moore,
     224 S.W.3d 440 (Tex. App.–Dallas 2007, no pet.). .......................... 10

Columbia N. Hills Hosp. Subsidiary, L.P. v. Tucker,
     No. 05-14-00056-CV, 2014 Tex. App. LEXIS 13685 (Tex. App.—
     Dallas Dec. 22, 2014, no pet.) ......................................................... 7, 8

Fortner v. Hosp. of the Sw., LLP,
     399 S.W.3d 373 (Tex. App.—Dallas 2013, no pet.) ............................. 9

Foster v. Zavala,
     214 S.W.3d 106 (Tex. App.—Eastland 2006, pet. denied) ................. 11

Hollingsworth v. Springs,
      353 S.W.3d 506 (Tex. App.–Dallas 2011, no pet.) ......................... 6, 10
Jones v. Ark-La-Tex Visiting Nurses, Inc.,
     128 S.W.3d 393 (Tex. App.—Texarkana 2004, no pet.) .................... 10

Ortiz v. Patterson,
      378 S.W.3d 667 (Tex. App.—Dallas 2012, no pet.) ............................. 7

Rittmer v. Garza,
     65 S.W.3d 718 (Tex. App.–Houston [14th Dist.] 2001, no pet.) ........ 6

Simonson v. Keppard,
    225 S.W.3d 868 (Tex. App.–Dallas, 2007, no pet.). ......................... 10

                                                v
Windsor v. Maxwell,
    121 S.W.3d 42 (Tex. App.–Fort Worth 2003, pet. denied) ................. 6

Statutes

Tex. Civ. Prac. & Rem. Code § 51.014(a)(9) ............................................. 3, 6
Tex. Civ. Prac. & Rem. Code § 74.351 ............................................. 1, 3, 9, 13
Tex. Civ. Prac. & Rem. Code § 74.402 ......................................................... 9

Rules

TEX. R. APP. P. 39.1 ...................................................................................... ii

TEX. R. APP. P. 39.8 ..................................................................................... ii

TEX. R. APP. P. 9.4 ....................................................................................... 13

                                                     vi
                                01-15-00793-CV

                             In the Court of Appeals
                    For the First District of Texas at Houston

           Nexion Health at Beechnut, Inc. d/b/a Beechnut Manor,
                                      Appellant,

                                        v.

            Maria Moreno, Individually and as Representative of
                      the Estate of Mario Moreno,
                                    Appellee.

                              On Appeal from the
              133rd Judicial District Court of Harris County, Texas
                          Cause Number: 2015-01975
              The Honorable Jaclanel McFarland, Presiding Judge

TO THE HONORABLE COURT OF APPEALS:

      Appellant Nexion Health at Beechnut, Inc. d/b/a Beechnut Manor complains

of the trial court’s Order denying its motion to dismiss Appellee’s lawsuit for

failure to serve an expert report that complied with Texas Civil Practice and

Remedies Code Chapter 74.351, and shows:

                                        1
                            STATEMENT OF THE CASE

      This is an interlocutory appeal from a health care liability claim filed under

the Texas Medical Liability Act. Mario Moreno was a resident at Beechnut Manor

(“Beechnut”) between April and May 2013, and passed away on May 30, 2013.

CR:22. In January 2015, Maria Moreno (“Plaintiff” or “Appellee”), the underlying

plaintiff, filed suit against Beechnut, alleging claims for medical negligence

stemming from Mr. Moreno’s residency at the Beechnut facility in 2013. CR:20-

26.

      On February 23, 2015, Appellee served Beechnut with the purported expert

reports and CVs of (1) Dr. Donald H. Marks (“Dr. Marks”) and (2) Nurse Rhonda

Rotterman (“Nurse Rotterman”). CR:27-63. On June 29, 2015, Beechnut filed

objections to both reports and a Motion to Dismiss the complaint based on

deficiencies in the reports. CR:6-19. Appellee filed a response to the motion to

dismiss on August 21, 2015. CR:81-88. The trial court heard Beechnut’s Motion

to Dismiss on August 24, 2015 and signed an order denying the motion. CR:143.

