Court Opinion

ID: 9324511
Source: CourtListenerOpinion
Date Created: 2022-12-12 14:08:05.942696+00
Date Added: 2024-06-11T17:14:55.353943
License: Public Domain

In the
                    Court of Appeals
            Second Appellate District of Texas
                     at Fort Worth
                 ___________________________
                      No. 02-22-00169-CV
                 ___________________________

WOODLAND NURSING OPERATIONS, LLC F/D/B/A EASTLAND NURSING
  & REHABILITATION AND TRINITY HEALTHCARE, LLC, Appellants

                                V.

 MISTY VAUGHN, INDIVIDUALLY AND ON BEHALF OF THE ESTATE OF
                 THOMAS VAUGHN, Appellee

              On Appeal from the 236th District Court
                      Tarrant County, Texas
                  Trial Court No. 236-314075-19

               Before Bassel, Womack, and Walker, JJ.
               Memorandum Opinion by Justice Bassel
                          MEMORANDUM OPINION

                                  I. Introduction

      In two issues, Appellants Woodland Nursing Operations, LLC f/d/b/a

Eastland Nursing & Rehabilitation and Trinity Healthcare, LLC1 challenge the trial

court’s denial of their motion to dismiss the health care liability claim of Appellee

Misty Vaughn, individually and on behalf of the Estate of Thomas Vaughn, that she

filed pursuant to the Medical Liability Act (MLA). See Tex. Civ. Prac. & Rem. Code

Ann. §§ 74.001–.507. Eastland moved to dismiss Vaughn’s claim by asserting that the

expert report that she had filed in support of her claim was inadequate because it

failed to comply with requirements of the MLA.

      Vaughn’s claim against Eastland alleged that her husband Thomas had suffered

a head injury while he was a patient at Eastland and was receiving rehabilitation to

address a stroke that he had suffered prior to his admission to Eastland. The author

of the expert report that Vaughn had filed opined that the second head injury was

caused by a number of breaches of the appropriate standard of care by Eastland.

Eastland does not challenge the expert’s qualifications to formulate the opinions

contained in the report or his formulation of the applicable standard of care. Instead,

Eastland asserts that the expert’s opinions on both the existence of a breach of the

standard of care and causation are conclusory. We disagree. Though the report is not

      1
        The petition in this matter states that both Appellants “managed, operated,
supervised[,] and/or staffed Eastland Nursing and Rehabilitation Center.” Thus, we
refer to them collectively as Eastland.

                                          2
a model of clarity, it provides facts to support (1) the expert’s conclusions that

Thomas suffered a new injury while a patient at Eastland, (2) why the expert

concluded that Thomas would not have suffered the injury if Eastland had been using

the protective measures required by the standard of care, and (3) how and why these

breaches of the standard of care caused Thomas’s injury. Accordingly, we affirm the

trial court’s order denying Eastland’s motion to dismiss.

                     II. Procedural and Factual Background

      Procedurally, this is the second time that the parties have been before us on the

question of the adequacy of the expert report. When Vaughn first filed suit, Eastland

moved to dismiss, claiming that the expert report that Vaughn had filed did not

comply with the MLA. The trial court denied Eastland’s motion to dismiss, and

Eastland perfected an interlocutory appeal to challenge that ruling. In that appeal, the

parties filed a “Joint Motion to Reverse Order Below Pursuant to Agreement,” which

we granted, and we remanded the matter to the trial court.

      After the remand, Vaughn served an amended expert report. In response to

this filing, Eastland filed a “Motion to Dismiss for Failure to Cure Inadequate Chapter

74 Report.” In turn, Vaughn responded to the motion, and then Eastland replied.

The trial court heard argument on Eastland’s motion and denied it, stating in its order

that it was “of the opinion that the . . . [r]eport constitutes a good[-]faith effort to

comply with the requirements of Chapter 74.” Eastland has now perfected an appeal

of that order.

                                           3
      With respect to the nature of Vaughn’s claims, her amended petition alleged

that Thomas had been admitted to Eastland’s nursing and rehabilitation center for

rehabilitation after suffering an intracerebral hemorrhagic stroke. The petition alleged

that Eastland was required to formulate a comprehensive care plan for Thomas and

that Eastland had represented that it was equipped to meet Thomas’s needs. The

allegations continue that Eastland failed to provide the care that Thomas needed and

that he suffered abuse that caused a second cerebral hemorrhage. The petition stated

that “[Thomas] informed his family that while he was in the shower that morning, the

two nurse aides that assisted him hit him over the head, squeezed his testicles,

pinched him, and struck him with a belt. After the shower, one of the aides kneed

him in his testicles.” The petition provided a chronology showing that two or three

days after Thomas’s admission to Eastland, he was discharged from that facility and

then “admitted to Eastland Memorial Hospital, where he was diagnosed with a new

cerebral hemorrhage as a result of the assault.” After discharge from the local

Eastland hospital, Thomas was transferred to a hospital in Arlington. According to

the petition, Thomas was discharged from the Arlington hospital and placed in home

hospice care. A few weeks after being placed in hospice, Thomas passed away. The

petition alleged that Thomas’s death was caused by a lack of care and by the abuse

that he received at Eastland.

                                           4
      Based on its factual allegations, the petition alleged a cause of action for

medical negligence and asserted that Eastland was liable for acts and omissions that

included the following:

      a. Failing to observe, intervene, and care for [Thomas];

      b. Neglecting [Thomas] to such a degree that he was assaulted and
      suffered a cerebral hemorrhage and other injuries that would result in
      pain, suffering[,] and death[;]

      c. Failing to provide the medical and nursing care reasonably required
      for [Thomas’s] known conditions[; and]

      d. Failing to provide the appropriate supervision and training to its staff
      and personnel that were providing care to [Thomas,] including
      appropriate care related to [Thomas’s] treatment needs at all relevant
      times.

The petition also alleged causes of action for corporate negligence and gross

negligence. The petition appears to allege damages for both a wrongful-death claim

and a survival claim.2

      2
        We have previously described the distinction between the two types of claims
as follows:

      Survival claims result from Texas Civil Practice and Remedies Code
      Section 71.021, which provides that a claim for injury to a person’s
      health does not abate on death and may be prosecuted by “heirs, legal
      representatives, and the estate of the injured person.” Tex. Civ. Prac. &
      Rem. Code Ann. § 71.021(a), (b). A wrongful-death claim is generally
      covered by the Texas Wrongful Death Act, and “damages recoverable in
      a wrongful[-]death action are for the exclusive benefit of the defined
      statutory beneficiaries and are meant to compensate them for their own
      personal loss.” Cunningham v. Haroona, 382 S.W.3d 492, 508 (Tex.
      App.—Fort Worth 2012, pet. denied) (citing Tex. Civ. Prac. & Rem.
      Code Ann. § 71.002, defining wrongful-death cause of action).

