                    NUMBER 13-13-00238-CV

                      COURT OF APPEALS

               THIRTEENTH DISTRICT OF TEXAS

                 CORPUS CHRISTI - EDINBURG


TRISUN HEALTHCARE, LLC AND
TRISUN CARE CENTER RIVER RIDGE,                         Appellant,

                                  v.

MINERVA LOPEZ, INDIVIDUALLY AS
WRONGFUL DEATH BENEFICIARY OF
HUMBERTO LOPEZ, DECEASED, ON BEHALF
OF THE ESTATE OF HUMBERTO LOPEZ,
DECEASED, AND ON BEHALF OF ALL
WRONGFUL DEATH BENEFICIARIES
OF HUMBERTO LOPEZ, DECEASED,                            Appellee.


             On appeal from the 214th District Court
                   of Nueces County, Texas.


                      MEMORANDUM OPINION

 Before Chief Justice Valdez and Justices Rodriguez and Longoria
          Memorandum Opinion by Chief Justice Valdez
        Appellee, Minerva Lopez, individually and as wrongful death beneficiary of

Humberto Lopez, deceased, on behalf of the estate of Humberto Lopez, deceased, and

on behalf of all wrongful death beneficiaries of Humberto Lopez, deceased, filed a health

care liability cause of action against appellant, Trisun Healthcare, LLC and Trisun Care

Center River Ridge (“Trisun”). Trisun appeals the trial court’s denial of its motion to

dismiss appellee’s health care liability claim.               By two issues, Trisun contends that

appellee’s expert report does not comply with the requirements of section 74.351(r)(6)

and that the expert, Michael P. Zeitlin, M.D., CMD, is not qualified to opine regarding

causation. We affirm.1

                        I.      STANDARD OF REVIEW AND APPLICABLE LAW

        We review the trial court’s decision on a motion to dismiss a health care liability

claim under an abuse of discretion standard. Am. Transitional Care Ctrs. of Tex., Inc. v.

Palacios, 46 S.W.3d 873, 877–78 (Tex. 2001). “An abuse of discretion occurs when a

trial court acts in an arbitrary or unreasonable manner or without reference to any guiding

principles.” Moore v. Sutherland, 107 S.W.3d 786, 789 (Tex. App.—Texarkana 2003,

pet. denied) (citing Garcia v. Martinez, 988 S.W.2d 219, 222 (Tex. 1999)). We may not

reverse for abuse of discretion simply because we would have decided the matter

differently. Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238, 242 (Tex. 1985).

        We may not substitute our judgment for that of the trial court concerning the

resolution of factual issues or matters committed to the trial court’s discretion. Walker v.

Packer, 827 S.W.2d 833, 839 (Tex. 1992). The appellant must “establish that the trial


        1  As this is a memorandum opinion and the parties are familiar with the facts, we will not recite the
facts in this opinion except as necessary to advise the parties of the Court's decision and the basic reasons
for it. See TEX. R. APP. P. 47.4.


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court could reasonably have reached only one decision.” Id. at 840. A trial court has no

discretion in determining what the law is or in applying the law to the facts and “a clear

failure by the trial court to analyze or apply the law correctly will constitute an abuse of

discretion.” Id.

       Section 74.351 requires a plaintiff to serve on each defendant physician or health

care provider whose conduct is implicated by a healthcare liability claim a curriculum vitae

of each expert listed in the report and one or more expert reports setting forth the standard

of care, breach of the standard of care, and causation. TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.351(a), (r)(6) (West, Westlaw through 2013 3d C.S.). An “expert report” is

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

Id. § 74.351(r)(6).

       A court must grant a motion to dismiss under section 74.351(b) if, after the 120-

day deadline has passed, it appears to the court that the report does not represent an

objective, good-faith effort to comply with the definition of an expert report. Id. § 74.351(l).