On September 14, 2015, Beechnut timely filed its Notice of Accelerated Appeal.

                                         2
                           STATEMENT OF JURISDICTION

      This Court has jurisdiction over this accelerated appeal pursuant to Texas

Civil Practice and Remedies Code section 51.014(a)(9), because Beechnut seeks

interlocutory relief from an order denying the relief sought by a dismissal motion

under Section 74.351(b).

                               ISSUES PRESENTED

                                  FIRST ISSUE

            Did the trial court abuse its discretion when it denied
            Appellant’s motion to dismiss because Dr. Marks’ report
            fails to establish the causal relationship between the
            alleged harm and Beechnut’s conduct?

                                 SECOND ISSUE

            Did the trial court abuse its discretion when it denied
            Appellant’s motion to dismiss because Dr. Marks’ report
            and CV show that he lacks the requisite qualifications?

                                  THIRD ISSUE

            Did the trial court abuse its discretion when it failed to
            dismiss Appellee’s claims?

                                        3
                                STATEMENT OF FACTS

      Appellee’s complaint alleges that Beechnut breached its duties and was

negligent in “one or more of the following ways:

             a.     Failing to exercise ordinary care while treating a
                    patient;
             b.     Failing to adequately diagnose and treat a patient;

             c.     Failing to provide adequate supervision to a
                    patient;

             d.     Failing to provide adequate supervision when the
                    patient returned to the facility;
             e.     Failing to act as a reasonable and prudent medical
                    care facility would under the same or similar
                    circumstances; and

             f.     Failing to adequately assess medical condition.”

CR:23. Appellee alleges that “Defendant’s acts and omissions were a proximate

cause of Plaintiff’s injuries.” Id.

      Dr. Marks’ report states that Mr. Moreno fell outside of the Beechnut facility

on May 23, 2013 and was found lying in the hallway of the Beechnut facility on

May 29, 2013. CR:41. Dr. Marks states that Mr. Moreno’s death certificate

indicates that he died of “blunt head trauma” on May 30, 2013. Id. Dr. Marks

incorporates Nurse Rotterman’s opinion on the applicable standard of care and

states that “based on reasonable medical probability, bruises, lacerations, blunt

head trauma and death are all reasonably foreseeable injuries when a cognitively

                                          4
impaired patient prescribed six different mind altering medications is improperly

supervised and falls repeatedly.” Id. Dr. Marks’ opinion on causation consists of

the following:

             Mr. Moreno was prescribed and administered six
             different antipsychotic medications, was improperly
             supervised and fell on his head on two separate
             occasions, the latter of which directly preceded his
             death.”

Id.

      Beechnut objected to both reports report and moved to dismiss Appellee’s

complaint because Dr. Marks failed to causally link Beechnut’s alleged conduct to

the injuries that led to Mr. Moreno’s falls or death. CR:15-17. Beechnut also

objected that neither Dr. Marks’ nor Nurse Rotterman’s reports evidenced

sufficient qualifications to opine on the standards of care and causation issues in

this case. CR:9-12. The trial court denied Beechnut’s motion on August 24, 2015

and this appeal followed. CR:143.

                          SUMMARY OF THE ARGUMENT

      The trial court abused its discretion because Dr. Marks’ report failed to

causally link Beechnut’s alleged negligence to Mr. Moreno’s falls or death.

Additionally, neither Dr. Marks’ report nor his CV shows that he is qualified to

provide opinions concerning the alleged negligent activity in this case.

                                          5
                                   ARGUMENT

I.    Standard of Review

      An abuse of discretion standard of review is applicable to this case.

Hollingsworth v. Springs, 353 S.W.3d 506, 512 (Tex. App.–Dallas 2011, no pet.).

An abuse of discretion occurs when a trial court acts in an unreasonable and

arbitrary manner, or when it acts without reference to any guiding principles.

Rittmer v. Garza, 65 S.W.3d 718, 721-22 (Tex. App.–Houston [14th Dist.] 2001,

no pet.). To the extent resolution of the issue before the trial court requires

interpretation of a statute, a de novo standard is applicable. Id. at 722; Buck v.