                                          5
      After the first interlocutory appeal and the remand from this court, Vaughn

submitted an amended expert report authored by Gregg Davis, a physician, to satisfy

the expert-report requirements of the MLA. We will more fully detail Dr. Davis’s

eight-page, single-spaced report in the analysis section of this opinion, but we briefly

note here that his report took a different tack than the petition. No mention was

made in the report of an alleged assault on Thomas while he was in the shower.

      Instead, the report began by noting Dr. Davis’s clinical experience in the care

of patients, such as Thomas, who spend time in “a nursing home, outpatient, and

hospital environment.” The report next outlined the records that Dr. Davis had

reviewed regarding Thomas’s care at various facilities, as well as a police report, the

death certificate, and photos and videos.

      The report next contained a “chronology of care” outlining that prior to

admission to Eastland, Thomas had been hospitalized for an intercranial hemorrhage,

and the report described the CT scans of that hemorrhage. The report stated that

hospital staff were able to stabilize Thomas, “and after application of [a] soft helmet,”

he was transferred to Eastland where, at the time of the admission, he suffered from a

number of medical conditions.        The report described the following:         (1) the

      “Damages recoverable by the statutory beneficiaries under the Wrongful
      Death Act include pecuniary losses to the beneficiaries, such as loss of
      inheritance and non-economic damages to compensate for the losses
      caused by the destruction of the familial relationship.” Id.

Jacksboro Nursing Operations, LLC v. Norman, No. 02-20-00262-CV, 2021 WL 1421431,
at *9 n.3 (Tex. App.—Fort Worth Apr. 15, 2021, no pet.) (mem. op.).

                                            6
assessment of Thomas when he arrived at Eastland; (2) the creation of a care plan that

“did not address [the] assistance level required”; (3) notes that Thomas was supposed

to wear a “soft helmet at all times when ambulating”; (4) documentation of a shower

that he had received; and (5) a discharge summary that Eastland created several days

after Thomas was discharged. The chronology concluded by noting that Thomas was

transferred from Eastland to a local hospital.        The report described a diagnosis

obtained at that hospital of an intercranial hemorrhage and the findings of CT scans

with respect to that hemorrhage. The chronology concluded with Thomas’s family’s

decision to place him in hospice, the fact of his death, and a listing of the causes of

death in his death certificate (i.e., cerebral hemorrhage, cirrhosis, and diabetes).

       The report next outlined Dr. Davis’s opinions “related to [a] [b]reach in

[s]tandard of [c]are.” This section began by outlining Dr. Davis’s view of what the

standard of care for Thomas required, including “a duty to prevent accidents and

injury in all residents[] but particularly so in high-risk residents such as” Thomas. The

report then outlined how Eastland had allegedly breached the standard of care by

Eastland’s failure to put into place a “comprehensive baseline care plan” that

addressed Thomas’s need for assistance in “ambulation and transfer,” the failure in

the notes of Thomas’s care to show that he received the assistance he needed, and

inconsistencies in the notes. Dr. Davis opined that the unreliability of Eastland’s

records called “into question the care provided to [Thomas] during the entirety of his

stay.” The report highlighted Dr. Davis’s criticism that Eastland’s records lacked the

                                             7
following:     (1)   a   baseline   evaluation   of   Thomas’s    neurological    status;

(2) documentation of what prompted his transfer from Eastland to a local hospital;

and (3) a comprehensive assessment of Thomas on admission and discharge.

Dr. Davis opined that this deviation from the standard of care delayed the diagnosis

of Thomas’s injury and impeded his opportunity for recovery. Next, the report

offered opinions on breaches of the standard of care by the corporate owner of

Eastland.

      The report then turned to Dr. Davis’s opinions regarding causation.            To

support his conclusion that “there is a causal link between the failures set forth above

and the injuries[,] including death[,] suffered by” Thomas, Dr. Davis stated that the

“[n]ursing staff of Eastland failed to implement a care plan to prevent falls.” Based

on the absence of documentation in the records that he reviewed, Dr. Davis

concluded that neither a soft helmet nor a shower chair was provided to Thomas.

Further, Dr. Davis opined that “the interventions detailed on the care plan were not

tailored to [Thomas’s] needs as they should have been” and that “they did not include

providing him with assistance at the level and of the kind he required.” Dr. Davis

summed up his conclusion by stating that

      [m]ore likely than not, [Thomas] was not provided adequate support,
      including use of [a] shower chair and support to protect his head. This
      in turn, more likely than not, led to [Thomas’s] hitting his head against
      an object. Notes from the hospital[] indicate that he had suffered head
      trauma prior to admission. [Thomas] was transported from Eastland to
      the hospital. Again, because the nursing notes trail off and are poor, in
      breach of the standard of care, I can reasonably conclude within

                                           8
      reasonable medical probability that [Thomas] experience[d] a fall at the
      defendant facility. The force of hitting his head against an object led to
      tears in the blood vessels, causing bleeding into the space between the
      inner layer of the dura mater and the arachnoid mater of the meninges
      surrounding the brain. This buildup of blood placed pressure on
      [Thomas’s] brain, causing damage to brain tissue. Decrease in brain
      function continued, however, leading to mental[-]status deterioration
      and accelerating brain[-]tissue dysfunction.

      Dr. Davis concluded the report by stating that “[d]ue to [Eastland’s] failures

above stated, [Thomas] endured unnecessary and preventable suffering that resulted

in [Thomas’s] pain and suffering” and that all the opinions that he had expressed in

the report were based on reasonable medical probability.

                                   III. Analysis

      A.     We set forth the expert-report requirements that apply to a health
             care liability claim, the substance that an expert report must
             contain, and the standard and scope of review that we apply to
             determine an expert report’s sufficiency.

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

[MLA], 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.” Abshire v.

Christus Health Se. Tex., 563 S.W.3d 219, 223 (Tex. 2018) (citing Tex. Civ. Prac. &

Rem. Code Ann. § 74.351(a)). When a report is “found deficient,” the trial court may

grant a thirty-day extension “to cure the deficiency.” Tex. Civ. Prac. & Rem. Code

Ann. § 74.351(c).

      “If the claimant fails to clear this substantive hurdle [of filing an adequate

expert report], the trial court must dismiss the suit with prejudice and award

                                          9
reasonable attorney’s fees and costs to the affected defendant.” E.D. ex rel. B.O. v.

Tex. Health Care, P.L.L.C., 644 S.W.3d 660, 664 (Tex. 2022) (citing Tex. Civ. Prac. &

Rem. Code Ann. § 74.351(b)). The report requirement functions “to weed out

frivolous malpractice claims in the early stages of litigation, not to dispose of

potentially meritorious claims.” Abshire, 563 S.W.3d at 223.

      The MLA requires an expert report to

      provide[] a fair summary of the expert’s opinions as of the date of     the
      report regarding applicable standards of care[;] the manner in which    the
      care rendered by the . . . health care provider failed to meet          the
      standards[;] and the causal relationship between that failure and       the
      injury, harm, or damages claimed.

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(6).

      The test applied by the trial court in determining the sufficiency of the report is

one of objective good faith. Id. § 74.351(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).”). The Texas Supreme Court has

held that a good-faith effort occurs when a report “(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.” Abshire, 563 S.W.3d at 223 (quoting Baty v. Futrell,

543 S.W.3d 689, 693–94 (Tex. 2018)).

      Various general principles guide the determination of whether an expert report

is sufficient. “A report ‘need not marshal all the claimant’s proof,’ but ‘a report that

                                           10
merely states the expert’s conclusions about the standard of care, breach, and

causation’ is insufficient.” Id. (quoting Am. Transitional Care Ctrs. of Tex. v. Palacios, 46

S.W.3d 873, 878–79 (Tex. 2001)). Nor does a report have to meet the standards of

summary-judgment evidence. Miller v. JSC Lake Highlands Operations, LP, 536 S.W.3d

510, 517 (Tex. 2017) (“We remain mindful that an ‘adequate’ expert report ‘does not

have to meet the same requirements as the evidence offered in a summary-judgment

proceeding or at trial.’” (quoting Scoresby v. Santillan, 346 S.W.3d 546, 556 n.60 (Tex.

2011))). Also, an expert report need not convince the reader that its conclusions are

reasonable. See Abshire, 563 S.W.3d at 226 (stating that at the “preliminary [expert-

report] stage, whether th[e] standards [referenced in the report] appear reasonable is

not relevant to the analysis of whether the expert’s opinion constitutes a good-faith

effort” (quoting Miller, 536 S.W.3d at 516–17)).

       The following statutory provisions guide the determination of whether the

expert making the report is qualified and whether the report adequately describes the

applicable standard of care and explains causation:

       • The MLA provides specific criteria to determine if the expert making a

          report is qualified.    “‘Expert’ means[] 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.”         Tex. Civ. Prac. & Rem. Code Ann.

          § 74.351(r)(5)(B). In turn, Section 74.402(b) provides that

                                             11
             [i]n a suit involving a health care liability claim against a health
             care provider, a person may qualify as an expert witness on the
             issue of whether the health care provider departed from accepted
             standards of care only if the person:

                    (1) is practicing health care in a field of practice that
                    involves the same type of care or treatment as that
                    delivered by the defendant health care provider, if the
                    defendant health care provider is an individual, at the time
                    the testimony is given or was practicing that type of health
                    care at the time the claim arose;

                    (2) has knowledge of accepted standards of care for health
                    care providers for the diagnosis, care, or treatment of the
                    illness, injury, or condition involved in the claim; and

                    (3) is qualified on the basis of training or experience to
                    offer an expert opinion regarding those accepted standards
                    of health care.

          Id. § 74.402(b). 3 In making the determination of whether an expert is

          qualified on the basis of training or experience, the trial court considers

          whether the witness

                    (1) is certified by a licensing agency of one or more states
                    of the United States or a national professional certifying
                    agency, or has other substantial training or experience, in
                    the area of health care relevant to the claim; and

                    (2) is actively practicing health care in rendering health care
                    services relevant to the claim.

          Id. § 74.402(c). The expert’s qualifications must appear in the report or in a

          curriculum vitae and cannot be inferred. See Savaseniorcare Admin. Servs.,

      3
        Subsection (1) of Section 74.402(b) applies only if the provider is an individual.
See Premieant Inc. v. Snowden ex rel. Snowden, No. 04-19-00238-CV, 2020 WL 1159055, at
*3 n.4 (Tex. App.—San Antonio Mar. 11, 2020, no pet.) (mem. op.).

                                           12
   L.L.C. v. Cantu, No. 04-14-00329-CV, 2014 WL 5352093, at *2 (Tex.

   App.—San Antonio Oct. 22, 2014, no pet.) (mem. op.); see also Tex. Civ.

   Prac. & Rem. Code Ann. § 74.351(a) (requiring service of “a curriculum

   vitae of each expert listed in the report”).

• “To adequately identify the standard of care, an expert report must set forth

   ‘specific information about what the defendant should have done

   differently.’” Abshire, 563 S.W.3d at 226 (quoting Palacios, 46 S.W.3d at 880).

   “While the Act 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. (quoting Palacios, 46 S.W.3d at 880).

• On the issue of causation, the report must “explain ‘how and why’ the

   alleged negligence caused the injury in question.” Id. at 224. Conclusory

   descriptions of causation are not adequate; “the expert must explain the

   basis of his statements and link conclusions to specific facts.” Id. But “[i]n

   satisfying th[e] ‘how and why’ requirement, the expert need not prove the

   entire case or account for every known fact; the report is sufficient if it

   makes ‘a good-faith effort to explain, factually, how proximate cause is

   going to be proven.’” Id. (quoting Columbia Valley Healthcare Sys., L.P. v.

   Zamarripa, 526 S.W.3d 453, 460 (Tex. 2017)). Further, “[t]he sufficiency of

   the expert report’s causation statement should be viewed in the context of

   the entire report.” Columbia Med. Ctr. of Arlington Subsidiary L.P. v. L.M., No.

                                     13
           02-17-00147-CV, 2018 WL 1095746, at *7 (Tex. App.—Fort Worth Mar. 1,

           2018, no pet.) (mem. op.). Finally, “the detail needed to establish a causal

           link generally is proportional to the complexity of the negligent act giving

           rise to the claim.”     Id.   In other words, a “causation opinion is not

           conclusory simply because it is not complex.” Id. And the supreme court

           has recently reemphasized that a good-faith effort occurs when the form of

           the report provides an explanation of the “how and why” of causation that

           is more than conclusory. Tex. Health Care, 644 S.W.3d at 667. When the

           report meets this requirement, it is adequate, even if we are skeptical of the

           opinions expressed or conclude that they will ultimately fail to meet the

           standards of proof required at trial. Id.

      We apply an abuse-of-discretion standard to test the trial court’s decision to

grant or deny a motion to dismiss that challenges the adequacy of an expert report.

Abshire, 563 S.W.3d at 223. The scope of our review is limited to “the information

contained within the four corners of the report.” Id.

      B.      We set forth why we overrule Eastland’s challenges to Dr. Davis’s
              report.

      Eastland does not challenge Dr. Davis’s qualifications and is explicit in its reply

brief that it does not challenge how Dr. Davis articulated the appropriate standard of

care for Thomas. 4 Instead, Eastland argues that Dr. Davis’s report is conclusory on

      4
       Dr. Davis states the applicable standard of care as follows:

                                            14
the issues of breaches in the standard of care and medical causation. We reject both

arguments. Eastland bases its arguments on a portrayal of the report that turns a

blind eye to the facts that Dr. Davis relied on to form his opinions. To reiterate, the

question of whether Dr. Davis drew reasonable inferences from those facts is not

before us.

              1.    Dr. Davis’s report adequately describes the medical
                    causation of Thomas’s injury.

       In its first issue, Eastland backs into its challenge of Dr. Davis’s report by

highlighting deficiencies in his initially filed report, which was the subject of the prior

appeal. The deficiencies in that report are not the question before us; our focus is on

the amended report that Dr. Davis filed after the case was remanded to the trial court.

       With one paragraph each, Eastland makes its two attacks on the report for

failing “to provide any meaningful analysis of medical causation or explain how any

alleged breach in the standard of care proximately caused an injury to” Thomas.

      The paragraph launching Eastland’s first attack states in whole that

      In order to meet the standard of care, Eastland . . . is required to provide
      a level of care and treatment that an otherwise reasonable and prudent,
      similar facility and staff would provide under the same, or similar,
      circumstances. Specifically, in order to meet the standard of care[,] a
      skilled nursing facility such as Eastland must ensure that its residents
      receive and are provided with the necessary care and services to attain or
      maintain the highest practicable physical, mental, and psychosocial well-
      being. Skilled nursing facilities such as Eastland have a duty to prevent
      accidents and injury in all residents[] but particularly so in high-risk
      residents such as [Thomas].

                                            15
       the Second Davis Report does not identify a single injury allegedly sustained by
       [Thomas]. Dr. Davis vaguely refers to “head trauma” purportedly
       sustained by [Thomas,] but Dr. Davis does not explain or identify the
       specific nature of the head trauma or how that trauma differed, if at all,
       from that suffered pre-admission by [Thomas]. An explanation of the
       “head trauma” is particularly important in this case because [Thomas]
       was admitted to Eastland after suffering a massive intracranial
       hemorrhage. Dr. Davis claims that [Thomas] was diagnosed with an acute
       intracranial hemorrhage following his discharge from Eastland, but he specifically does
       not state that the hemorrhage was the result of any actions or inactions of Eastland.
       Dr. Davis does not explain the intracranial hemorrhage or link it to any specific
       conduct of Eastland. Rather, Dr. Davis vaguely claims that because
       Eastland records do not specifically show [that Thomas] was provided a
       shower chair – though the records do clearly show that [Thomas] was
       supervised in the shower and sustained no fall – that he must have fallen
       and hit his head on some unknown object at some unknown point in
       time and sustained unexplained “head trauma.” The causation analysis
       set forth in the Second Davis Report is conclusory and speculative.
       [Emphases added in italics.]

As we interpret this argument, it focuses on the alleged failure of Dr. Davis’s report to

explain how Thomas fell. That this is the focus of Eastland’s attack becomes clearer

in its reply brief where it argues that

       Dr. Davis is flatly unable to explain “how” [Thomas] sustained an injury.
       Dr. Davis assumes that [Thomas] sustained a fall[] but does not state
       when, where, or how the fall occurred or explain how the fall, if it
       occurred at all, was proximately caused by Appellants. Absence of evidence
       of a fall is not evidence of a fall.

       Eastland’s argument—that Dr. Davis fails to explain the fact and mechanism of

Thomas’s post-Eastland-discharge hemorrhage—ignores many of the statements in

Dr. Davis’s report. The report stated Dr. Davis’s opinion that Thomas experienced a

new head injury while at Eastland. The report began by describing the clinical

findings made regarding a hemorrhage in Thomas’s brain before his admission to

                                                 16
Eastland. Dr. Davis highlighted the fact that CT scans reflected that the injury was

“with no midline shift.” The chronology ended with a description of the clinical findings

made by the local hospital with respect to another hemorrhage in Thomas’s brain

after his transfer from Eastland. Dr. Davis recited that the notes of the second injury

indicate that Thomas “was struck in the head.” Much later in the report after

describing why he concluded that Thomas had struck his head while he was a patient

at Eastland, Dr. Davis stated, “It is due to these injuries that [Thomas] more likely

than not suffered [a] head injury causing new acute intracranial hemorrhage with

midline shift.”

      Dr. Davis’s report also noted that the paperwork for Thomas’s admission to

Eastland “document[ed] a right eyebrow abrasion as the only facial injury shown.”

Later in the report, Dr. Davis recited that he had reviewed photographs showing

bruising to Thomas’s face and the left side of Thomas’s head. The report then stated,

      It can be reasonably concluded that [Thomas] suffered a trauma
      and/[]or bumping to the head, more likely than not caused by failing to
      provide him with needed assistance. [Thomas] required wearing [a] soft
      helmet due to his increased . . . risk for head injury. Notes are silent
      regarding [Thomas’s] wearing his helmet. Had [Thomas] been wearing
      his soft helmet as he was supposed to, [Thomas] more likely than not
      would not have suffered bruising to head as shown in photographs.

      We will discuss how Dr. Davis contended that Eastland deviated from the

required standard of care in the next section of this opinion; the report stated that the

deviations led to the new injury that Dr. Davis opined that Thomas had suffered:

                                           17
      More likely than not, [Thomas] was not provided adequate support,
      including use of [a] shower chair and support to protect his head. This
      in turn, more likely than not, led to [Thomas’s] hitting his head against
      an object. Notes from the hospital[] indicate that he had suffered head
      trauma prior to admission.

      Another opinion expressed in the report about a breach in the standard of care

noted a lack of care in planning for Thomas. Dr. Davis also concluded from the

records that he had reviewed that the absence of entries showing certain protective

measures were taken created the inference that the measures were not taken.

      With this context in place, we quote the section of Dr. Davis’s report

addressing causation:

      It is my opinion that there is a causal link between the failures set forth
      above and the injuries[,] including death[,] suffered by [Thomas].