A “good-faith effort” means that the report “provide[s] enough information to . . . inform

the defendant of the specific conduct the plaintiff has called into question . . . [and] a

basis for the trial court to conclude that the claims have merit.” Palacios, 46 S.W.3d at

879.   A report cannot constitute a good-faith effort if it omits any of the statutory

requirements. Id.

       The trial court should look no further than the report itself, because all the

information relevant to the inquiry is contained within the document's four corners. Id. at



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878. The report does not need to marshal all of the plaintiff’s proof, but it must include

the expert’s opinion regarding the three elements identified in section 74.351(r)(6), which

include the standard of care, breach, and the causal relationship. Bowie Mem’l Hosp. v.

Wright, 79 S.W.3d 48, 52 (Tex. 2002) (citing Palacios, 46 S.W.3d at 878).

                        II.    ADEQUACY OF DR. ZEITLIN’S REPORT

       By its first issue, Trisun contends that Dr. Zeitlin’s report is not a good-faith effort

to comply with section 74.351. Appellee responds that Dr. Zeitlin’s report adequately

addresses at least one theory; thus, the trial court properly denied Trisun’s motion to

dismiss. See Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 630 (Tex. 2013) (“If a health

care liability claim contains at least one viable liability theory, as evidenced by an expert

report meeting the statutory requirements, the claim cannot be frivolous. . . . In sum, an

expert report that adequately addresses at least one pleaded liability theory satisfies the

statutory requirements, and the trial court must not dismiss in such a case.”).

       First, Dr. Zeitlin stated in his report that Trisun owed the following standards of

care to the deceased: (1) “to immediately notify [the deceased’s] physician when his left

hand wound deteriorated and obtain additional treatment orders for hyperbaric wound

treatment and consultation with a wound care specialist or plastic surgeon”; (2) “to monitor

and treat the pressure ulcer documented on [the deceased’s] scrotum at admission”; (3)

“to institute standard and recognized precautionary measures for [the deceased] to

prevent the development of pressure sores”; and (4) “to contact a surgeon or other

physician when they knew that [the deceased’s] left hand ulcerations had deteriorated

and they had been ordered by Dr. Ramirez to obtain a consultation with a surgeon.” Dr.

Zeitlin opined that Trisun breached these standards of care by failing to: (1) “immediately



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notify [the deceased’s] physician when his left hand wound deteriorated”; (2) “obtain

additional treatment orders for hyperbaric wound treatment and consultation with a wound

care specialist or plastic surgeon when [the deceased’s] left hand wounds deteriorated”;

(3) “monitor and treat the pressure ulcer documented on [the deceased’s] scrotum at

admission”; (4) “institute standard and recognized precautionary measures for [the

deceased] to prevent the development of pressure sores”; (5) place the deceased on “an

air mattress with padding to areas of boney prominence”; (6) reposition the deceased

every two hours “to relieve pressure on areas of boney prominence”; and (7) comply with

Dr. Ramirez’s order to consult with a surgeon concerning the deterioration of the wound

on the deceased’s hand.

      In her pleading, appellee alleged, among other things, that Trisun had failed to

properly care for the wound on the deceased’s hand, thus causing him injury requiring

amputation. Dr. Zeitlin opined that the standard of care required Trisun “to immediately

notify [the deceased’s] physician when his left hand wound deteriorated and obtain

additional treatment orders for hyperbaric wound treatment and consultation with a wound

care specialist or plastic surgeon” and “to contact a surgeon or other physician when they

knew that [the deceased’s] left hand ulcerations had deteriorated and they had been

ordered by Dr. Ramirez to obtain a consultation with a surgeon.”     Although not set out

under the heading “Standards of Care,” Dr. Zeitlin also stated that the standard of care

required Trisun to “obtain additional treatment orders for hyperbaric wound treatment and

consultation with a wound care specialist or plastic surgeon when [the deceased’s] left

hand wounds deteriorated” and to “recognize and treat” the deceased’s wound on his

hand. According to Dr. Zeitlin, Trisun’s failure to immediately notify the deceased’s



                                               5
physician of the deterioration of the wound on his hand and failure to recognize and treat

the deteriorating wound on the deceased’s hand caused the infection to progress and

worsen. Dr. Zeitlin said that the wound had been described as deteriorating on June 25,

2010 and that if Trisun had contacted the deceased’s physician and recognized and

treated the wound properly when it began to deteriorate, the wound would not have

progressed and worsened leading to the hand becoming gangrenous and mummified.