Blum, 130 S.W.3d 285, 290 (Tex. App.–Houston [14th Dist.] 2004, no pet.).

      When reviewing the sufficiency of an expert report in a health care liability

case, this Court is confined to the four corners of the expert’s report. Baker v.

Gomez, 276 S.W.3d 1, 8 (Tex. App.–El Paso 2008, pet. denied). This Court may

not draw inferences to supply necessary information missing from the expert’s

report, nor construe a report in Appellee’s favor.     Bowie Memorial Hosp. v.

Wright, 79 S.W.3d 48, 53 (Tex. 2002); Windsor v. Maxwell, 121 S.W.3d 42, 50

(Tex. App.–Fort Worth 2003, pet. denied).

                                        6
II.   First Issue: Trial court abused its discretion in denying Appellant’s
      motion to dismiss because Dr. Marks’ report does not sufficiently
      identify causation.

      To adequately address causation, an expert report under Chapter 74 must

“explain, to a reasonable degree, how and why the breach [of the standard of care]

caused the injury based on the facts presented.”       Columbia N. Hills Hosp.

Subsidiary, L.P. v. Tucker, No. 05-14-00056-CV, 2014 Tex. App. LEXIS 13685,

*5-6 (Tex. App.—Dallas Dec. 22, 2014, no pet.) (citing Ortiz v. Patterson, 378
S.W.3d 667, 671 (Tex. App.—Dallas 2012, no pet.). The Court “may not ‘fill

gaps’ in an expert report by drawing inferences or guessing what the expert likely

meant or intended.” Id. at *6 (citation omitted).

       A Chapter 74 expert report may not simply identify a breach and

imprecisely state that the breach caused an injury. The report must explain the

causal connection between the breach and the injury. That causal connection is

missing in this case.

      Dr. Marks’ report states that upon admission, Beechnut staff observed that

Mr. Moreno “suffered from an impaired level of consciousness, impaired balance,

schizophrenia, seizures and a tendency to wander” and that a physician’s

examination shortly after his admission “indicated Moreno required long term

residential nursing home care and close supervision and assistance.” CR:40. Dr.

                                          7
Marks’ report notes that Mr. Moreno was prescribed six “mind altering

medications” by the physician. CR:40-41.

      Dr. Marks refers to Nurse Rotterman’s report and states:

             Causation in this case is extremely straightforward.
             Mario Moreno was prescribed and administered six
             different antipsychotic medications, was improperly
             supervised and fell on his head on two separate
             occasions, the latter of which directly preceded his death.

CR:41. Dr. Marks concludes “that Beechnut Manor and its staff were negligent in

the care and supervision of Moreno” which was “the proximate cause of Mario

Moreno’s fall and subsequent death caused by blunt force trauma Moreno suffered

during that fall.” Id.

      Dr. Marks’ report does not contain any factual explanation of the causal

connection between Beechnut’s alleged failure to supervise Mr. Moreno and Mr.

Moreno’s falls on May 23 and May 29. Instead, he simply states that Mr. Moreno

was “improperly supervised.” CR:41. This statement is conclusory and is legally

insufficient to satisfy the Chapter 74 causation requirement. See Columbia N.

Hills, 2014 Tex. App. LEXIS 13685, *12-13. Chapter 74 required Dr. Marks to

explain how and why there would be a different result if Beechnut complied with

the standard of care.     Id. at *14-15.       Although the court may read Nurse

Rotterman’s report in conjunction with Dr. Marks’, Nurse Rotterman cannot

                                           8
provide a causation opinion because she is not a physician and cannot cure Dr.

Marks’ conclusory causation statements. Id. at *15-16.

       The expert report must contain sufficiently specific information to

demonstrate causation beyond conjecture—the mere provision of some insight into

the plaintiff’s claims does not address causation adequately. See Bowie Mem'l

Hosp., 79 S.W.3d at 52; Fortner v. Hosp. of the Sw., LLP, 399 S.W.3d 373, 379

(Tex. App.—Dallas 2013, no pet.). Dr. Marks was required to explain how the

alleged negligence of Beechnut caused the conditions that led to Mr. Moreno’s

death. Because Dr. Marks’ report did not do that, it failed to adequately address

causation and the trial court erred in failing to dismiss Appellee’s complaint.

