Court Opinion

ID: 9840365
Source: CourtListenerOpinion
Date Created: 2023-09-17 14:05:47.207779+00
Date Added: 2024-06-11T10:28:00.810670
License: Public Domain

Supreme Court of Texas
                            ══════════
                             No. 22-0317
                            ══════════

         Jesse Uriegas, as Guardian of Brandon Uriegas,
                    an Incapacitated Person,
                               Petitioner,

                                   v.

              Kenmar Residential HCS Services, Inc.,
                              Respondent

   ═══════════════════════════════════════
               On Petition for Review from the
      Court of Appeals for the Seventh District of Texas
   ═══════════════════════════════════════

                            PER CURIAM

      A care facility resident fell twice and sustained serious injuries.
His guardian sued the facility for negligence and provided two expert
reports to support the claims. The trial court ruled that the reports
provide a fair summary of the experts’ opinions regarding the standard
of care, breach, and the cause of injury, as the Texas Medical Liability
Act requires. See TEX. CIV. PRAC. & REM. CODE § 74.351(a), (l), (r)(6).
The court of appeals reversed, concluding that the reports lack sufficient
detail about the appropriate standard of care and breach. We conclude
that the reports sufficiently set forth a standard of care and breach
linked to the underlying alleged facts, and therefore we reverse the court
of appeals’ judgment.

                                    I

      Brandon Uriegas, a nonverbal adult, lives with severe intellectual
disabilities, deformity of both feet, scoliosis, autism, and osteoporosis.
In 2006, he moved into a residential care facility for people with
developmental disabilities.      Respondent Kenmar Residential HCS
Services managed the facility.
      In September 2018, Uriegas fell and hit his head while showering.
The parties dispute whether a Kenmar staff member attended Uriegas
at the time he fell. At the emergency room, Uriegas received three
staples to treat lacerations to his scalp. Later that evening, Kenmar
staff reported that Uriegas appeared “wobbly.”
      The following day, Uriegas fell a second time while using the
toilet, allegedly without staff assistance. Kenmar staff allegedly did not
arrange for a medical evaluation.
      On the morning of September 24—one day after the second fall
and two days after the first—Kenmar staff reported that Uriegas could
not stand and that his foot was swollen. Uriegas was taken to the
hospital and admitted that afternoon with a fractured left hip and
femur. He required surgery and was hospitalized for twenty-one days.
      Jesse Uriegas, Uriegas’s father and legal guardian, sued Kenmar
for negligence, gross negligence, and negligent hiring and supervision of
its employees. He alleged that Kenmar, among other things, “fail[ed] to
provide adequate supervision for [Uriegas] during daily activities,

                                    2
including the use of bathroom facilities,” “fail[ed] to provide reasonable
and adequate care,” and “fail[ed] to timely seek medical treatment.”
      Jesse Uriegas served Kenmar with an expert report by Maureen
Hildebrandt, a certified rehabilitation registered nurse.           Nurse
Hildebrandt’s report states that the appropriate standard of care
requires that “all injuries, regardless of severity, . . . be assessed and
documented” because Uriegas was “incapable of verbalizing his needs”
and “could not be relied upon to report injury-related pain/discomfort.”
Uriegas also “was incapable of independently performing all aspects of
personal care in the bathroom,” and thus “a staff member would need to
be present while [Uriegas] was taking a bath/shower.”          The report
indicates that after the first fall, the standard of care required “close
monitoring at all times, especially when [Uriegas] was walking
anywhere.” Nurse Hildebrandt’s report identifies Kenmar’s breach as
“failing to [e]nsure that [Uriegas]’s [individual care plan] accurately
reflected the specific care necessary based on [Uriegas]’s specific needs”
and “failing to properly implement the necessary interventions in
[Uriegas]’s plan of care both before and after [the date of injury].”
      Kenmar objected to Nurse Hildebrandt’s report on several
grounds.    The trial court sustained Kenmar’s objection to Nurse
Hildebrandt’s qualifications to opine on causation; it overruled
Kenmar’s other objections and permitted supplementation with an
expert report by Dr. Brett Cascio, an orthopedic surgeon. In his report,
Dr. Cascio opined that the standard of care included “significant
monitoring and assistance when moving” to prevent falls, “frequent and
thorough evaluations for injury,” and, after a fall, “a complete and

                                     3
thorough medical evaluation . . . to ensure that [Uriegas] did not sustain
a serious injury that he is unable to relay to caretakers.” Dr. Cascio
identified Kenmar’s breach: “there was not any staff to assist [Uriegas]
getting in and out from the bathroom”; “Kenmar failed to provide
assistive care personnel and equipment”; “[a]fter the falls, Kenmar did
not properly assess [Uriegas] for injuries”; and “Kenmar and employees
failed to provide the appropriate monitoring and assistance.”
      Kenmar objected to this report as well. The trial court overruled
Kenmar’s objections and denied its motion to dismiss.             Kenmar
appealed.
      The court of appeals reversed, holding that the reports failed to
provide a fair summary of the standard of care and the alleged breach
of that standard. ___ S.W.3d ___, 2022 WL 843890, at *1 (Tex. App.—
Amarillo Mar. 11, 2022). One justice would have held that Dr. Cascio’s
report provided a fair summary. Id. at *6 (Quinn, C.J., concurring and
dissenting).

                                    II

      The Texas Medical Liability Act requires healthcare liability
claimants to timely serve a defendant healthcare provider with an
adequate expert report. TEX. CIV. PRAC. & REM. CODE § 74.351(a), (l).
An expert report is adequate if it “represent[s] an objective good faith
effort” to provide a “fair summary of the expert’s opinions . . . regarding
applicable standards of care, the manner in which the care rendered by
the physician or health care provider failed to meet the standards, and
the causal relationship between that failure and the injury, harm, or
damages claimed.” Id. § 74.351(l), (r)(6). An expert report demonstrates

                                    4
a good faith effort and thus satisfies the statute’s requirements when it
“(1) inform[s] the defendant of the specific conduct called into question
and (2) provid[es] a basis for the trial court to conclude the claims have
merit.”   Baty v. Futrell, 543 S.W.3d 689, 693-94 (Tex. 2018).         In
articulating the standard of care and breach, an expert report “must set
forth ‘specific information about what the defendant should have done
differently’”; that is, “‘what care was expected, but not given.’” Abshire
v. Christus Health Se. Tex., 563 S.W.3d 219, 226 (Tex. 2018) (quoting
Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 880
(Tex. 2001)).
      The Act permits a claimant to satisfy the requirement with
multiple reports “by serving reports of separate experts regarding
different physicians or health care providers or regarding different
issues arising from the conduct of a physician or health care provider.”
TEX. CIV. PRAC. & REM. CODE § 74.351(i). Thus, we review the adequacy
of reports in the aggregate. See Abshire, 563 S.W.3d at 223 (“[O]ne
expert need not address the standard of care, breach, and causation;
multiple expert reports may be read together to determine whether
these requirements have been met.”).
      In this case, the trial court properly sustained Kenmar’s objection
to Nurse Hildebrandt’s report because she was not qualified to opine on
causation. See TEX. CIV. PRAC. & REM. CODE § 74.351(r)(5)(C) (requiring
that a qualified physician opine on causation). The trial court granted
an extension to file Dr. Cascio’s report and, after receiving the second
report, viewed both reports together and permitted the suit to proceed.
In denying Kenmar’s motion to dismiss, the trial court necessarily found

                                    5
that the two reports together provide a fair summary of the alleged
standard of care, breach, and causation, as the Act requires.
      In Nurse Hildebrandt’s report, she opines that the standard of
care required “a staff member . . . to be present while [Uriegas] was
taking a bath/shower” because Uriegas “was incapable of independently
performing all aspects of personal care in the bathroom.” His diagnoses
of osteoporosis and bilateral pedal deformity “increas[ed] the risk of
falls” and “placed [him] at a higher risk for injury in the event of a fall.”
      Leaving aside Uriegas’s general increased risk of falling, Nurse
Hildebrandt further explains that a fall placed Uriegas at an increased
risk of an undetected injury because he was “incapable of verbalizing his
needs” and “could not be relied upon to report injury-related
pain/discomfort.” Given his limited ability to self-report injury, the
standard of care in Uriegas’s case required that “all injuries, regardless
of severity, . . . be assessed and documented.” After the first fall, the
report indicates that it was “clearly and undeniably the responsibility of
the nursing staff” to modify Uriegas’s care to include “close monitoring
at all times, especially when [Uriegas] was walking anywhere.”
      In further support of the alleged standard of care, Dr. Cascio
explains in his report that the care plan for someone with Uriegas’s
diagnoses should include “significant monitoring and assistance when
moving” to prevent falls, “frequent and thorough evaluations for injury,”
and, after a fall, “a complete and thorough medical evaluation . . . to
ensure that [Uriegas] did not sustain a serious injury that he is unable
to relay to caretakers.”

                                     6
      Dr. Cascio opines that “the proper standard of care [was] to fully
examine [Uriegas] for injury and evaluate the existing care plan to
determine if a change or correction is needed.” Kenmar “should have
conducted a thorough evaluation for injury considering that [Uriegas] is
essentially nonverbal and cannot convey injuries himself.”
      Kenmar contends that the reports do not provide a fair summary
of the standard of care.   In its view, Nurse Hildebrandt’s report is
impermissibly vague. For example, the report recommends updating
the care plan after a “change in status” but does not define what a
“change in status” means; she suggests that “immediate interventions”
were required after Uriegas’s fall but fails to describe those
interventions; and she prescribes training for staff without explaining
what instruction should have been given to train them in “how to
properly monitor and care for the client.” Kenmar further contends that
Dr. Cascio should have addressed the number of people Kenmar should
have placed in the position of monitoring Uriegas, their schedule, and
the type of assistance they should have provided.        Agreeing with
Kenmar, the court of appeals concluded that Nurse Hildebrandt
provided “conclusory statements that fail[ed] to inform Kenmar of what
it should have done differently.” 2022 WL 843890, at *4. The court of
appeals similarly rejected Dr. Cascio’s report because it “provide[d] no
details regarding what constitutes ‘appropriate’ or ‘significant’
monitoring and assistance,” did not “explain who was responsible for
administering an examination or what an examination should have
encompassed,” and did not “explain what specific action Kenmar should
have taken but did not.” Id. at *5.

                                      7
      While the two reports may lack sufficient specificity with respect
to initial monitoring and fall protection, when viewed together, they
sufficiently describe the standard of care for someone with Uriegas’s
diagnoses as requiring a thorough evaluation for injuries after a fall and
increased staff monitoring after a fall takes place to ensure that the
patient does not attempt to use the toilet without assistance. According
to the alleged underlying facts, Uriegas received no medical evaluation
or treatment after his second, unmonitored fall until the next day. With
respect to Kenmar’s alleged lack of post-fall monitoring, evaluation for
injury, and treatment, Dr. Cascio’s report sufficiently sets forth the
standard of care and breach. Dr. Cascio’s report calls for monitoring
Uriegas “when moving” after the first fall.      While the reports lack
specifics in some instances, they provide a fair summary of the standard
of care for the claim of failure to appropriately monitor Uriegas after his
two falls. Further, the reports are based on the underlying factual
allegations that Kenmar failed to monitor according to an appropriate
care plan after a fall. In Dr. Cascio’s view, Kenmar failed to increase
monitoring, evaluate Uriegas for injuries, or seek evaluation before and
after his second fall, as he states the appropriate standard of care
requires.
      In Miller v. JSC Lake Highlands Operations, LP, a nursing home
resident died after aspirating on her dental bridge. 536 S.W.3d 510, 512
(Tex. 2017). The expert reports explained that the nursing home staff
knew her dental bridge was missing and that her voice sounded raspy;
under those circumstances, the standard of care required staff to check
the resident’s throat for the missing bridge and take her to the

