Court Opinion

ID: 5142411
Source: CourtListenerOpinion
Date Created: 2021-12-31 08:13:49.538109+00
Date Added: 2024-06-11T08:24:36.877754
License: Public Domain

In The

                                Court of Appeals

                    Ninth District of Texas at Beaumont

                               __________________

                               NO. 09-20-00266-CV
                               __________________

          MAGNOLIA PLACE HEALTH CARE, L.L.C., Appellant

                                         V.

       QULIA JACKSON, INDIVIDUALLY AND AS PERSONAL
   REPRESENTATIVE OF THE ESTATE OF GENE EARL ROBINSON,
               AND DOMINIQUE SAULS, Appellees

__________________________________________________________________

               On Appeal from the 253rd District Court
                       Liberty County, Texas
                     Trial Cause No. CV1914851
__________________________________________________________________

                          MEMORANDUM OPINION

      This is an interlocutory accelerated appeal from the trial court’s order

overruling the Defendant’s objections to Plaintiffs’ expert reports and denying a

motion to dismiss Plaintiffs’ health care liability claim. See Tex. Civ. Prac. & Rem.

Code Ann. § 74.351; see also id. § 51.014(a)(9) (providing for interlocutory appeal

of an order denying relief under section 74.351). Defendant Magnolia Place Health

Care, L.L.C. (“Magnolia,” “Defendant,” or “Appellant”) timely filed this appeal

                                         1
complaining that the trial court erred in overruling their objections and in failing to

dismiss the health care liability claim of Plaintiffs Qulia Jackson, Individually and

as Personal Representative of the Estate of Gene Earl Robinson, Deceased, and

Dominique Sauls (collectively “Plaintiffs” or “Appellees”). We affirm.

                                      Background

Allegations in Plaintiffs’ Petition

      On July 1, 2019, Plaintiffs filed their Original Petition stating a claim for

negligence against Magnolia under Chapter 74 of the Texas Civil Practice and

Remedies Code. On December 4, 2019, Plaintiffs filed their Fourth Amended

Petition, the live pleading at the time the trial court entered the order being appealed,

which stated claims for wrongful death under Chapter 74 and survival under Chapter

71.

      Plaintiffs alleged that Gene Robinson (“Robinson”) had lived at Magnolia for

about a year and a half before July 2, 2017, when he was transferred from his dialysis

appointment at Dayton Dialysis to Liberty ER due to critically low levels of

potassium. Later that same day, Robinson was transferred to Kingwood Medical

Center (“Kingwood”), where Robinson was found to have “an unstageable decubitus

ulcer measuring 7x8 cm on his backside, cellulitis of left AV fistula, and 2 punctured

ulcers on his left AV fistula, which tested positive for Methicillin-Sensitive Staph

                                           2
Aureus” (“MSSA”). The ulcer and infected AV fistula were “managed,” and

Robinson was discharged back to Magnolia on July 20, 2017.

      On July 25, 2017, Robinson was sent to ICON Wound Center (“ICON”),

where he was diagnosed with “osteomyelitis (infection of the bone) in the sacral

region with stage IV decubitus sacral ulcer.” The petition alleged that the ulcer was

infected with pseudomonas, Robinson’s blood cultures were positive for MSSA, and

Robinson had a “stage IV facility acquired pressure ulcer on his buttocks.” At ICON,

Robinson underwent two debridements of the ulcer on his sacrum. According to the

petition, “due to the infection already being spread throughout his body,” Robinson

died on August 26, 2017, from septic shock.

      The Plaintiffs alleged that Magnolia 1 was negligent in its care and treatment

of Robinson for:

      a. Failing to prevent ulcers,
      b. Failing to assess, document and report a change in the Decedent’s
      condition,
      c. Failing to institute appropriate nursing interventions to stabilize a
      patient’s condition and/or prevent complications, and
      d. Failing to properly train its employees.

The petition alleged that Robinson’s death certificate listed sepsis as the cause of

death, secondary to end stage renal failure. Plaintiffs claimed Magnolia was grossly

      1
          Plaintiffs’ petition asserted no claims against any other health care provider.
                                              3
negligent for “knowingly and intentionally allow[ing] the deceased to essentially rot

in his own bed causing hi[m] to suffer huge, ulcerated bed sores that led to his death.”

Dr. Rushing’s Report

      On or about October 30, 2019, Plaintiffs produced a report and curriculum

vitae (“CV”) from Lige B. Rushing, M.D. (“Rushing” or “Dr. Rushing”). In the

October 2018 report, Dr. Rushing stated that he received his M.D. degree from

Baylor University College of Medicine, and interned at Harris Hospital in Fort

Worth, Texas. Rushing also has a Master of Science degree in medicine from the

University of Minnesota, and he received “specialty training in internal medicine

and rheumatology” at the Mayo Clinic in Rochester, Minnesota. According to the

October 2018 report and CV, Dr. Rushing is board-certified in internal medicine,

rheumatology, and geriatrics, and he continues to actively practice these specialties.

Rushing is on the affiliate staff of the Presbyterian Hospital in Dallas, Texas. In the

report, Rushing stated that over the course of his medical practice, he had occasion

to diagnose and treat patients with conditions similar to or identical with Robinson’s,

and he was familiar with the standard of care that apply to Magnolia and the health

care workers assigned to care for Robinson. Specifically, Rushing stated that he had

issued orders for the prevention and treatment of pressure ulcers and supervised the

execution of those orders.