III.   Second Issue: Trial court abused its discretion in denying Appellant’s
       motion to dismiss because Dr. Marks’ report and CV do not evidence
       adequate qualifications.

       Dr. Marks’ report and C.V. failed to satisfy the expert qualification

requirements of Chapter 74 because (1) he is not actively practicing health care in

a nursing home—Beechnut’s healthcare field, and (2) he has no training or

experience working in a nursing home or supervising nurses. Tex. Civ. Prac. &

Rem. Code §§ 74.351(r)(5)(B) and 74.402. Chapter 74 requires that the expert be

actively practicing health care in the “same field as the defendant health care

provider.” Tex. Civ. Prac. & Rem. Code § 74.402(a)(2). When assessing the

qualifications of a purported expert under Chapter 74, the trial court “may not draw

                                          9
any inferences” and “must rely exclusively on the information contained within the

four corners of the report.” Cayton v. Moore, 224 S.W.3d 440, 445 (Tex. App.–

Dallas 2007, no pet.).

      In this case neither Dr. Marks’ report nor his CV shows that he has any

qualification or experience in a nursing home setting or supervising a nursing staff.

Indeed, Dr. Marks’ report describes the “reasonable standard of care required of a

hospital when treating patients similar to Mario Moreno.”         CR:41 (emphasis

added). The absence of any qualification relating to nursing supervision or nursing

homes precludes the report from satisfying the requisites of Chapter 74. Simonson

v. Keppard, 225 S.W.3d 868, 873 (Tex. App.–Dallas, 2007, no pet.); Jones v. Ark-

La-Tex Visiting Nurses, Inc., 128 S.W.3d 393, 397 (Tex. App.—Texarkana 2004,

no pet.). Accordingly, the trial court abused its discretion in denying Appellant’s

motion to dismiss.

IV.   Third issue: The trial court abused its discretion in failing to dismiss
      Appellee’s claims.

      Dr. Marks’ report omits necessary causation information and does not reflect

any qualifications to provide an expert opinion in this case. While the statute

allows for a discretionary 30 day period to cure deficiencies where a deficient

report is timely served, “[a] court may not provide opportunities to cure, however,

when an expert report is ‘absent’ as opposed to deficient,” such as when a report

“fails to address all required elements of a claim.” Hollingsworth, 353 S.W.3d at

                                         10
524 (denying a health care liability claimant an opportunity to cure when the expert

report “omitted any discussion of the element of causation,” so the “report could

not qualify as a good faith effort to meet Chapter 74’s requirements”). Beechnut

asks that this Court deny any opportunity to cure and require dismissal based on

Dr. Marks’ lack of adequate qualifications. See e.g., Foster v. Zavala, 214 S.W.3d
106, 116 (Tex. App.—Eastland 2006, pet. denied) (An expert report by a person

not qualified to testify does not represent a good-faith effort to comply with the

definition of an expert report.). Alternatively, Beechnut requests that this Court

remand the case to the trial court to determine whether to dismiss or grant Appellee

an opportunity to cure.

                              PRAYER FOR RELIEF

      WHEREFORE, PREMISES CONSIDERED, Appellant Nexion Health at

Beechnut, Inc. d/b/a Beechnut Manor prays: that this Court reverse the trial court’s

August 24, 2015 Order denying Appellant’s dismissal motion; that this Court

render judgment holding Appellant is entitled to dismissal of Appellee’s claims

with prejudice, and that this Court remand to the trial court to award Appellant its

attorney’s fees and costs in the trial court and in this Court; and for general relief.