             Nursing staff of Eastland failed to implement a care plan to
      prevent falls. The care plan called for the use of a soft helmet and
      should have included use of a shower chair as nursing staff assessed this
      as necessary. I have concluded that the fall care plan was not
      implemented because there is no documentation of a shower chair being
      used or a soft helmet being used. When care is not documented, I can
      reasonably conclude the care was not provided as when care is not
      documented, it was not performed. It is the standard of care that all
      services provided to a patient are to be documented, and if they are not
      documented, they did not occur. Further, the interventions detailed on
      the care plan were not tailored to [Thomas’s] needs as they should have
      been. Specifically, they did not include providing him with assistance at
      the level and of the kind he required. On 4/15/2018, nursing staff did
      not provide [Thomas] with adequate assistance. [Thomas] was
      documented as being combative and agitated surrounding the time of his
      shower. Despite nursing staff documenting that he required assistance
      of a male aide, he was not provided this level of assistance. There is also
      no documentation to demonstrate that [Thomas] was wearing his soft
      helmet. Agitation would have increased [Thomas’s] thrashing around,
      increasing his chances of hitting his head. Additionally, [Thomas]

                                          18
      required shower via [a] shower chair. This was not provided, increasing
      his risk for falls and head injury. More likely than not, [Thomas] was not
      provided adequate support, including use of [a] shower chair and
      support to protect his head. This in turn, more likely than not, led to
      [Thomas’s] hitting his head against an object. Notes from the hospital[]
      indicate that he had suffered head trauma prior to admission. [Thomas]
      was transported from Eastland to the hospital. Again, because the
      nursing notes trail off and are poor, in breach of the standard of care, I
      can reasonably conclude within reasonable medical probability that
      [Thomas] experience[d] a fall at the defendant facility. The force of
      hitting his head against an object led to tears in the blood vessels,
      causing bleeding into the space between the inner layer of the dura mater
      and the arachnoid mater of the meninges surrounding the brain. This
      buildup of blood placed pressure on [Thomas’s] brain, causing damage
      to brain tissue. Decrease in brain function continued, however, leading
      to mental[-]status deterioration and accelerating brain[-]tissue
      dysfunction.

      We acknowledge that Dr. Davis’s report is disjointed, but it is our duty to read

it as a whole. When read as a whole, we do not agree that it either fails to state how

Thomas suffered a head injury or that it is a valid challenge to the adequacy of the

report that it does not “link it to any specific conduct of Eastland.” Dr. Davis states

facts based on the clinical records of Thomas’s hemorrhages and his comparison of

Eastland’s documentation of Thomas’s physical condition at admission versus photos

taken later showing that Thomas had suffered a new injury while at Eastland.

Dr. Davis said that the evidence of the injury that he noted would not have occurred

had Thomas been wearing the protective helmet that Eastland claims he was wearing

or if Thomas had been properly evaluated and had received the level of care that his

condition required—simply, protective measures that should have been in place so

that Thomas would not have suffered the injury that was documented when he was

                                          19
transferred to the local hospital. Contrary to Eastland’s argument, Dr. Davis opined

that there was a fall (though admittedly he does not know how it occurred). At

bottom, and though not artfully done, Dr. Davis provided facts to support his

conclusion regarding how and why Thomas suffered a second head injury.

       Nor can we adopt the logic of Eastland’s argument that when an expert finds

various failures in the records maintained by the health care provider but concluded

the patient was injured while in the provider’s care, a report is deficient because it fails

to detail the injury-causing event suffered by the patient, i.e., Eastland’s argument that

“[a]bsence of evidence of a fall is not evidence of a fall.” Dr. Davis’s report explicitly criticized

Eastland’s records for not documenting the condition that warranted his transfer to

the local hospital. Under Eastland’s logic, a provider’s best course would be not to

document the injury. This would leave the report—even though the expert detailed

why he had concluded that an injury had occurred and how the injury should not have

occurred if the patient had received the protective measures that the provider claims

that the patient received—inadequate because the expert could not describe what was

unknowable at the time of creation of the report because of deficiencies in the

records. Certainly, what did or did not occur may later be revealed in discovery, but

what may be uncovered in discovery is not known when an expert report is served

because any discovery other than for medical records or hospital records is stayed

until service of the expert report. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(s).

                                                 20
      Thus, Eastland’s challenges to Dr. Davis’s opinions on causation fail because

the report is a good-faith effort in that it provides an explanation of causation that is

more than bare conclusions: it offers facts and then explains the how and why of

Thomas’s injury. By this effort, the report achieves the requisite level of detail, which

as the First Court of Appeals explained is not onerous:

      The expert must simply provide some basis that a defendant’s act or
      omission proximately caused injury. And, the expert must explain the
      basis of his statements and link his conclusions to the facts. “No
      particular words or formality are required [in the expert report], but bare
      conclusions will not suffice.”

Pinnacle Health Facilities XV, LP v. Chase, No. 01-18-00979-CV, 2020 WL 3821077, at

*12 (Tex. App.—Houston [1st Dist.] July 7, 2020, no pet.) (mem. op.) (citations

omitted).

      And again, the testing of whether Dr. Davis’s opinions are reasonable is for

another day. See Tex. Health Care, 644 S.W.3d at 667. Dr. Davis was allowed to draw

the inferences from the records that he reviewed, and even if those inferences appear

flawed, a motion challenging the adequacy of the report is not the proper vehicle to

test the reasonableness of the inferences. As the First Court of Appeals also noted,

      [Appellant] complains that [the expert] improperly inferred that [the
      patient’s] bedrails were not in place on the night of his fall. In assessing
      the sufficiency of a report, a trial court may not draw inferences; instead,
      it must exclusively rely upon the information contained within the four
      corners of the report. In re McAllen Med. Ctr.[, Inc.], 275 S.W.3d [458,]
      463 & n.14 [(Tex. 2008) (orig. proceeding)]. However, [S]ection 74.351
      does not prohibit experts, as opposed to courts, from making inferences
      from the medical records. See Clavijo v. Fomby, No. 01-17-00120-CV,
      2018 WL 2976116, at *10 (Tex. App.—Houston [1st Dist.] June 14,

                                           21
      2018, pet. denied) (mem. op.). Whether an expert’s factual inferences in
      the report are accurate is an issue for summary judgment, not a Chapter
      74 motion to dismiss. See id.

Pinnacle Health Facilities, 2020 WL 3821077, at *12.