                                           4
      Rushing’s report stated that he had reviewed Robinson’s records from

Kingwood, ICON, and Robinson’s death certificate, but that he anticipated

additional records would be forthcoming, and he had specifically requested records

from Magnolia. Rushing stated that Robinson had a history of hypertension,

dementia with Lewy bodies, end-stage renal disease with dialysis, cellulitis of the

arm, and type II diabetes. The report stated that when Robinson was admitted at

Kingwood, he was a resident at Magnolia long-term care facility and had been noted

to have a decline in status and appetite for about two weeks and a significant decline

in mentation. Robinson was taken to the Liberty Emergency Department, where he

had been found to have “abdominal distention and an ileus” and very low potassium

levels, and he was transferred to Kingwood for further care. Upon admission at

Kingwood, it was noted that Robinson had an unstageable deep tissue injury to the

buttocks that was “a real problem.” Robinson was also treated at Kingwood for

hypokalemia and ileus, which improved, but the sacral pressure ulcer did not

improve.

      Robinson was admitted to ICON on July 27, 2017, and according to Rushing,

ICON’s records stated the reason for his admission was “a sacral decubitus ulcer,

generalized weakness and critical illness myopathy.” The ICON records reported

that Robinson was diagnosed with advanced dementia, Parkinson’s, end-stage renal

disease with dialysis three times a week, failure to thrive secondary to decreased PO

                                          5
intake and secondary to other medical conditions, moderate-to-severe malnutrition,

and a necrotic stage IV decubitus ulcer. On August 11, 2017, debridement of the

sacral decubitus ulcer was performed, and on August 19, 2017, Robinson had a

diverting colostomy. On August 26, he became hypotensive, he was transferred to

intensive care, and he developed septic shock, after which his family requested he

be placed on comfort care only. Robinson died on August 26, 2017, with the cause

of death listed in the hospital record as “septic shock secondary to infected decubitus

ulcer, stage IV with necrosis.”

      According to Rushing’s report, the standard of care required Magnolia to:

provide necessary care and services to achieve the best practicable well-being

pursuant to a comprehensive assessment and plan of care; insure that a resident who

enters the facility without pressure ulcers does not develop them unless the resident’s

condition demonstrates such ulcers were unavoidable; a resident who develops

pressure ulcers should receive “the necessary care, treatment, and services” to

promote healing, to prevent infection, and to prevent new ulcers; and a facility

should not accept nor retain a resident whose needs the facility cannot meet. Further,

Rushing stated that Magnolia’s conduct fell below the accepted standards of care

because (1) Magnolia accepted and retained a resident whose needs it could not meet

and (2) Magnolia failed to prevent Robinson’s developing a pressure ulcer.

                                          6
      Rushing’s report stated that pressure ulcers result from unrelieved pressure on

a body part, and such pressure deprives body tissue of necessary oxygen and

nutrients. Rushing further stated that in this case, as a result of diminished blood

flow, “the tissues died and became necrotic or decayed[,]” which provided a medium

for bacteria to invade and multiply. According to Rushing, when this process is

unchecked, blood cannot flow to the tissues and organs, sepsis develops, and

multiorgan failure and death result. Rushing further stated that when a pressure ulcer

develops in the sacral area, fecal material may cause infection or damage the tissues,

and to divert fecal material away from the ulcer, a diverting colostomy may become

necessary. He also stated that a large, infected pressure ulcer increases the body’s

caloric requirements by at least 100% to promote wound healing. Rushing’s report

concluded that the harm or injury that resulted from Robinson’s pressure ulcer was:

      …Robinson’s malnutrition required a gastric feeding tube, placement
      and a diverting colostomy, a surgical debridement of his sacral ulcer. If
      there had been no pressure ulcer there would have been no malnutrition.
      If there had been no malnutrition then there would have been no
      necessity for a gastric feeding tube. If there had been no pressure ulcer
      then there would have been no necessity for a diverting colostomy, a
      major surgical procedure that could have been avoided.

Nurse Gardner’s Report

      On or about July 31, 2019, Plaintiffs also produced the report and CV of

Ventura Gardner, a registered nurse. Gardner stated she had clinical experience in

critical care, Emergency Department, peri-operative nursing, medical/surgical,

                                          7
endoscopy nursing, ambulatory care, and wound care nursing. She also stated she

had served as a hospital supervisor and Lead for The Joint Commission Certification

for specialty diseases (Orthopedics). Gardner’s report stated that she had reviewed

Robinson’s medical records from Kingwood and ICON but that at the time of her

report, records from Magnolia or Liberty ER were not available. Gardner’s report

included a similar medical overview as Rushing’s, and Gardner added that upon

admission at Kingwood, Robinson’s decubitus ulcer was extensive enough as to

leave his tailbone exposed. Gardner’s report also stated that Robinson “was non-

verbal, unable to advocate for himself, and unable to understand simple directions

or questions.”

      According to Gardner, the standard of care required the nursing staff to

provide a safe environment and to protect the patient from avoidable injury and to

assess, document and timely report a change in the patient’s condition to the

physician. Gardner stated that “[t]he nurses from facilities prior to [Robinson’s

admission to] Kingwood” breached the standard of care by (1) failure to implement

interventions to prevent ulcer development, such as frequent turning, padding bony

areas, using a specialty bed, and closely monitoring his nutritional status; and

(2) failure to report a change in Robinson’s condition to a physician. According to

Gardner, the fact that Robinson’s tailbone was exposed indicated that the nursing

staff failed to meet basic standards of care. Gardner stated that “there is no indication

                                           8
nursing from [facilities that treated Robinson prior to Kingwood] notified the

physician in a timely manner to intervene when the ulcers began to develop and

continued to worse[n.]” Gardner’s report stated that standard nursing interventions

to reduce the development of decubitus ulcers include:

      …turning him every 2 hours, providing a specialty bed which off loads
      pressure points of bedridden patients, hourly rounds to assist with
      toileting (assess for urine/stool and clean him as needed to prevent
      further decubitus ulcer development), and clear plan of care, especially
      related to changes in condition of ulcers, between nursing and
      physician.