                                           11
                                         Respectfully submitted,

                                         MACDONALD DEVIN, PC

                                         By: /s/ Weston M. Davis
                                           Gregory N. Ziegler
                                           Texas Bar No. 00791985
                                           GZiegler@MacdonaldDevin.com
                                           Weston M. Davis
                                           Texas Bar No. 24065126
                                           WDavis@MacdonaldDevin.com

                                         1201 Elm Street
                                         3800 Renaissance Tower
                                         Dallas, Texas 75270
                                         214.744.3300 telephone
                                         214.747.0942 facsimile

                                         Attorneys for Appellant

                           CERTIFICATE OF SERVICE

      The undersigned attorney certifies that a true and correct copy of the
foregoing Appellant’s Brief was served on all counsel of record in accordance with
the Texas Rules of Appellate Procedure via e-Filing, on November 10, 2015.

                                             /s/ Weston M. Davis
                                             Weston M. Davis

                                        12
                     CERTIFICATE OF COMPLIANCE

     Pursuant to TEX. R. APP. P. 9.4, I hereby certify that this petition

contains 2,938 words, including those not required to be counted in the

word limits. This is a computer-generated document created in Microsoft

Word, using 14-point typeface for all text, except for footnotes which are in

12-point typeface. In making this certificate of compliance, I am relying

upon the word count provided by the software used to prepare the

document.

                                            /s/ Weston M. Davis
                                          Weston M. Davis

                        APPENDIX CONTENTS

     A.     CR 143, Order denying Appellant’s Motion to Dismiss,
            signed August 24, 2015

     B.     CR 27-34; 40-42, Expert Report and C.V. of Dr. Donald
            H. Marks

     C.     Texas Civil Practice and Remedies Code § 74.351

                                     13
                                                                                    Chris Daniel -District Clerk
                                                                                    Harris County
                                                                                    Envelope No: 6909288
                                                                                    By: WASHINGTON, PHYLLIS
                                                                                    Filed: 9/14/20151:13:17 PM

(                                           Cause No 2015-01975-133                            j)t~
              MARIO MORENO, lndMdually          §                IN THE DISTRICT COURT OF                '/
              and as Representabve of the ESTATE§
              OF MARIO MORENO                   §
                                                §
                                                §
               v                                §               HARRIS COUNlY, TEXA
                                                §
                                                §
             . NEXION HEALTH AT BEECHNUT, INC , §                                         i
                                                                                          'G
               dfb/a BEECHNUT MANOR             §                 133m JUDICIAL DISTRI

                        ORDER DENYING DEFENDANT NEXION AT BEECHNUT, INC
                       D/B/A BEECHNUT MANOR'S CHAPTER 74 MODON TO DISMISS

                    The Court heard Defendant's Chapter 74 Motion to DISmiSS After reVIewing the

              pleadings, the ev1dence and arguments by counsel, If any, the Court DENIES Defendanrs

              Chapter 74 Mabon to D1sm1ss

                    SIGNED ON    ~W ~                              '2015
(
\

    .-...0

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                                                                                                              34
                        Donald. U Marks, MJ)N, PJ*SL
                      Módicia% Màdic4iot M’Effc    MobioIoy
           tirnrrnt      T1IUIUUJflH)JJ
                                   —         imnn Jrlliu
 1348 Buena Road
                                                                       —

                                                     p)ot 1473407-0364
 Suite F-414                                         p
 HaotciMabm4 $5244                                   omaU: Extnt4t$Z!hlJS

                                  ?4PERt REPORT

 :ar Mr Gibson:

    thark      •ftttho ôpØbd it flthsate the ma k& racords of £ •* Mcrenoio
review my quaflftcatrons I have QVOf 20 years of expenance in phermscsutlcal, clinical
and hospital internal medkine Addftfonaily I am a diplomat of The American Board of
Internal Madine, lIcensed to ptsctJce medicrne fri four states and a Fellow of tie
American College of Phlcians I also have a PhD n Mkbio1ogy with srgrn&ant
dlinloal and research expenente My pit4ssional expenenoG is dotiLlmeflted in my
aftached cant (cmi: Wthe.
     As a pic&hg phsloIan,. I have the epwtise and lçnowiedge ‘to render opinions
 regaming Mr Morenfl death and whether the negiience of $eeclinut Manor end Its
‘staff, In masonable medical probability, caused his death In this report I elso
 Ificorporale by referenos the Expert Report of Rhonda Rouer’mafl
                                                       1 BSN RHO dated
       jst242014 aeaotve*atlnt
Doduments P Mewed:
    1. Mark, Moreno Death
    2. Beechnut Manor Medical Records
    &RhondaRoUnuiafl,BSN, RNC’s:$tanderd of:Care Expert Report
:CIEnk$l Summasyt,