                                    8
emergency room. Id. at 517. The staff’s failure to do so contributed to
the delay that ultimately, in the experts’ opinion, caused her death. Id.
In this case, as in Miller, the standard of care depends on the facility
staff’s alleged knowledge: that Kenmar staff knew that Uriegas was at
increased risk of injury from falls due to his diagnoses and he could not
verbalize his complaints.     In Miller, the standard of care required
looking in the patient’s throat; according to the experts in this case, it
required additional monitoring and evaluation of symptoms, like
appearing “wobbly” after a fall.
      Kenmar further challenges the reports as lacking specificity
about breach of the standard of care. Kenmar observes that it brought
Uriegas to the hospital after his first fall, which, it contends, disproves
that it breached the standard of care. Without more, a health care
provider’s disagreement with the expert’s opinion in a Chapter 74 report
does not render the report insufficient. See, e.g., Miller, 536 S.W.3d at
516-17 (“At this preliminary stage, whether [the expert’s articulated
standards] appear reasonable is not relevant to the analysis of whether
the expert’s opinion constitutes a good-faith effort.”). Even so, Dr. Cascio
faults Kenmar for failing to monitor Uriegas upon his return to the
facility, which he notes resulted in delayed medical evaluation, and for
its failure to properly treat Uriegas’s injuries after the second fall. The
first trip to the hospital does not address these alleged breaches. We
conclude that Dr. Cascio’s opinion as to breach provides a fair summary
of the claims against Kenmar.
      The court of appeals likened Dr. Cascio’s report to one that
improperly “infer[red] breach of a standard of care from the fact that an

                                     9
injury exists that normally should not.” 2022 WL 843890, at *6 (quoting
Hoelscher v. San Angelo Cmty. Med. Ctr., No. 03-03-00236-CV, 2004 WL
2731967, at *3 (Tex. App.—Austin Dec. 2, 2004, no pet.)). But the report
notes that Uriegas required a thorough examination after a fall and
additional monitoring because Uriegas’s condition prevents him from
communicating his personal needs and injuries to a caregiver.        Dr.
Cascio recites specific facts to support his opinions: Kenmar allegedly
knew of Uriegas’s diagnoses, knew that he was at risk for falling again
without assistance, and knew that because Uriegas could not report
injuries to staff, he required a thorough evaluation after a fall. In Dr.
Cascio’s opinion, Kenmar did not provide the required assistance and
evaluation.
      Finally, the court of appeals faulted Nurse Hildebrandt’s report
for “not explain[ing] how the outcome would have changed” had Kenmar
complied with the alleged standard of care and for “not assert[ing] that
the failure to have a nurse assess [Uriegas] after this fall was the
proximate cause of his injuries.” 2022 WL 843890, at *5. Dr. Cascio
opines, however, that a proper assessment would have led to earlier
medical intervention and treatment and the thirty-hour delay
contributed to Uriegas’s injuries. Only physicians are qualified to opine
on causation, and Kenmar does not challenge Dr. Cascio’s opinion as to
causation. See TEX. CIV. PRAC. & REM. CODE § 74.351(r)(5)(C).

                             *     *      *

                                   10
      We hold that the trial court did not abuse its discretion in denying
Kenmar’s motion to dismiss under Chapter 74. The proffered reports
provide a fair summary of the experts’ opinions as to the appropriate
standard of care and breach of that standard. Accordingly, without
hearing oral argument, we reverse the court of appeals’ judgment and
remand the cause to the trial court for further proceedings. See TEX. R.
APP. P. 59.1.

OPINION DELIVERED: September 15, 2023

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