According to Gardner, as a result of deficient nursing care, the pressure ulcer

developed, the tailbone became exposed, Robinson became septic and required

additional procedures, and subsequently died.

Magnolia’s Objections to the Reports and Motion to Dismiss

      Magnolia filed objections to Rushing’s and Gardner’s reports. Magnolia then

filed a Motion to Dismiss Plaintiffs’ Suit Pursuant to C.P.R.C. § 74.351 & Response

to Plaintiffs’ Motion to Deem Sufficiency (“Motion to Dismiss”). Magnolia argued

that Rushing was not qualified to render an opinion on standard of care or liability

in this case and his report was “non-specific speculation and conclusory” because

Rushing failed to identify specific actions or omissions by Magnolia and was

insufficient to show causation. As to Gardner’s report, Magnolia argued that she was

not qualified to render an expert opinion in this case, her report was speculative, and

the standard of care she offered was “non-specific speculation and [] conclusory.”
                                          9
According to Magnolia, Gardner failed to identify specific actions or omissions by

Magnolia and lacked specificity regarding what conduct was expected. Magnolia

also argued that Gardner’s report was conclusory and insufficient as to causation.

Magnolia also acknowledged that the Plaintiffs had requested the statutory option of

a thirty-day extension of time to correct deficiencies if the trial court found

deficiencies that were curable.

Plaintiffs’ Response to Magnolia’s Objections

      In their response, the Plaintiffs argued that both Rushing’s and Gardner’s

reports provided “at a minimum, a good faith effort to comply” with the

requirements of Chapter 74, both reports set forth a fair summary of the relevant

standard of care and breach thereof, and that Rushing’s report established a causal

link between Magnolia’s breach and Robinson’s death. The Plaintiffs denied that the

reports were conclusory because both reports “clearly state the cause of [Robinson’s]

death as supported by the death certificate and the standard of care that was

breached.”

      The Plaintiffs argued that Rushing was qualified to render an opinion in this

case based on his expertise and experience in internal medicine, geriatrics, and

rheumatology. The Plaintiffs denied that Rushing’s report was conclusory or

speculative. According to the Plaintiffs, Rushing’s report was clear that Magnolia

breached the applicable standard of care by (1) accepting and retaining a resident

                                         10
whose needs Magnolia could not meet and (2) failing to prevent Robinson from

developing a pressure ulcer. The Plaintiffs also argued that Magnolia knew or should

have known that Robinson was at high risk of developing pressure ulcers.

      The Plaintiffs also argued that Gardner was qualified to render an opinion in

this case based on her thirty-nine years as a registered nurse and her experience in

critical care and nursing leadership and supervision. The Plaintiffs argued that

Gardner had specifically stated that Magnolia breached the applicable standard of

care by failing to notify a physician of a change in Robinson’s status—specifically

his development of a stage IV decubitus ulcer—and failing to institute appropriate

nursing interventions to prevent the development of decubitus ulcers, to stabilize

Robinson’s condition, and to prevent complications. The Plaintiffs’ response also

noted that Gardner had identified specific nursing practices that should have been

implemented, including assistance with toileting, providing a specialty bed, and

repositioning and cleaning the patient every two hours or as needed.

Trial Court’s Order

      The trial court found the expert reports were deficient as set out in Magnolia’s

objections. The court further found that the deficiencies were curable and granted a

thirty-day extension to cure defects, as provided by section 74.351.

                                         11
Dr. Rushing’s Amended Report

      Dr. Rushing provided an amended report dated January 9, 2020. The amended

report was substantially the same as his original report, with a few additions. As to

his qualifications, Rushing added that he had many years of direct care for nursing

home residents and “[b]eginning in 1959 I had the primary responsibility for nursing

home patients and I have continued to have nursing home patients during 2019.”

Rushing also stated that he had testified as a medical expert numerous times

concerning nursing home and bedsore or pressure ulcer cases. Dr. Rushing also

added the following to his report:

      Magnolia Place [] thus far has refused to produce the clinical records
      for Gene Earl Robinson. I have been forced to produce a chapter 74
      report without this vital record. I reserve the right to amend my initial
      chapter 74 report and the first amended report when and if the
      defendant[] produce[s] the Magnolia Place health records. As a result I
      have had to rely on the records available to me at the time of preparation
      of this report. When he arrived at the Liberty Emergency Department
      he was found [to] have a deep tissue injury/pressure ulcer on hi[s]
      buttocks measuring 7x8 cm, unstageable. I am concluding that Mr.
      Robinson did in fact have this injury when he left Magnolia Place. My
      opinion is that he more likely than not developed the pressure
      ulcer/deep tissue injury while he was a resident at Magnolia Place. If
      records are provided to me that demonstrate that he was admitted to
      Magnolia Place with the pressure ulcer then obviously my opinion
      would change.

Nurse Gardner’s Amended Report

      Nurse Gardner provided an amended report dated January 9, 2020. In her

amended report, Gardner stated that her nursing duties included acute and chronic

                                         12
wound management as well as bathing, feeding, turning, and repositioning patients.

She also reported that she had been responsible for cleaning wounds according to a

physician’s order and notifying a charge nurse of changes in patients’ condition. As

to the applicable standard of care, Gardner added the following: “Institute

appropriate nursing interventions that might be required to stabilize a client’s

condition and/or prevent complications[.]”