       Mario Mereno (Morena) was s newly ad itt fld.nt ot Bethnut Màrar a
restdenttal nursing and rehabRtaUon facility Upon admittance on April 43, 2ti1$
Beechnut Manor staff observed Moreno axtiered from an impaired level at
ConsciusnsS, Unpaired bance, schizophrenia, seizures and a tendency to wander A
ph’slctant examination pertrmed on April 17, 2013, indicated Moreno required ion
term re&derithi nursing hOthe C re and tlosesUpeMsk.n andassistance.

      Mario Moreno’s daily treatment regimen at Beachnut Manner includad the
fvIlø*g mind aWng fflcãfk

    • Phenobarb                                                             129 hig

                                                                                Exhibit 4
                                                                                      40
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                         TIW

      #

      •
        Seitqu1 200mQ
        .tYaØaiøte.2 000n?ig
                                                                                                (
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                                        at hour olsidep
      •ZtioftBOfl

       :Nursing.nctes dfr?teon May2$
                                  7 20t3 at:1.0: Sam, Mbrønc. $ outside: and was
 tàund lying on his side with Jacerations and bruises to the Left side of his face Moreno
 was I nsfened tu WHMC by ambulance, treated, and returned to Beechnut Manor at
 S;OOam.
       Qfl f
           >4fl $ 2G13. tat. 9tfla utt4qg Notes lndipfl Moreno wa ØriitIg
           t
about the fac% pusNng key path At I SQprn Moreno wai found lying In the hallway
riser an exit door Mcflno was observed on his beck with an Hopi    Idenfifted on
the back of his head Moreno was iii and out of consciousness. meiency msdicai
         Were contacted and M&eno wsttfetredto.WHMC
        The Death Certificate issued by the Tes Departrnent of State Hosith Servicos   —

Vital Statistics .thdiátes Moreno.dle4ori May *20fl due te tlwt•Head TraumC

‘trndarflftnnd $reach’ctSn4ard otCare
     :lnporathig the standard .01 care as repöited. by Rhonda RbhsrmSn;, .SSN,
RNCr Mane Momno
          s frnes are consistent with a breach of the reasonable standai
          1
of    ret*hd ate hospital when tree tth patent Sfmfiir to: Mend Morern
        Mario. Moreno% injuries. :tt consistent wit. tIW 1 Qf iryries: ibly tø ba
sustained by a mentally impaired patert who suffers multiple falls SpecMcaJlç based
on reasonable medical probablhty *ruises, lacerations, blunt head trauma and death
arc all reasonably foreseeable Injuries when a cognitively Impaired patont prescribed
six dritarent mind afterin medications is improperly supennsed and 1lls repeatedly
Causataan In thia case is extremely straighiforward Marx Moreno was prescribed and
‘admInItsred six differant int1pychotlo medications, was imprnpedy supervised arid fell
   hI head OJI t*d 2ep ratecoca *%teaaaofthioh dfredt1preoededNs .d2
                                         Tex. Civ. Prac. & Rem. Code § 74.351

    (d) to (h) [Reserved].

     (i) Notwithstanding any other provision of this section, a claimant may satisfy any requirement of this section for
serving an expert report by serving reports of separate experts regarding different physicians or health care providers or
regarding different issues arising from the conduct of a physician or health care provider, such as issues of liability and
causation. Nothing in this section shall be construed to mean that a single expert must address all liability and causation
issues with respect to all physicians or health care providers or with respect to both liability and causation issues for a
physician or health care provider.

    (j) Nothing in this section shall be construed to require the serving of an expert report regarding any issue other
than an issue relating to liability or causation.

    (k) Subject to Subsection (t), an expert report served under this section:

      (1) is not admissible in evidence by any party;

      (2) shall not be used in a deposition, trial, or other proceeding; and

      (3) shall not be referred to by any party during the course of the action for any purpose.