      Eastland’s second argument in support of its first issue—also contained in but

one paragraph—mimics the first argument that we addressed dealing with the

adequacy of Dr. Davis’s opinion on causation:

      Dr. Davis does not explain the intracranial hemorrhage or link it to any
      specific conduct of Eastland other than an alleged documentation
      failure. Poor documentation or the lack of documentation does not and
      cannot cause an intracranial hemorrhage. [Thomas] was admitted to
      Eastland with an intracranial hemorrhage, discharged against medical
      advice, and presented to the hospital more than twenty-four hours later
      with an intracranial hemorrhage. Dr. Davis ignores these facts and
      contends that [Thomas] must [have] fallen and hit his head on some
      unknown object at some unknown point in time and sustained the head
      trauma during his residency at Eastland, essentially attempting to replace
      medical causation with a res ipsa loquitor analysis. [Eastland has] no idea
      what specific new injury [it is] alleged to have proximately caused
      [Thomas] or how such new injury purportedly occurred at Eastland.
      Dr. Davis also does not know and does not so state in the Second Davis
      Report. The Second Davis Report fails to adequately address medical
      causation or cure the First Davis Report and does not comply with
      Section 74.351.

      Without repeating our previously stated reasons for rejecting Eastland’s

arguments, we will note our specific disagreements with Eastland’s premises:

      • Dr. Davis described the clinical findings of the hospital into which Thomas

          was admitted after his discharge from Eastland, and Dr. Davis stated why

          he had concluded that the documented injury was caused by Eastland’s

          failures.   He may well be wrong in his conclusions, but again we are

                                           22
          examining whether the form of his report is conclusory, not the ultimate

          validity of his conclusions.

      • Eastland relies on facts that are not in our record regarding the chronology

          of Thomas’s discharge from Eastland and his admission to a local hospital.5

          Dr. Davis may well have ignored these facts, but we do not have a way to

          know whether he did or not. And the time lag is not ignored by Dr. Davis.

          The report noted a discrepancy about the date of Thomas’s discharge as

          follows: “Medical records document discharge on 4/15/2018. However,

          medication administration records show provision of wound care to

          [Thomas] and administration of other treatments on 4/16/2018, including

          treatments that would require assessment of [Thomas].” Again, whether

          this portrayal of the records is accurate, we cannot say. 6

      5
        Vaughn challenged Eastland’s reliance on extrinsic evidence not contained in
the trial-court record. The trial court sustained Vaughn’s objection, and Eastland
raises no issue on appeal complaining of that ruling.
      6
       Eastland’s opening brief contains a footnote that states,

      In a strange attempt to justify his false representation concerning
      [Thomas’s] dates of residency, Dr. Davis cites a medical record which he
      claims shows the facility provided care to [Thomas] on April 16, 2018 –
      that record, however, is clearly that of another resident whose name
      appears on the record.

The statement is not supported by a record reference.

                                            23
       • It is too crabbed a view of the report to conclude that Eastland has “no idea

           what specific new injury [it is] alleged to have proximately caused [Thomas]

           or how such new injury purportedly occurred at Eastland.” Again,

           Dr. Davis’s report described the clinical findings made when Thomas was

           admitted to the hospital after being in Eastland’s care and how the injuries

           in the photos that Dr. Davis had reviewed would not have occurred if he

           had been wearing the protective helmet that Eastland’s records claim he was

           wearing or had he been properly evaluated and cared for. 7

              2.     Dr. Davis’s report adequately describes how Eastland
                     breached the standard of care.

       In its second issue, Eastland also takes the approach of parsing Dr. Davis’s

opinions with respect to deviations from the standard of care by arguing that “[n]ot

only does the Second Davis Report fail to identify the specific injury, if any, sustained

by [Thomas] at Eastland, it fails to explain how [Eastland] breached the standard of
       7
        Vaughn did plead in her amended petition that Thomas claimed that he had
been assaulted in the shower. Eastland emphasizes that Dr. Davis makes no mention
of an assault. The allegation in the pleading reports what Thomas told his family.
The statement does not exclude the possibility that he experienced a fall and is not a
judicial admission that he did not experience a fall. See Estate of Stavron, No. 02-20-
00404-CV, 2021 WL 5227081, at *7 (Tex. App.—Fort Worth Nov. 10, 2021, no pet.)
(mem. op.) (stating that a judicial admission must be deliberate, clear, and
unequivocal). The amended petition also alleges various theories of negligence. A
report need only support a single theory of liability. Jacksboro, 2021 WL 1421431, at
*8 (“Succinctly, the Texas Supreme Court held that a report that satisfies the
requirements, ‘even if as to one theory only, entitles the claimant to proceed with a
suit against the physician or health care provider.’” (quoting Certified EMS, Inc. v. Potts,
392 S.W.3d 625, 630 (Tex. 2013))). Thus, we do not view the report’s failure to
mention Thomas’s claim that he was assaulted as being fatal to Vaughn’s claim.

                                            24
care leading to the alleged injuries.”   As before, we reject Eastland’s arguments

because they unreasonably cabin the opinions and supporting facts contained in the

report.

      First, Eastland characterizes Dr. Davis’s report as turning on the contention

that there was a breach of the standard of care for not providing Thomas a shower

chair and for not using a soft helmet in the shower and also turning on the

assumption that he hit his head in the shower, though in Eastland’s view, Dr. Davis

did not come out and claim that. Pivoting off this argument, Eastland again argues

that the report leaves it to conjecture how Thomas was injured:

      Dr. Davis simply contends that [Thomas] did not have access to a
      shower chair and soft helmet – never mind that the nurse’s notes
      document that [Thomas] was wearing his soft helmet around the facility
      – and thus, fell and/or hit his head on an unknown object. No further
      details are provided such as when the fall occurred; where the fall
      occurred; how the fall occurred; how the fall could have been prevented;
      or what [Thomas] allegedly hit his head on in the fall. Dr. Davis is flatly
      unable to explain “how” [Thomas] sustained any new injury. Dr. Davis
      is unable to even state whether [Thomas] fell.

      Eastland then highlights Dr. Davis’s attack on Eastland’s care for not having a

male aide assist Thomas in the shower. Eastland notes that the report acknowledged

that a female aide had assisted Thomas and that a male aide was assisting another

patient in the shower. Thus, Eastland argues that it is criticized for an act—having a

female aide assist Thomas—that produced no injury to Thomas. Based on this

portrayal of the report, Eastland concludes that “[t]his informs [Eastland] of no

                                          25
wrongdoing and certainly not how [Eastland] breached the standard of care and

caused an injury to [Thomas].”

      Shifting gears in its reply brief, Eastland rehashes its attack that the report does

not adequately describe what injury Thomas actually suffered. The failings that it

catalogs are as follows: (1) a lack of an explanation regarding how the head trauma

that Thomas suffered after being in Eastland’s care differed from his preadmission

head trauma; (2) a failure to state that the second trauma resulted from Eastland’s

actions, arguing again that poor documentation cannot cause a head injury; and

(3) failing to explain the more-than-twenty-four-hour gap between Thomas’s

discharge from Eastland and his admission to a local hospital.