Dr. Zeitlin stated that on

              June 26, 2010, Dr. Ramirez ordered a surgical consultation for [the
       deceased] due to his deteriorating left hand wound. Despite this order, no
       surgeon or other physician was contacted until June 28, 2010. During this
       two day time period, [the deceased’s] left hand wound worsened as
       evidenced by the descriptions of the wound as progressing from dark red to
       maroon to black. In reasonable medical probability, if the wound had been
       immediately treated on June 25, 2010 or June 26, 2010 when it was
       alternately described as dark red and maroon, by a surgeon, it would have
       been debrided before it became gangrenous and would have been
       susceptible to treatment with hyperbaric oxygen. This would have in
       medical probability prevented [the deceased’s] hand from becoming
       mummified and requiring amputation.

       We understand Dr. Zeitlin’s opinion as explaining the following: (1) the standard

of care required that when Trisun documented that the deceased’s wound on his hand

was deteriorating, Trisun should have contacted the deceased’s physician and a surgeon

and Trisun also should have “immediately treated” the wound on either June 25 or June

26, 2010; (2) if Trisun had complied with these standards, the deceased’s wound would

have been debrided before it became gangrenous and would have been susceptible to

hyperbaric oxygen treatment; and (3) if Trisun had not breached the standards of care,

the deceased’s hand wound would not have become mummified and, eventually

amputated. We conclude that Dr. Zeitlin’s report provided a fair summary of his opinions

regarding the standards of care that Trisun was required to follow in treating the

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deceased’s wound on his hand, the manner in which the care rendered by Trisun failed

to meet those standards, and the causal relationship between that failure and the injury,

harm, or damages claimed by appellee. See TEX. CIV. PRAC. & REM. CODE ANN. §

74.351(r)(6). The report provides enough information to inform Trisun of the specific

conduct regarding the deceased’s hand wound that appellee has called into question.

See Certified EMS, Inc., 392 S.W.3d at 630 (explaining that if the expert report adequately

addresses at least one pleaded liability theory and satisfies the statutory requirements

regarding that theory, “the trial court must not dismiss in such a case”); Palacios, 46

S.W.3d at 879. Thus, Dr. Zeitlin’s report represents a good-faith effort to comply with

section 74.351(r)(6). See TEX. R. CIV. P. 74.351(r)(6). The trial court did not abuse its

discretion when it denied Trisun’s motion to dismiss appellee’s claim.2 We overrule

Trisun’s first issue.3

                                 III.     DR. ZEITLIN’S QUALIFICATIONS

        By its second issue, Trisun contends that Dr. Zeitlin is not qualified to opine

regarding causation. Specifically, Trisun argues that Dr. Zeitlin failed to establish that “he