      In addressing deviation from the standard of care, Gardner added the

following in her amended report:

      [] The nurses from facilities prior to Kingwood Medical Center did not
      provide the appropriate basic nursing interventions to help prevent the
      pressure ulcers and did not seek further treatments of his pressure ulcers
      in a timely fashion. If they had taken the proper precautions discussed
      to prevent the pressure ulcer and advocate to the physician on behalf of
      the patient to refer the patient to a wound specialist sooner, the pressure
      ulcer would not have been as extensive as described. The nurses at the
      facility failed to do this.…Mr. Robinson was nonverbal. He could not
      speak for himself to even tell anyone he was in pain or uncomfortable
      and this type of wound is very painful. The nurses did not seek
      additional treatment and care for this patient who could not speak for
      himself. Again, if this had been done he would have received
      appropriate wound care treatments much sooner than he had.
      ....
      …The nurses also did not advocate on behalf of the patient to receive
      the specialized care that he desperately needed to help treat his wounds.
      According to the records, Mr. Robinson did not go to a wound care
      specialist until after he was admitted to Kingwood Medical Center on
      7/2/17 and his bone was exposed. As nurses, our basic fundamental of
      nursing is to care for our patients. Not just “provide” care such as
      bathing and giving medications but to actually “care” about their well-
      being and to take the extra steps that are needed sometimes to champion
      on their behalf or advocate for them. The wounds that Mr. Robinson
      had did not develop overnight, it took hours, days, and weeks to develop
                                          13
      a pressure ulcer of that magnitude and the nurses failed to properly
      assess the extent of Mr. Robinson’s injuries and advocate for his proper
      care.

Gardner also added narrative about the nature of pressure ulcers, prevention of

pressure ulcers, and a facility’s responsibility for the residents’ quality of life.

Magnolia’s Objections to the Amended Reports

      Magnolia filed Objections to Plaintiffs’ Amended Expert Reports &

Supplemental Motion to Dismiss with Attorney[’]s Fees Pursuant to C.P.R.C.

§ 74.351. Therein, Magnolia argued that

      …Plaintiffs’ Reports fail to satisfy the statutory requirements and admit
      to never having received or reviewed Gene Robinson’s medical records
      from Magnolia Place, thus having no knowledge of events, Robinson’s
      condition or Defendant’s conduct they can not meet statutory
      requirements as a matter of law. [] See Transitional Care Ctrs[.] of Tex.
      Inc., v. Palacios, 46 S.W.3d 873, 879 (Tex. 2001).

Magnolia argued that the reports did not have a reliable basis as to any element of

Plaintiffs’ claims and, therefore, they cannot be a good faith effort to comply with

the requirements of Chapter 74. According to Magnolia, because Rushing and

Gardner only reviewed records from Kingwood and ICON, their reports rely on

reports by persons without personal knowledge of Magnolia or what occurred at

Magnolia, and as a consequence, the reports constitute “speculation and unfounded

conclusions” regarding any liability by Magnolia for Robinson’s injuries and death.

      Magnolia’s motion alleges that it had advised Plaintiffs from February 28,

2018 to April 29, 2019, that an authorization signed by a legally authorized
                                           14
representative of Robinson’s estate was required to obtain Robinson’s medical

records from Magnolia. Only after the trial court found the first reports deficient and

granted a thirty-day extension of time did the Plaintiffs produce an authorization for

medical records signed by a court-appointed administrator of Robinson’s estate.

Magnolia further alleged that it produced three volumes of Magnolia’s medical

records for Robinson on January 10, 2020, and three days later, Plaintiffs produced

Rushing’s and Gardner’s amended reports.

      As to Nurse Gardner, Magnolia argued that her experience was in acute

hospital care, and her CV identified no training, experience, or education in the same

field as Magnolia—nursing home care. According to Magnolia, lacking such

experience or training, Gardner “is no more than a lay witness[.]” As to the standard

of care Gardner outlined, Magnolia argued that Gardner did little more than cite to

government statutes and regulations that are “mere global comments and principles,”

and insufficient to specify Magnolia’s duty of care. In addition, Magnolia argued

that Gardner’s report did not satisfy statutory requirements because it failed to

specifically identify what Magnolia should have done, what it did not do, and what

it should have done differently. In particular, Magnolia stated that Gardner’s report

referred vaguely to “facilities prior to Kingwood[]” and cited no specific conduct by

Magnolia. Magnolia further argued that the standard of care offered by Gardner are

only general concepts regarding assessment, monitoring, and interventions that are

                                          15
insufficient as a matter of law. In addition, Magnolia argued that as a nurse, Gardner

is not qualified to render an opinion on causation as a matter of law, citing to section

74.351(r)(5)(C) of the Texas Civil Practice and Remedies Code.

      As to Dr. Rushing, Magnolia argued that Rushing was not qualified because

Rushing’s report and CV demonstrate no experience in the field of nursing home

care and Rushing reported his experience was as a physician in private practice at

hospitals. According to Magnolia, the standards of care Rushing provided pertain to

administrative functions of a nursing home and not the conduct of RNs, LVNs, or

CNAs. Magnolia also argued that Rushing offered only “vague general principles”

taken from the Code of Federal Regulation and the Texas Administrative Code that

only address administrative responsibilities and do not define the duties or

responsibilities of RNs, LVNs, or CNAs. Magnolia further argued that Rushing

failed to describe any breach of administrative duties by Magnolia that resulted in

Robinson’s injuries or death. According to Magnolia, Rushing’s report is

speculative, misleading, and conclusory and fails to explain specifically how and

why Magnolia’s alleged negligence caused Robinson’s injuries and ultimate death,

and any connection between Magnolia’s conduct and Robinson’s injuries and death

is too attenuated to articulate a causal relationship. Therefore, Magnolia argued the

expert reports did not satisfy the requirements of section 74.351 and the case should

be dismissed with prejudice.

                                          16
Plaintiffs’ Response to Magnolia’s Second Motion to Dismiss

      In their response to Magnolia’s motion, the Plaintiffs acknowledged that

Linda Robinson was appointed as the administrator of Robinson’s estate on

November 26, 2019, Plaintiffs paid for Magnolia’s records on December 17, 2019,

and Plaintiffs received the medical records from Magnolia on January 13, 2020.

According to the Plaintiffs, “Magnolia Place has continually been obstructive”

trying to get the case dismissed. Plaintiffs argued that because Magnolia had not

argued in its first motion to dismiss that Dr. Rushing’s and Nurse Gardner’s initial

reports did not mention Magnolia’s medical records for Robinson, it could not make

this argument in its second motion to dismiss, citing to Bakhtari v. Estate of Dumas,

317 S.W.3d 486 (Tex. App.—Dallas 2010, no pet.). Plaintiffs further argued that

Magnolia had “unclean hands in attempting to use its refusal to produce records for

[] Robinson as a sword in claiming that the amended reports are not adequate under

Chapter 74[]” and it should not profit “from these unfair tactics.”

      Plaintiffs also argued that Chapter 74 does not require the expert to review

any particular records, that Dr. Rushing based his opinion on Robinson’s condition

upon arrival at the Liberty ER and at Kingwood where Robinson had a severe,

unstageable pressure ulcer on his buttocks, and that according to Dr. Rushing, it was

more likely than not that the pressure ulcer developed at Magnolia due to negligent

care. According to the Plaintiffs, the amended reports identify the relevant standard

                                         17
of care, how Magnolia breached the standard of care, and the causal link between

Magnolia’s breach and Robinson’s untimely death. Plaintiffs maintained that both

Nurse Garner and Dr. Rushing were qualified to render an opinion in this case based

on their experience and training. Plaintiffs further argued that Dr. Rushing’s opinion

on causation was not speculative or conclusory: Rushing stated that Robinson died

of sepsis from bed sores that Robinson developed as a resident at Magnolia, that

Magnolia knew or should have known Robinson was at high risk of development

bed sores, and that Rushing could make inferences about Robinson’s care at

Magnolia based on “circumstantial evidence in the records” and inferences from

other medical records. Plaintiffs argue that the amended reports satisfy Chapter 74’s

requirements because they inform Magnolia of the specific conduct called into

question and provide a basis for the trial court to conclude that the Plaintiffs’ claims

have merit.

Magnolia’s Reply to Plaintiffs’ Response

      In its Reply to the Plaintiffs, Magnolia argued it did not have “unclean hands,”

and that any delay in the production of Magnolia’s medical records for Robinson

was due to Plaintiffs’ failure to produce an authorization signed by a legally

authorized representative of Robinson’s estate. According to Magnolia, Plaintiffs

only obtained a valid authorization on December 2, 2019, and then delayed another

sixteen days before producing the authorization to Magnolia. In addition, Magnolia

                                          18
argued that its statement that Dr. Rushing and Nurse Gardner had not reviewed the

medical records from Magnolia “is not an objection, it is a fact[,]” and therefore

Plaintiffs’ waiver argument was misplaced. Magnolia argued that Rushing’s and

Gardner’s reports improperly opine from assumptions that were not linked to the

facts, and as such, were speculative and conclusory. Magnolia argued that Robinson

had pressure sores at the time he was admitted.

      After a hearing, on November 12, 2020, the trial court signed an order denying

Defendant’s Objections to Plaintiffs’ Amended Expert Reports and Defendant’s

Supplemental Motion to Dismiss, and Magnolia filed its notice of interlocutory

appeal.

                                       Issue

      In a single issue on appeal, Magnolia argues that the trial court abused its

discretion in denying its motion to dismiss because the expert reports were deficient

regarding the applicable standard of care, Magnolia’s breach of the standard of care,

and proximate cause. Magnolia also argues that Nurse Gardner is not qualified to

opine regarding causation and not qualified to testify against a nursing home.

                                Standard of Review

      In health care liability cases, we review a trial court’s ruling on a motion to

dismiss based on the adequacy of an expert report for an abuse of discretion. See

Abshire v. Christus Health Se. Tex., 563 S.W.3d 219, 223 (Tex. 2018) (per curiam);

                                         19
Van Ness v. ETMC First Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam);

Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 877-78 (Tex.

2001). “A trial court abuses its discretion if it acts in an arbitrary or unreasonable

manner without reference to any guiding rules or principles.” Bowie Mem’l Hosp. v.

Wright, 79 S.W.3d 48, 52 (Tex. 2002) (per curiam). A trial court’s ruling does not

constitute an abuse of discretion simply because the appellate court would have ruled

differently under the circumstances. See id. A trial court also abuses its discretion if

it fails to analyze or apply the law correctly. See In re Prudential Ins. Co. of Am.,

148 S.W.3d 124, 135 (Tex. 2004) (citing Walker v. Packer, 827 S.W.2d 833, 840

(Tex. 1992)).

      In reviewing a report’s sufficiency under this standard, “we consider only the

information contained within the four corners of the report.” Abshire, 563 S.W.3d at

223 (citing Palacios, 46 S.W.3d at 878). In determining whether the report contains

the requisite information, we view the entirety of the report rather than isolating

specific portions or sections. See Baty v. Futrell, 543 S.W.3d 689, 694 (Tex. 2018);

Van Ness, 461 S.W.3d at 144. One expert need not address the standard of care,

breach, and causation, and multiple expert reports may be read together to determine

whether these requirements have been met. Abshire, 563 S.W.3d at 223 (citing Tex.

Civ. Prac. & Rem. Code Ann. § 74.351(i)).

                                          20
      While the report “need not marshal all the plaintiff’s proof,” it must provide

a fair summary of the expert’s opinions as to the applicable standards of care, how

the care rendered by the health care provider failed to meet the standards, and the

causal relationship between that failure and the injury claimed. Jelinek v. Casas, 328

S.W.3d 526, 543 (Tex. 2010); see also Tex. Civ. Prac. & Rem. Code Ann.

§ 74.351(r)(6); Jernigan v. Langley, 195 S.W.3d 91, 93 (Tex. 2006); Palacios, 46

S.W.3d at 875, 878. In determining the adequacy of an expert report, a court reviews

the pleadings to determine the claims alleged and whether the report addresses those

claims. See Christus Health Se. Tex. v. Broussard, 306 S.W.3d 934, 938 (Tex.

App.—Beaumont 2010, no pet.) (citing Windsor v. Maxwell, 121 S.W.3d 42, 51

(Tex. App.—Fort Worth 2003, pet. denied)). The report must “explain, to a

reasonable degree, how and why the breach caused the injury based on the facts

presented.” Jelinek, 328 S.W.3d at 539-40.

                  Expert Report Requirements Under Chapter 74

      Chapter 74 of the Civil Practice and Remedies Code, also known as the Texas

Medical Liability Act (“the Act”), requires health care liability claimants to serve an

expert report upon each defendant not later than 120 days after that defendant’s

answer is filed. Tex. Civ. Prac. & Rem. Code Ann. § 74.351(a). The purpose of the

expert report requirement is to weed out frivolous malpractice claims in the early

stages of litigation, not to dispose of potentially meritorious claims. Abshire, 563

                                          21
S.W.3d at 223 (citing Palacios, 46 S.W.3d at 877); see also Loaisiga v. Cerda, 379

S.W.3d 248, 258 (Tex. 2012) (“[Expert report] requirements are meant to identify

frivolous claims and reduce the expense and time to dispose of any that are filed.”).

In accordance with that purpose, the Act provides a mechanism for dismissal of the

claimant’s suit in the event of an untimely or deficient report. Tex. Civ. Prac. &

Rem. Code Ann. § 74.351(b).

      An expert report is sufficient under the Act if it “provides a fair summary of

the expert’s opinions…regarding applicable standards of care, the manner in which

the care rendered…failed to meet the standards, and the causal relationship between

that failure and the injury[.]” Id. § 74.351(r)(6). The trial court need only find that

the report constitutes a “good faith effort” to comply with the statutory requirements.

Id. § 74.351(l); see also Abshire, 563 S.W.3d at 223; Palacios, 46 S.W.3d at 878.

The Texas Supreme Court has held that an expert report demonstrates a “good faith

effort” 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, 543 S.W.3d at 693-94. A report “need not marshal all the claimant’s

proof,” but “a report that merely states the expert’s conclusions about the standard

of care, breach, and causation” is insufficient. Abshire, 563 S.W.3d at 223; Palacios,

46 S.W.3d at 878-79.

                                          22
                                Expert Qualifications

      According to Appellant, to the extent Nurse Gardner’s report opines on

medical causation, her report is deficient because as a matter of law, a nurse is not

qualified to give opinion testimony on medical causation. See Tex. Civ. Prac. &

Rem. Code Ann. § 74.351(r)(5)(C). Appellee concedes that Gardner is not qualified

to render opinions on causation, so we do not address the point further. See Tex. R.

App. P. 47.1.

      Appellant also argues that Gardner is not qualified to render an opinion in this

case because her CV identifies no training, education, or experience in the same field

as Magnolia—that is, in nursing home care. According to Appellant, Gardner’s

experience is as a nurse working in acute care hospitals, not in a nursing home.

      To be qualified to opine that an institutional health-care provider breached the

applicable standard of care, a person must have “‘knowledge of accepted standards

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

injury, or condition involved in the claim’” and be “‘qualified on the basis of training

or experience to offer an expert opinion regarding those accepted standards of health

care.’” Mem’l Hermann Health Sys. v. Heinzen, 584 S.W.3d 902, 911 (Tex. App.—

Houston [14th Dist.] 2019, no pet.) (quoting Tex. Civ. Prac. & Rem. Code Ann.

§ 74.402(b)(2), (b)(3)). For certain medical-negligence claims against non-

physicians, a person is qualified to render an expert report only if the person had

                                          23
been engaged in a field of health care involving the same care or treatment as the

defendant—but only if the defendant health care provider is an individual. Id. (citing

Tex. Civ. Prac. & Rem. Code Ann. § 74.402(b)(1)). Because Magnolia is not an

individual, this provision does not apply to a report regarding the care Magnolia

provided through its nursing staff. See id. at 911-12 (citing Harvey v. Kindred

Healthcare Operating, Inc., 578 S.W.3d 638, 644-46 (Tex. App.—Houston [14th

Dist.] 2019, no pet.) (determining subsection inapplicable to an expert report

addressing a claim against a hospital for its nursing staff’s conduct)). A person may

be qualified to render an expert opinion regarding the applicable standard of care for

hospital nursing staff based on previously acquired experience. See, e.g., id. at 912;

see also Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 461

n.37 (Tex. 2017). “Section 74.351(r)(5)(B) does not require an expert to have the

same specialty as the health care provider she evaluates.” Zamarripa, 526 S.W.3d at

461 n.37 (citations omitted).

      In this case, Nurse Gardner reported that her thirty years of nursing experience

included work as a wound management nurse, including cleaning wounds according

to a physician’s order, cleaning and dressing wounds, repositioning patients every

two hours, and reporting to the charge nurse of any changes in the patient’s status.

She also reported experience with both chronic and acute wounds. Therefore, the

trial court did not err in concluding that Gardner’s training and experience was

                                         24
adequate to render a report on the applicable standard of care and breach based on

the Plaintiffs’ claims in this case. See Zamarripa, 526 S.W.3d at 461 n.37; Heinzen,

584 S.W.3d at 911-12.

                            Standard of Care and Breach

      The standard of care is defined by what an ordinarily prudent healthcare

provider would have done under the same or similar circumstances. See Palacios,

46 S.W.3d at 880. “Identifying the standard of care is critical: Whether a defendant

breached his or her duty to a patient cannot be determined absent specific

information about what the defendant should have done differently.” See id. While

Chapter 74 requires only a “fair summary” of the standard of care and how it was

breached, “even a fair summary must set out what care was expected, but not given.”

Id. (quotation omitted).

      Appellant argues that Nurse Gardner did not identify Magnolia specifically,

nor did she identify the standard of care applicable to Magnolia nor any conduct or

breach by Magnolia. According to Appellant, Gardner “vaguely and collectively

referred to ‘nurses’ at ‘facilities prior to Kingwood Medical Center.’” Appellant also

argues that Gardner did not review the medical records from Magnolia, Dayton

Dialysis, or Liberty Medical Center ER, and that her report did not differentiate

between these providers. According to Appellant, the standards of care Gardner

identified were “no more than general assertions and statements that a patient should

                                         25
be kept safe.” Appellant also argues that Gardner did not identify any interventions

to prevent ulcer development that Magnolia failed to implement or how and when

Magnolia failed to assess Robinson’s skin.

      As to Dr. Rushing, Appellant argues that the standard of care provided in

Rushing’s report was impermissible global or general assertions and statements

regarding safety without explaining what constituted necessary care and services or

discussing the standards for accepting or retaining residents. According to Appellant,

Rushing’s report failed to tie his opinion to any facts regarding care by Magnolia

and failed to discuss the alleged breaches of care with specificity. Appellant argues

that Rushing did not explain how Magnolia failed to prevent Robinson from

developing a pressure ulcer nor did he tie Robinson’s ulcer to any negligent acts or

omissions by Magnolia.

      We read Gardner’s and Rushing’s report together to determine whether the

statutory requirements have been met. See Abshire, 563 S.W.3d at 223 (citing Tex.

Civ. Prac. & Rem. Code Ann. § 74.351(i)). Nurse Gardner’s amended report stated

that the applicable standard of care required Magnolia: to provide a safe

environment; protect the patient from avoidable injury; to provide care in a safe

setting; to assess, document, and timely report a change in a patient’s condition to a

physician; and to institute appropriate nursing interventions to stabilize a patient’s

condition and prevent complications. Gardner stated that appropriate interventions

                                         26
for the prevention of bed sores include daily assessment of skin and pressure points,

turning the patient every two hours, padding bony prominences, using a specialty

bed, closely monitoring the patient’s nutritional status, and using skin cleansers and

moisturizers. Dr. Rushing’s amended report stated that the applicable standard of

care required Magnolia to provide necessary care and services to maintain the

highest practicable patient well-being; to insure that a patient who enters the facility

without pressure sores does not develop them unless unavoidable; to provide care,

treatment, and services to a patient with pressure sores to promote healing, prevent

infection, and prevent new ulcers from forming; and not to accept or retain a resident

whose needs the facility cannot meet. Rushing also stated that Robinson’s clinical

condition did not demonstrate that his pressure ulcers were unavoidable.

      As to breach, Gardner’s amended report stated that nurses at facilities where

Robinson was treated prior to his admission to Kingwood failed to appropriately

assess Robinson for pressure ulcers, failed to implement interventions to prevent

ulcer development, and failed to timely report a change in Robinson’s condition to

a physician. Gardner’s report also stated that the nurses failed to adequately advocate

for Robinson, who was nonverbal and could not report pain or discomfort.

According to Gardner, Robinson was not transferred to an emergency room because

his pressure ulcer was severe, but rather he went to his regular dialysis appointment

on July 2, 2017, where he was transferred to an emergency room due to critically

                                          27
low potassium and then to Kingwood, where the pressure ulcer was extensive, and

his tailbone was found to be exposed. Gardner wrote:

      …This type of ulcer does not develop overnight. Stage IV decubitus
      ulcers develop when nursing fails to meet basic standards of care. The
      ulcer with exposure of bone is evidence of extended periods without
      being turned, poor padding of bony prominence, and nursing failure to
      provide safe environment, failure to perform appropriate physical
      assessments and report changes in condition to a physician, failure to
      provide adequate nutrition to prevent ulcer, and overall gross neglect of
      Mr. Robinson at facilities prior to his admission to Kingwood[.]

Dr. Rushing’s amended report stated that Magnolia knew or should have known that

Robinson was at high risk for the development of pressure ulcers because his

mobility was greatly limited, and he was generally confined to bed. According to

Rushing, Magnolia accepted and maintained a resident whose needs it could not

meet and it failed to prevent Robinson from developing a pressure ulcer.

      We conclude that Dr. Rushing’s and Nurse Gardner’s amended reports read

together adequately identify “what care was expected, but not given.” See Palacios,

46 S.W.3d at 880. Both Rushing and Gardner stated that Magnolia failed to prevent

Robinson from developing a pressure ulcer. Gardner’s report provides several

specific examples of nursing interventions for the assessment, care, and prevention

of pressure sores. Therefore, we conclude that the trial court did not err in concluding

that the amended reports met the Act’s requirement for identifying the applicable

standard of care and how Magnolia failed to meet the standards, and they were

                                          28
sufficient to put Magnolia on notice of the conduct complained of. See Tex. Civ.

Prac. & Rem. Code Ann. § 74.351(r)(6); Palacios, 46 S.W.3d at 880.

                                        Causation

      The Act also requires an expert report to address causation—“how and why”

the alleged negligence caused the injury in question. See Tex. Civ. Prac. & Rem.

Code Ann. § 74.351(r)(6); Abshire, 563 S.W.3d at 224 (quoting Jelinek, 328 S.W.3d

at 536). A conclusory statement of causation is inadequate, and the expert must

explain the basis of his statements and link conclusions to specific facts. Abshire,

563 S.W.3d at 224; Jelinek, 328 S.W.3d at 539; see also Zamarripa, 526 S.W.3d at

461 (“[W]ithout factual explanations, the reports are nothing more than the ipse dixit

of the experts, which…are clearly insufficient.”). In satisfying this “how and why”

requirement, the expert need not prove the entire case or account for every known

fact, and the report is sufficient if it makes “‘a good-faith effort to explain, factually,

how proximate cause is going to be proven.’” Abshire, 563 S.W.3d at 224 (quoting

Zamarripa, 526 S.W.3d at 460).

      According to the Appellant, Rushing’s report was deficient regarding

proximate cause because he did not opine that an alleged breach of care by Magnolia

proximately caused Robinson’s death nor that a pressure ulcer was a proximate cause

of death. Appellant argues that Rushing’s report is “no more than a series of

conclusory statements[]” and failed to identify any conduct by Magnolia that caused

                                            29
injury or death. Appellant further argues that Rushing’s opinion is based upon

“assumptions surmised” only from the records of Kingwood and ICON and that such

assumptions are mere conjecture and speculation because they fail to link

conclusions to specific conduct by Magnolia. Appellant also argues that the failure

to have medical records from Magnolia does not excuse a deficient expert report.

      Dr. Rushing’s amended report stated that the cause of death listed in the

records of Kingwood Medical Center was “septic shock secondary to infected

decubitus ulcer, stage IV with necrosis.” Rushing’s amended report also stated that

upon admission to Kingwood, a physical examination of Robinson showed “a deep

tissue injury to the buttocks measuring 7x8 cm, unstageable.” Rushing further stated

that unrelieved pressure on blood vessels shut off blood flow to tissues, “the tissues

died and became necrotic or decayed[]” and “[t]he decayed tissue is an ideal culture

medium for bacteria.” Rushing also stated that, if unchecked, the spread of infection

results in sepsis and multiorgan failure and death. According to Rushing, because

Robinson arrived at the Liberty ER with a 7x8 cm pressure ulcer, he concluded that

Robinson had this injury when he left Magnolia and “he more likely than not

developed the pressure ulcer/deep tissue injury while he was a resident at

Magnolia[.]”

      We initially note that, according to Appellant, in Estate of Regis v. Harris

County Hospital District, 208 S.W.3d 64 (Tex. App.—Houston [14th Dist.] 2006,

                                         30
no pet.), the Houston Fourteenth Court held that the trial court did not err by

dismissing plaintiff’s claims where the plaintiff did not provide a valid authorization

for the release of medical records and plaintiff failed to timely serve an adequate

expert report. We find Regis factually distinguishable. In Regis, the court explained

that a plaintiff’s failure to provide proper authorization for the release of medical

information abates the proceedings until sixty days following receipt of the required

authorization, but the sixty-day abatement period does not toll the 120-day period

for filing an expert report. Id. at 69. In the case at bar, Plaintiffs’ expert reports were

timely filed, and Regis does not apply.

      We conclude that Dr. Rushing’s explanation provides a sufficient preliminary

link between the nurses’ alleged breach of the standard of care at Magnolia and

Robinson’s development of a severe pressure ulcer and sepsis. See Abshire, 563

S.W.3d at 225. That is, the report draws a line directly from the nurses’ failure to

properly provide care to prevent and treat pressure ulcers to Robinson’s development

of complications (malnutrition and the need for a diverting colostomy) and to the

ultimate injury (sepsis, multiorgan failure, and death). Id. Dr. Rushing’s report then

also ties his conclusion to the underlying facts—the failure to implement preventive

measures, to assess and treat pressure sores, and to timely report patient changes to

a physician. See id. at 225-26. Because at this stage of the proceeding we are not

supposed to require a claimant to “present evidence in the report as if it were actually

                                            31
litigating the merits[,]” we simply cannot say that the trial court abused its discretion

in reaching the conclusion that Dr. Rushing’s amended report constitutes a good

faith effort to comply with the Act’s requirement to provide a fair summary of his

opinion with respect to the causal relationship between Magnolia’s alleged breach

and Robinson’s death, and we cannot say that the amended report failed to inform

the Defendant of the specific conduct called into question or that it fails to provide

a basis for the trial court to conclude the claims have merit. See Abshire, 563 S.W.3d

at 226 (citing Tex. Civ. Prac. & Rem. Code Ann. § 74.351(l), (r)(6); Palacios, 46

S.W.3d at 879); Baty, 543 S.W.3d at 693-94. Accordingly, we must overrule

Appellant’s issue, and we affirm the trial court’s order.

      AFFIRMED.

                                                      _________________________
                                                          LEANNE JOHNSON
                                                                Justice

Submitted on June 23, 2021
Opinion Delivered December 30, 2021

Before Golemon, C.J., Kreger and Johnson, JJ.

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