      Again, we reject Eastland’s efforts to tell us that Dr. Davis’s opinions are faulty

because they are at odds with the medical records as those records show that Thomas

was not admitted to the local hospital for more than twenty-four hours after his

discharge from Eastland or that nurses’ notes show that Thomas was wearing a soft

helmet around the facility. We do not know what the records actually state. And we

have already noted that Dr. Davis’s report indicated that Eastland’s records document

care in the twenty-four-hour period that Eastland highlights and, as indicated below,

speak of Thomas’s being transported from Eastland to the hospital.

      As we read Dr. Davis’s report, his premise is simple: after reviewing the

medical records of Thomas’s original injury and the ones when he was admitted to the

local hospital after being in Eastland’s care, the records reflect that Thomas had

                                           26
suffered another head injury. As we have documented, Dr. Davis stated some factual

basis for this opinion. The report also outlined a number of deviations from the

standard of care that Dr. Davis opined are an explanation for why Thomas suffered

this injury and how those injuries that Thomas exhibited would not have been present

had the protective gear—which Eastland claims that Thomas wore—actually been

worn at the time of the injury. Eastland’s fundamental attack—that the deviations are

not tied to the new injury—ignores these facts.

      The report also marched through what Dr. Davis opined are breaches of the

standard of care throughout the course of Thomas’s stay at Eastland. Dr. Davis

began with Thomas’s admission to Eastland:

      In the present case, there was a deviation in the standard of care by
      nursing staff of Eastland. No comprehensive baseline care plan was put
      in place for [Thomas] when he [was] admitted to the facility. This
      baseline care plan would have needed to include providing [Thomas]
      with [the] assistance of at least one person for ambulation and transfer.
      That was not done in the present circumstances. The baseline/[]interim
      care plan simply included a fall mat and wearing his soft helmet when
      up. Despite being noted to have increased confusion and a decreased
      level of comprehension, [Thomas’s] care plan did not include providing
      him with assistance of a staff member.

      The report then noted how the care that Thomas received during his stay at

Eastland was inadequate by noting that “[t]he standard of care requires that residents

who need assistance with ADL[] receive the needed assistance. [Thomas] was not

provided the level of assistance he needed.”

                                          27
        It is at this point that the report documented specific failings, including those

associated with the shower incident.       Dr. Davis opined on both Thomas’s not

receiving the required care and what the evidence of Thomas’s injuries revealed as to

whether he had received what he should have been accorded under the standard of

care:

        Based off of my training and experience, when care is not documented
        at a facility, this denotes that the care was not performed. It is
        imperative that all care and treatment given to a resident, like [Thomas]
        be documented, so that the next shift(s) will know what treatments have
        been given and/or what treatments need to be given. All these are
        deviations from the standard of care. It is a breach of the standard of
        care to assess a resident as needing a certain level of assistance (male
        aide) and then failing to provide this level of assistance. Photographs
        show bruising to face and left side of head. It can be reasonably
        concluded that [Thomas] suffered a trauma and/[]or bumping to the
        head, more likely than not caused by failing to provide him with needed
        assistance. [Thomas] required wearing [a] soft helmet due to his
        increased . . . risk for head injury. Notes are silent regarding [Thomas’s]
        wearing his helmet. Had [Thomas] been wearing his soft helmet as he
        was supposed to, [Thomas] more likely than not would not have
        suffered bruising to [his] head as shown in photographs.

        Next, Dr. Davis documented the failings he saw in the end of the chronology

of Thomas’s stay at Eastland and how that tied to the prior deviations from the

standard of care:

        The nursing staff at Eastland . . . breached the accepted standard of care
        by not producing a comprehensive baseline evaluation of his
        neurological status and a contemporaneous documentation of the events
        leading to [Thomas’s] admission to Eastland Hospital emergency
        department and transfer to Medical City of Arlington on 4/16/2018. A
        breach in the standard of care occurred when nursing staff failed to
        perform a comprehensive assessment of [Thomas] upon admission and
        then again failed to provide [Thomas] with a discharge assessment.

                                            28
Dr. Davis then explained why he saw an additional deviation of the standard of care

because Eastland did not “document all significant changes in a patient’s condition

concurrently.” It appears that this opinion takes two forms: (1) failing to document

what necessitated Thomas’s transfer to a local hospital; and (2) “fail[ing] to provide

the generally accepted level of care, which would [have] be[en] provided by a similar

facility under similar clinical circumstances.” The section dealing with deviations

from the standard of care concluded as follows:

      The lack of documentation indicates [that] the nursing staff failed to
      provide any additional care before his transfer to . . . Medical City of
      Arlington. This breach was proximate to and contributed to the decline
      in [Thomas’s] health, resulting in a delay in the diagnosis of his
      intracranial hemorrhage. Patients with an intracranial hemorrhage
      require emergent neurosurgical evaluation. With a delay in diagnosis, the
      resulting compressive effect on the brain results in a reduction in blood
      flow to the brain, an increased risk of brain herniation, and a progressive
      neurological deterioration. The delay in diagnosis adversely impacted his
      opportunity for recovery and survival.

      We agree that Dr. Davis’s report could have been more coherent and could

have stated his conclusions with greater precision. But the measure for stating the

standard of care is that “an expert report must set forth ‘specific information about

what the defendant should have done differently.’”        Abshire, 563 S.W.3d at 226

(quoting Palacios, 46 S.W.3d at 880). The report details what should have been done

differently. And many of these failings documented by Dr. Davis are not simply free-

floating deviations that cannot be tied to the new injury. Dr. Davis opined in general

that the care plan for Thomas did not address his needs and also specifically opined

                                          29
that if Thomas had been accorded the appropriate standard of care, such as the

required wearing of a soft helmet, he would not have displayed the injuries portrayed

in the photos examined by Dr. Davis. Dr. Davis did not state how the injury that he

believes occurred specifically occurred but highlighted that the records that should

have explained why there was an injury that required Thomas’s transfer to a local

hospital should have been, but apparently were not, created and how that failure

delayed proper diagnosis that might have produced a better outcome. The four

corners of Dr. Davis’s report provide enough facts to take Dr. Davis’s opinions

beyond bare conclusions that there were deviations from the standard of care that had

more than a theoretical effect on Thomas’s condition. Here, the trial court’s decision

was perhaps a close call, but close calls fall within the discretion of the trial court. See

Tex. Health Care, 644 S.W.3d at 664 (“This adequacy inquiry is confined to the four

corners of the report, taken as a whole, . . . and under an abuse-of-discretion standard,

“‘[c]lose calls must go to the trial court.’” (quoting Larson v. Downing, 197 S.W.3d 303,

304 (Tex. 2006))).

               3.    We set forth authority dealing with expert reports addressing
                     a patient’s fall.

       To support our holdings, we contrast opinions dealing with patient falls—one

that holds that a report is adequate and another that holds the report inadequate. The

contrast supports our conclusion that Dr. Davis’s report lands on the adequate side of

the balance.

                                            30
      The First Court of Appeals, in an opinion that we have already cited, dealt with

a patient’s fall and noted that the expert-report stage of a proceeding is not one in

which causation must be proven by a preponderance of the evidence; it then outlined

a number of cases upholding the adequacy of reports with conclusions similar to

those drawn by Dr. Davis. See Pinnacle Health Facilities, 2020 WL 3821077, at *6.

      In Pinnacle Health Facilities, the expert report noted, as does Dr. Davis’s, how the

fall injured the patient’s brain structure. 8 The report went on to opine

      that there was no fall-prevention program in place at Pinnacle and that,
      “[h]ad side rails been present and raised” on [the patient’s] bed on the
      night of his fall, “this would have greatly reduced the chance of his
      getting out of bed and falling.” And, had a bed-pressure alarm been
      used, nursing staff would have been alerted and been given an
      opportunity to respond and intervene.

Id. at *12. The First Court concluded that in the context of an expert report and

when comparing the opinion to holdings in similar cases, the report adequately stated

an opinion on causation:

      At this pre-discovery stage, appellees’ burden is not to prove a causal
      link by a preponderance of the evidence to the satisfaction of a
      factfinder or to rule out all other possible causes of injury. See Palacios,

      8
       Specifically, Dr. Davis does the same in his report by describing the injury
process as follows:

      The force of hitting his head against an object led to tears in the blood
      vessels, causing bleeding into the space between the inner layer of the
      dura mater and the arachnoid mater of the meninges surrounding the
      brain. This buildup of blood placed pressure on [Thomas’s] brain,
      causing damage to brain tissue. Decrease in brain function continued,
      however, leading to mental[-]status deterioration and accelerating brain[-]
      tissue dysfunction.

                                           31
       46 S.W.3d at 879; Puppala v. Perry, 564 S.W.3d 190, 202 (Tex. App.—
       Houston [1st Dist.] 2018, no pet.) (“At this expert-report stage, an
       expert report does not have to meet the same requirements as the
       evidence offered in a summary-judgment proceeding or at trial.”). We
       conclude that [the expert’s] report provides a fair summary of the causal
       relationship between Pinnacle’s failure to meet the applicable standard of
       care and [the patient’s] injuries and death. See Tex. Civ. Prac. & Rem.
       Code [Ann.] § 74.351(r)(6); see, e.g., Nexion Health at Beechnut, Inc. v.
       Moreno, No. 01-15-00793-CV, 2016 WL 1377899, at *3–5 (Tex. App.—
       Houston [1st Dist.] Mar. 29, 2016, no pet.) (mem. op.) (holding expert
       report adequate as to causal connection between nursing home’s failure
       to supervise resident and death resulting from head wound from fall in
       hallway); Regent Care Ctr. of Laredo, Ltd. P’ship v. Abrego, No. 04-07-00320-
       CV, 2007 WL 3087211, at *6 (Tex. App.—San Antonio Oct. 24, 2007,
       pet. denied) [(mem. op.)] (holding experts’ reports, opining that had
       facility appropriately assessed, evaluated, and implemented fall-
       prevention and safety measures for patient, patient would not have
       sustained injuries that diminished her ability to respond to congestive
       heart failure, constituted good-faith effort to provide fair summary of
       ca[us]al relationship between facility’s action and patient’s death); Estate
       of Birdwell v. Texarkana Mem’l Hosp., Inc., 122 S.W.3d 473, 479–80 (Tex.
       App.—Texarkana 2003, pet. denied) (holding expert’s report gave fair
       notice to hospital that cause of patient’s hemorrhages and paralysis was
       her fall resulting from hospital’s failure to provide restraints as additional
       fall protection). Thus, [the expert’s] report presents an objective,
       good[-]faith effort to comply with the statute. See Tex. Civ. Prac. &
       Rem. Code [Ann.] § 74.351(l); Scoresby, 346 S.W.3d at 555–56.

Id.

       Recently, the Amarillo Court of Appeals contrasted the holding in Pinnacle

Health Facilities to facts before it and concluded that the report it reviewed was

deficient because it did not provide what specific interventions would have prevented

a fall by a patient:

       The deficiencies in [the expert’s] report are apparent when compared to
       a report [that] does satisfy the requirements of [S]ection 74.351. For
       example, Pinnacle . . . also involved an injury resulting from a fall and

                                            32
      considered whether the standard of care was adequately addressed in an
      expert report. . . . 2020 WL 3821077, at *4 . . . . In Pinnacle, the
      defendant care center argued that the expert’s report was inadequate
      with respect to the standard of care because the expert opined that the
      standard requires an “adequate fall prevention program” and a “safe
      environment.” Id. However, the appellate court determined that the
      report was adequate because the expert provided specific information to
      support his conclusions, namely that the standard of care required the
      care center to “have raised side rails whenever [decedent] was in bed”
      and to implement fall safety and protections measures including an
      operating bedside call button, bedside toileting device, bed-pressure
      alarm, and video monitoring of decedent’s room. Id. at *[11]. Thus, the
      expert explained what steps an ordinarily prudent health care provider
      would take under the same or similar circumstances. Id. In contrast to
      the report challenged in Pinnacle, [the expert’s] report does not identify
      what specific interventions should have been implemented by the facility
      or by the nurses, or what changes to [the decedent’s] care were required.

Kenmar Residential HCS Servs., Inc. v. Uriegas, No. 07-21-00233-CV, 2022 WL 843890, at

*4 (Tex. App.—Amarillo Mar. 11, 2022, pet. filed) (mem. op.).

      The contrasting holdings of the quoted cases support our conclusion that

Dr. Davis’s report is adequate. Dr. Davis’s report outlines specific interventions that

he contends should have been made and why the failure to implement those

interventions caused the injury that he opines the records show that Thomas suffered.

Because Dr. Davis’s report contained the facts supporting his opinions on breaches of

the standard of care and causation, its form met the requirements for an expert report

specified in Section 74.351(r)(6) of the MLA. See Tex. Civ. Prac. & Rem. Code Ann.

§ 74.351(r)(6). Thus, the trial court acted within its discretion by denying Eastland’s

motion to dismiss.

      We overrule Eastland’s first and second issues.

                                          33
                                 IV. Conclusion

     Having overruled Eastland’s two issues, we affirm the order of the trial court.

                                                    /s/ Dabney Bassel

                                                    Dabney Bassel
                                                    Justice

Delivered: December 8, 2022

                                         34