          2 Dr. Zeitlin also alleged that Trisun breached the standards of care by failing to prevent the

formation of pressure ulcers on the deceased’s buttocks. According to Dr. Zeitlin, Trisun was required to
institute standard and recognized precautionary measures to prevent the development of pressure sores,
to place the deceased on an air mattress, and to reposition the deceased every two hours in order to avoid
the development of the pressure ulcers. Dr. Zeitlin opined that due to Trisun’s failure to comply with the
above-stated standards of care, the pressure sores on the deceased’s buttocks developed and became
infected with “Fournier’s gangrene.” Thus, the report is also adequate as to this theory.
        3  It is possible that Dr. Zeitlin’s opinion is incorrect. However, at this stage of the proceeding, that
possibility does not render his report insufficient and appellant’s claims dismissible. See Fagadau v.
Wenkstern, 311 S.W.3d 132, 139 (Tex. App.—Dallas 2010, no pet.) (“The possibility that facts may later be
discovered that prove Dr. Goldman's opinions on causation are incorrect is not a basis for holding the report
insufficient under section 74.351.”); Methodist Hosp. v. Shepherd–Sherman, 296 S.W.3d 193, 200 (Tex.
App.—Houston [14th Dist.] 2009, no pet.) (noting that although discovery could later prove that a doctor’s
opinion is wrong, that is not a basis for holding report insufficient under chapter 74).


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has actual personal knowledge, skill, experience, training or education in the treatment of

nonhealing ischemic hand wounds and Fournier’s gangrene.”

       Not every licensed physician is always qualified to testify on every medical

question. Broders v. Heise, 924 S.W.2d 148, 152 (Tex. 1996). Therefore, the focus

should not be on whether the expert is a physician and instead should be on the medical

expert’s “knowledge, skill, experience, training, or education” concerning the specific

issue before the court which would qualify the expert to give an opinion on that particular

subject. Id. at 153–54 (applying Texas Rule of Evidence 702).

       Here, Dr. Zeitlin’s report sets out that he is “a medical doctor currently licensed in

California, Ohio, and Texas,” that he is board certified by the American Board of Family

Practice and that he has “the certificate of added qualifications in Geriatric Medicine.” Dr.

Zeitlin stated that he is also board certified as a long-term care medical director by the

American Medical Directors Association and that he practices in the area of geriatric

medicine. Dr. Zeitlin has also served as the medical director of several long-term care

facilities and has published peer reviewed articles in the areas of geriatric medicine. Dr.

Zeitlin, as of the date of the expert report, served as the regional medical director of the

“Health & Medical Practice Associates,” as medical director of the “Talecris Plasma

Services, Guimbarda Family Medicine, Texas Medical Transfer,” and had staff

appointments at “Golden Manor Nursing Home, Promise Long Term Acute Care Hospital”

and “Victor Hospital,” among others. Dr. Zeitlin was “in private practice with Alamo Area

Family & Geriatric Medicine Associates in San Antonio, Texas.”

       Dr. Zeitlin stated that, “during the time of this claim,” he has “as part of [his]

practice,” been and is “currently, involved in the diagnosis, care, and treatment of many



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elderly patients similar to [the deceased],” and he is “familiar with the diagnosis, care[,]

and treatment of elderly patients with diabetes, renal disease, hypertension[,] and

ulcerations at risk for the development of pressure sores and infections.” Dr. Zeitlin said

that he “treat[s] patients in nursing homes and supervises the nurses and staff in the care

that they provide my patients.” Dr. Zeitlin explained his expertise, in pertinent part, as

follows:

               At the time of the medical treatment of [the deceased], throughout
       2010, I was treating elderly patients with symptoms similar to those
       experienced by [the deceased]. I am familiar with the accepted medical
       standards of care applicable to the assessment, diagnosis, and treatment
       of patients with hypertension, diabetes, end stage renal disease,
       hypertension, and open ulcerations that require assistance with ambulation
       and other activities of daily living. I am also familiar with the preventative
       measures, diagnosis[,] and treatment to be provided to an elderly [patient]
       to prevent pressure sores, infection[,] and times diagnosis and treat
       infections should they occur. . . . I know the accepted standards of care,
       the breaches[,] and violations of the standards of care, and the causal link
       between the breaches and violations of the standards of care and the
       injuries and death [of the deceased] as they apply to [Trisun] and its nurses
       and staff on the basis of my education, knowledge, training, and experience.
       I acquired this education, knowledge, training[,] and experience through[,
       among other things]:

       1)     attending and successfully completing, medical school classes, and
              residency, that teach the evaluation, diagnosis, care[,] and treatment
              with elderly patients with the same or similar conditions as [the
              deceased] including hypertension, diabetes, end stage renal
              disease, hypertension, and open ulcerations who require assistance
              with ambulation and other activities of daily living;

       2)     practical experience of diagnosing and treating elderly patients with
              the same or similar conditions as [the deceased] including
              hypertension, diabetes, end stage renal disease, hypertension, and
              open ulcerations who are at risk for developing infections and require
              assistance with ambulation and other activities of daily living;

              ....

       4)     study of technical works routinely published in textbooks, journals,
              and literature concerning the evaluation, diagnosis, care[,] and

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                 treatment of elderly patients with the same or similar conditions as
                 [the deceased] including hypertension, diabetes, end stage renal
                 disease, hypertension, and open ulcerations who are at risk for
                 developing infections and require assistance with ambulation and
                 other activities of daily living;

          Dr. Zeitlin also stated that he has acquired his education, knowledge, training, and

experience of treating elderly patients such as the deceased with ulcerations and the

other above listed conditions through, among other things, the following: (1) his

discussions with colleagues; (2) his consultations with other physicians who also treat

such patients; (3) his experience as the medical director of nursing homes and long-term

care facilities; and (4) his routine and regular contact with and supervision of nurses and

staff who care for such patients. Dr. Zeitlin opined,

          Based on my education, training, knowledge, and direct experience, I am
          familiar with the accepted, and expected, standards of care, as listed below,
          for nurses and staff who work in a hospital or health care facility and take
          care of elderly patients with these conditions, the breaches of the standards
          of care and the causation of the injuries from these breaches.

          In summary, Dr. Zeitlin is licensed to practice medicine in California, Ohio, and

Texas. He is board certified by the American Board of Family Practice and in geriatrics.

Dr. Zeitlin is actively engaged in the practice of these specialties. He regularly engages

in the diagnosis and treatment of patients who have similar or identical conditions suffered

by the deceased, including the diagnosis and treatment of ulcerations and the infections

that could result from improper treatment. Finally, Dr. Zeitlin stated that he has diagnosed

and treated patients in nursing homes with the same conditions as the deceased with

ulcerations and has experience in the prevention of ulcerations and infections to those

ulcers.




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       Trisun argues that Dr. Zeitlin was not qualified to opine on the cause of the infection

of the deceased’s wound on his hand. We disagree and conclude that Dr. Zeitlin has the

knowledge, skill, experience, training, and education to opine on the issue before the trial

court of whether Trisun’s alleged breach in not providing appropriate treatment to the

deceased’s wound on his hand caused the infection and eventual amputation of that

hand. Trisun also complains that Dr. Zeitlin never specifically said that he has experience

treating “Fournier’s gangrene.” However, Dr. Zeitlin did explain that he has experience

preventing and treating ulcerations in patients, such as the deceased, including the

treatment and prevention of infection of the ulcerations and that “Fournier’s gangrene” is

an infection that occurs in pressure ulcers. Thus, we conclude that Dr. Zeitlin has the

knowledge, skill, experience, and training to opine on the link between Trisun’s alleged

breach of the standards of care in treating and preventing pressure ulcers to develop and

the infection that followed due to Trisun’s alleged breach. See Broders, 924 S.W.2d at

153–54. Therefore, the trial court did not abuse its discretion by determining that Dr.

Zeitlin was qualified to opine regarding causation in this case. See Palacios, 46 S.W.3d

at 877–78. We overrule Trisun’s second issue.

                                    IV.    CONCLUSION

       We affirm the trial court’s denial of Trisun’s motion to dismiss.

                                                         /s/ Rogelio Valdez
                                                         ROGELIO VALDEZ
                                                         Chief Justice

Delivered and filed the
3rd day of July, 2014.




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