    (l) A court shall grant a motion challenging the adequacy of an expert report only if it appears to the court, after
hearing, that the report does not represent an objective good faith effort to comply with the definition of an expert report
in Subsection (r)(6).

    (m) to (q) [Reserved].

    (r) In this section:

       (1) "Affected parties" means the claimant and the physician or health care provider who are directly affected by
an act or agreement required or permitted by this section and does not include other parties to an action who are not
directly affected by that particular act or agreement.

      (2) "Claim" means a health care liability claim.

      (3) [Reserved].

      (4) "Defendant" means a physician or health care provider against whom a health care liability claim is asserted.
The term includes a third-party defendant, cross-defendant, or counterdefendant.

      (5) "Expert" means:

        (A) with respect to a person giving opinion testimony regarding whether a physician departed from accepted
standards of medical care, an expert qualified to testify under the requirements of Section 74.401;

        (B) with respect to a person giving opinion testimony regarding whether a health care provider departed from
accepted standards of health care, an expert qualified to testify under the requirements of Section 74.402;

        (C) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or
damages claimed and the alleged departure from the applicable standard of care in any health care liability claim, a
physician who is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence;

      (D) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or
damages claimed and the alleged departure from the applicable standard of care for a dentist, a dentist or physician who
                                                                                                                     Page 3
                                         Tex. Civ. Prac. & Rem. Code § 74.351

is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence; or

        (E) with respect to a person giving opinion testimony about the causal relationship between the injury, harm, or
damages claimed and the alleged departure from the applicable standard of care for a podiatrist, a podiatrist or physician
who is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence.

      (6) "Expert report" means a written report by an expert that provides 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, and the causal relationship between that failure and the injury, harm,
or damages claimed.

    (s) Until a claimant has served the expert report and curriculum vitae as required by Subsection (a), all discovery in
a health care liability claim is stayed except for the acquisition by the claimant of information, including medical or
hospital records or other documents or tangible things, related to the patient's health care through:

      (1) written discovery as defined in Rule 192.7, Texas Rules of Civil Procedure;

      (2) depositions on written questions under Rule 200, Texas Rules of Civil Procedure; and

      (3) discovery from nonparties under Rule 205, Texas Rules of Civil Procedure.

    (t) If an expert report is used by the claimant in the course of the action for any purpose other than to meet the
service requirement of Subsection (a), the restrictions imposed by Subsection (k) on use of the expert report by any
party are waived.

    (u) Notwithstanding any other provision of this section, after a claim is filed all claimants, collectively, may take
not more than two depositions before the expert report is served as required by Subsection (a).

HISTORY: Enacted by Acts 2003, 78th Leg., ch. 204 (H.B. 4), § 10.01, effective September 1, 2003; am. Acts 2005,
79th Leg., ch. 635 (H.B. 2645), § 1, effective September 1, 2005; am. Acts 2013, 83rd Leg., ch. 870 (H.B. 658), § 2,
effective September 1, 2013.

NOTES:

  Applicability. --
  Acts 2005, 79th Leg., ch. 635 (HB. 2645), § 2 provides: "This Act applies only to a cause of action that accrues on or
after the effective date of this Act. An action that accrued before the effective date of this Act is governed by the law
applicable to the action immediately before the effective date of this Act, and that law is continued in effect for that
purpose."
  Acts 2013, 83rd Leg., ch. 870 (S.B. 658), § 3(b) provides: "Section 74.351(a), Civil Practice and Remedies Code, as
amended by this Act, applies only to an action commenced on or after the effective date of this Act [September 1,
2013]. An action commenced before the effective date of this Act is governed by the law in effect immediately before
that date, and that law is continued in effect for that purpose."
  2005 amendment,
  substituted "original petition" for "claim" in the first sentence in (a).
  2013 amendment,
  in (a), substituted "each defendant's original answer is" for "the original petition was" in the first sentence and in the
third sentence, added "the later of" and substituted "report is served or the 21st day after the date the defendant's answer
is filed" for "it was served"; and made a stylistic change.

LexisNexis (R) Notes: