                                   COURT OF APPEALS
                                EIGHTH DISTRICT OF TEXAS
                                     EL PASO, TEXAS


                                                §
 EAST EL PASO PHYSICIANS                                        No. 08-13-00358-CV
 MEDICAL CENTER, L.L.C..,                       §
                                                                     Appeal from the
                  Appellant,                    §
                                                             County Court at Law No. 5
 v.                                             §
                                                              of El Paso County, Texas
 OLIVIA VARGAS,                                 §
                                                               (TC# 2011-DCV00117)
                  Appellee.                     §

                                         OPINION

       Olivia Vargas alleged in the trial court that she was injured after automatic doors at

Appellant’s hospital malfunctioned and closed on her prematurely. In what would otherwise be

a “garden variety” slip-and-fall case, we must determine whether the Texas Medical Liability

Act required Vargas to serve Appellant with an expert report on what caused her injuries merely

because she sustained them at a hospital. We hold that it did not.

                                        BACKGROUND

       According to her live pleading, Vargas entered onto property owned by Appellant “as a

customer.” The property housed a state-licensed hospital facility operated by Appellant. The

pleadings do not indicate that she actually received any medical care while she was at the

hospital. At the time of the alleged accident, Vargas was eighty-one and used a walker to stay
ambulatory. As Vargas exited the building, the automatic doors at the entrance closed on her

walker, causing her to fall and sustain injuries. Her medical records indicate that she suffered a

humeral head fracture, which is a shoulder injury. Vargas sued, alleging among other things that

Appellant failed to remedy a dangerous condition, failed to warn her about a dangerous

condition, and failed to set and enforce appropriate safety standards.

       After more than 120 days had expired, Appellant moved to dismiss, arguing that Vargas’

claim was actually a health care liability claim (“HCLC”) under the Texas Medical Liability Act

(“TMLA”). As such, Vargas was required to submit an expert report on causation within 120

days of her suit’s inception, and her failure to do so was fatal. The trial court denied Appellant’s

motion to dismiss.

       This appeal followed. We have jurisdiction over this interlocutory appeal pursuant to

TEX.CIV.PRAC.&REM.CODE ANN. § 51.014(a)(9)(West 2008).

                                          DISCUSSION

       In its sole issue on appeal, Appellant contends that the trial court erred in denying the

motion to dismiss because Vargas’ allegations touch upon state regulations governing the

construction and operation of hospitals. As such, Vargas’ claim is not a regular premises

liability claim, but is instead a safety-related HCLC because it is premised on violations of the

very standards Appellant must meet in order to render health care services in the state of Texas.

We disagree that Appellant’s administrative regulation argument creates a meaningful distinction

between this case and similar premises-liability cases sufficient to bring Vargas’ claim within the

TMLA’s ambit.

                                       Standard of Review

       Whether a pleaded claim is actually an HCLC is a question of statutory construction



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reviewed de novo. Tex. W. Oaks Hosp., L.P. v. Williams, 371 S.W.3d 171, 177 (Tex. 2012). “In

construing a statute, our aim is to determine and give effect to the Legislature’s intent, and we

begin with the plain and common meaning of the statute’s words.” Id. [Internal citations and

quotation marks omitted].     Where a statute is unambiguous, “we adopt the interpretation

supported by its plain language unless such an interpretation would lead to absurd results.” TGS-

NOPEC Geophysical Co. v. Combs, 340 S.W.3d 432, 439 (Tex. 2011). “We further consider

statutes as a whole rather than their isolated provisions.” Id. at 439. “We presume that the

Legislature chooses a statute’s language with care, including each word chosen for a

purpose . . . .” Id. “When possible, each sentence, phrase, clause and word is given effect, so

that the statute makes sense as a cohesive whole.” Meritor Automotive, Inc. v. Ruan Leasing

Co., 44 S.W.3d 86, 90 (Tex. 2001). We “do not treat any statutory language as surplusage, if

possible.” Spradlin v. Jim Walter Homes, Inc., 34 S.W.3d 578, 580 (Tex. 2000).

                         Applicable Law: Texas Medical Liability Act

       In determining whether a claim is an HCLC, the Court considers the record as a whole,

the pleadings, and the factual allegations contained therein. Loaisiga v. Cerda, 379 S.W.3d 248,

255 (Tex. 2012). An HCLC consists of three elements: (1) the defendant must be either a health

care provider or a physician; (2) the plaintiff’s claim must concern treatment, lack of treatment,

or a departure from the accepted standards of care on one of four predicate grounds (“the Four

Breaches”); and (3) the conduct complained of in element two proximately caused the plaintiff’s

injury or death. See TEX.CIV.PRAC.&REM.CODE ANN. § 74.001(a)(13)(West 2011); Williams,

371 S.W.3d at 179-80. The Four Breaches covered by element two include departures from the

accepted standards of (a) medical care, (b) health care, (c) safety, and (d) professional or

administrative services directly related to health care.      TEX.CIV.PRAC.&REM.CODE ANN.



                                                3
§ 74.001(a)(13). A plaintiff “claimant” under the statute does not need to be the patient of a

health care provider or physician for her claim to be considered an HCLC. Williams, 371

S.W.3d at 179-80.

         In assessing whether a claim is an HCLC, the Court looks to the content and not the form

of the pleadings to see if the alleged conduct falls within the TMLA’s legislated scope.

Williams, 371 S.W.3d at 178 (court must look to the “gravamen of the claim . . . against the

health care provider”). A plaintiff cannot dodge the TMLA’s strictures through artful pleading;

where a pleaded tort or contract claim constitutes an HCLC, the TMLA’s procedural

requirements apply regardless of how the claim is recast. Diversicare General Partner, Inc. v.

Rubio, 185 S.W.3d 842, 851 (Tex. 2005).                    The TMLA does not permit “claim splitting.”

Yamada v. Friend, 335 S.W.3d 192, 195-96 (Tex. 2010). Where all claims arise from the same

nucleus of operative fact, and some pleaded claims are HCLCs, then the TMLA’s procedural

requirements must be followed or else all claims arising from the same fact scenario must be

dismissed. Id. at 195-96.

         A defendant is entitled to dismissal with prejudice of any HCLC if a plaintiff fails to

serve the defendant with a statutorily-compliant expert report on liability or causation within 120

days of the suit’s inception. TEX.CIV.PRAC.&REM.CODE ANN. § 74.351(b), (j)(West 2011).

                                             Scope of Safety HCLC

         At issue in this case is what constitutes a “safety” HCLC under the TMLA. Appellant

correctly notes that in Williams, 371 S.W.3d at 185, the Texas Supreme Court read the phrase

“directly relating to health care” as not modifying the word “safety” in the statute under the rule

of the last antecedent,1 a reading we are bound to apply2 but with which we respectfully disagree.


1
 The rule of the last antecedent states that “a qualifying phrase should be applied only to the portion of the sentence
immediately preceding it.” Williams, 371 S.W.3d at 185 [Internal citation and quotation marks omitted].

                                                           4
Accord Psychiatric Solutions, Inc. v. Palit, 414 S.W.3d 724, 729-30 (Tex. 2013)(Boyd, J.,

concurring)(noting that the lack of a serial comma between “safety” and “administrative

services” suggests that the two phrases constitute one grammatical item in a list and that the

phrase “directly related to health care” modifies both “safety” and “administrative services”).

This means that under current interpretations of the TMLA, a safety-related claim need not be

directly related to health care to constitute an HCLC. Williams, 371 S.W.3d at 186.

         In the wake of Williams, our sister courts are split on the issue of whether the nexus to

health care has been jettisoned entirely, or whether a defendant must still prove an indirect

connection to health care to establish that a plaintiff’s claim is really an HCLC. Compare

Williams v. Riverside Gen. Hosp., Inc., No. 01-13-00335-CV, 2014 WL 4259889, at *7

(Tex.App.--Houston [1st Dist.] Aug. 28, 2014, no pet. h.)(mem. op.); Methodist Hosps. of Dallas

v. Garcia, No. 05-13-01307-CV, 2014 WL 2003121, at *2 (Tex.App.--Dallas May 14, 2014, no

pet.)(mem. op.); Methodist Healthcare Sys. of San Antonio, Ltd., L.L.P. v. Dewey, 423 S.W.3d

516, 519 (Tex.App.--San Antonio 2014, pet. filed); Weatherford Tex. Hosp. Co., L.L.C. v. Smart,

423 S.W.3d 462, 464 (Tex.App.--Fort Worth 2014, pet. filed); Christus St. Elizabeth Hosp. v.

Guillory, 415 S.W.3d 900, 902-03 (Tex.App.--Beaumont 2013, pet. filed); Doctors Hosp. at

Renaissance, Ltd. v. Mejia, No. 13-12-00602-CV, 2013 WL 4859592, at *1, *3 (Tex.App.--

Corpus Christi Aug. 1, 2013, pet. filed)(mem. op.); Good Shepherd Med. Ctr.-Linden, Inc. v.

Twilley, 422 S.W.3d 782, 788 (Tex.App.--Texarkana 2013, pet. denied)(cases holding that slip-

and-fall or premises liability cases were not HCLCs); with E. Tex. Med. Ctr. Reg’l Health Care

Sys. v. Reddic, 426 S.W.3d 343, 348 (Tex.App.--Tyler 2014, pet. filed); Ross v. St. Luke’s



2
  See Williams v. Riverside Gen. Hosp., Inc., No 01-13-00335-CV, 2014 WL 4259889, at *6 (Tex.App.--Houston
[1st Dist.] Aug. 28, 2014, no pet.h.)(holding that although the interpretation of the word “safety” in Williams was
judicial dicta, the court was not free to completely disregard the language).

                                                          5
Episcopal Hosp., No. 14-12-00885-CV, 2013 WL 1136613 (Tex.App.--Houston [14th Dist.]

Mar. 19, 2013, pet. granted)(cases holding premises liability claims constituted safety HCLCs).

       The interpretation of the word “safety” and whether it encompasses slip-and-fall claims is

a question of first impression for this Court. Today, we join our sister courts in the Houston First

District, Dallas, Fort Worth, San Antonio, Beaumont, Corpus Christi, and Texarkana in rejecting

the premise that the TMLA’s safety ground is without limitation. The Loiasiga court noted that

by its breadth and mechanics, the TMLA essentially creates a presumption that a claim against a

health care provider is an HCLC.       Loaisiga, 379 S.W.3d at 256. Nonetheless, the Texas

Legislature did not pass a law stating that all suits against health care providers are, in fact,

HCLCs whose continued existence hinges on the presentment of an expert report on causation.

Id.

       Instead, the TMLA is limited in scope to the types of claims specifically enumerated in

the statute. See TEX.CIV.PRAC.&REM.CODE ANN. § 74.001(a)(13). We “must presume that the

Legislature chose its words carefully,” Spradlin, 34 S.W.3d at 580, particularly when it sets out

a specific list of conditions in a statute. Cf. Rodriguez v. State, 953 S.W.2d 342, 354 (Tex.App.-

-Austin 1997, pet. ref’d)(under statutory maxim expresio unius est exclusio alterius, legislature’s

inclusion of specific words in a statutory list limits application of the statute to the included

terms and nothing more). Reading the word “safety” as being “without limitation” threatens to

swallow up the statute in its entirety and render the specifically enumerated class of carefully

selected claims essentially meaningless by opening a back door through which virtually any

claim could be captured. See Williams, 371 S.W.3d at 198-99 (Lehrmann, J., dissenting). We

must interpret the statute as a whole, and in a way that gives meaning to all its words, not just

one word read in isolation. Combs, 340 S.W.3d at 439, Spradlin, 34 S.W.3d at 580. The more



                                                 6
natural reading of safety in its statutory context—a reading that gives meaning to all HCLCs

listed in Section 74.001(a)(13)—is the one espoused by our seven sister courts. If a claim is

wholly untethered from the rendition of health care, it is not, by definition, a safety-related

HCLC. Twilley, 422 S.W.3d at 789.

       This reading also comports with the Texas Supreme Court’s previous interpretations of

the word safety. In determining that certain classes of assault claims were not HCLCs, the court

in Loaisiga stated that the Legislature could not have intended to apply the expert report

requirement to cases “where the conduct of which a plaintiff complains is wholly and

conclusively inconsistent with, and thus separable from, the rendition of medical care, or health

care, or safety or professional or administrative services directly related to health care even

though the conduct occurred in a health care context.” Loaisiga, 379 S.W.3d at 257 [Internal

quotation marks omitted]. Loaisiga makes clear that where “the only possible relationship

between the conduct underlying a claim and the rendition of medical services or healthcare [is]

the healthcare setting[,]” “the defendant’s status as a doctor or health care provider, or both[,]”

the claim is not an HCLC. Id. at 256; accord Reddy v. Veedell, No. 01-14-00309, 2014 WL

4651211, at *3 (Tex.App.--Houston [1st Dist.] Sept. 18, 2014, pet. filed)(distracted driver

defendant who collided with bicyclist plaintiff not entitled to TMLA expert report merely

because defendant was a doctor). As such, we hold that a claim only becomes a safety-related

HCLC where the claim is indirectly tethered to the rendition of health care, i.e., where the

relationship between the claim and the rendition of medical services is more than mere situs of

injury or the defendant’s status as a health care provider.

            Administrative Regulation as an “Indirect” Connection to Health Care

       Having established that the safety ground does not convert all conceivable safety claims



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into HCLCs, we turn to the specifics of the argument at bar. Vargas points out that in nearly

every jurisdiction that follows the indirect nexus approach to safety HCLCs, ordinary premises

liability claims divorced from the rendition of health care do not fall within the TMLA’s scope.

Appellant concedes that our sister courts have found that cases similar to this one are not safety

HCLCs, including one case in which a non-patient was also injured by automatic doors. See

Methodist Healthcare Sys. of San Antonio, Ltd., L.L.P. v. Dewey, 423 S.W.3d 516 (Tex.App.--

San Antonio 2014, pet. filed). However, Appellant counters that the cases from our seven sister

courts are distinguishable.     Here, Appellant advances the new argument that Vargas’ live

pleadings essentially allege violations of the web of regulations that affect the safety and

operation of hospitals. Because the safety standards pertinent to Vargas’ claim are in many

respects set by regulation, and since Appellant’s continued licensure and ability to operate a

hospital, i.e. render health care, are predicated on compliance with those regulations, Vargas’

claims are, in fact, safety claims indirectly related to health care.

        Appellant’s argument holds some appeal at first blush, given the pervasiveness of

hospital regulation. Appellant explains that a hospital must be licensed by the State before it

may operate and render health care services. See TEX.HEALTH & SAFETY CODE ANN. § 241.021

(West 2010). As part of its licensing requirements, the hospital must also abide by regulations

promulgated by the Department of State Health Services.             25 TEX.ADMIN.CODE §§ 133.1-

133.169 (West 2014)(Tex. Dep’t of State Health Servs., Hospital Licensing). Those regulations

mandate among other things that a hospital create a multidisciplinary safety committee

consisting of people selected by the hospital’s chief executive officer. 25 TEX.ADMIN.CODE

§ 133.142(a)(West 2014)(General Safety). The committee, led by a “safety officer” also selected

by the CEO, is responsible for developing, implementing, and enforcing safety policies and



                                                   8
procedures, including a reporting system, new employee safety orientations, and continuing

education requirements, for every department and hospital service.          25 TEX.ADMIN.CODE

§ 133.142(a)(3)(A)-(C).

       The regulations also set construction guidelines and requirements for hospital buildings

already in existence as of June 21, 2007, as well as those constructed or modified after that date.

See 25 TEX.ADMIN.CODE § 133.161 (requirements for building in which existing licensed

hospitals are located); 25 TEX.ADMIN.CODE § 133.162 (new construction requirements). The

regulations for new constructions state that “[a] physical environment that protects the health and

safety of patients, personnel, and the public shall be provided in each hospital.”              25

TEX.ADMIN.CODE § 133.162(d)(1)(A). Compliance with the Americans with Disability Act and

other federal regulations is mandatory.       25 TEX.ADMIN.CODE § 133.162(d)(1)(D).            The

regulations even control general detail and finish requirements, 25 TEX.ADMIN.CODE

§ 133.162(d)(2)(A)(vi), including a subsection devoted entirely to sliding doors.          See 25

TEX.ADMIN.CODE § 133.162(d)(2). Per regulation, “[t]he force required to operate the door in

the direction of door travel is not more than 30 pounds per foot to set the door in motion and is

not more than 15 pounds per foot to close the door or open in the minimum required width.” Id.

The doors are also subject to numerous other requirements. Id.

       Appellant asserts that each of Vargas’ negligence allegations takes aim in some way at

Appellant’s compliance with these regulations, challenging the efficacy of Appellant’s safety

committee, its directives, and the operation of the premises. While Appellant’s argument is

novel, we are not completely without guidance on the role regulatory violations play in the safety

HCLC analysis. In Twilley, our sister court in Texarkana held that a similar premises liability

claim predicated on violation of Occupational Safety and Health Administration (“OSHA”)



                                                9
regulations was not a safety HCLC. Twilley, 422 S.W.3d at 789. There, a hospital employee

sustained two workplace-related injuries: falling off a ladder, and tripping over a mound of

hardened concrete. Id. at 783. The Texarkana court held that the OSHA claims did not relate at

all to the provision of health care, and that even under an indirect connection approach to safety,

a health care defendant still needed to establish “a more logical, coherent nexus to health care”

than was presented on the facts of that case. Id. at 788-89. As such, the statute did not require

an expert report from the plaintiff before the suit could proceed. Id.

        Although the case dealt with OSHA regulations governing workplace safety and not state

hospital licensing regulations, Twilley is similar enough to help ground our analysis. Vargas’

pleaded claims may touch upon or implicate hospital licensure regulations, but Twilley makes

clear that the existence of an on-point safety regulation does not automatically convert a claim

into a safety HCLC, nor should it. Indeed, pegging the already broad safety definition to

regulatory compliance violations risks opening the door to a scavenger hunt of the Texas

Administrative Code and would create a morass of uncertainty and needless litigation in what is

already a confused area of law. See Loaisiga, 379 S.W.3d at 264 (Hecht, J., concurring and

dissenting)(noting that disagreements over TMLA expert report requirement that was originally

intended to reduce cost and “weed out frivolous claims early on[] ha[s] resulted in protracted

pretrial proceedings and multiple interlocutory appeals, threatening to defeat the Act’s purpose

by increasing costs and delay that do nothing to advance claim resolution”).3

        We find no authority indicating that we must resort to administrative regulations in



3
  We recognize that under a “professional or administrative services” HCLC, resort to regulations is required, since
the services defined therein are “those duties or services that a physician or health care provider is required to
provide as a condition of maintaining the physician’s or health care provider’s license, accreditation status, or
certification to participate in state or federal health care programs.” However, unlike a safety HCLC which must be
indirectly tethered to health care, a professional or administrative services HCLC may only be brought when those
services are directly related to health care. See TEX.CIV.PRAC.&REM.CODE ANN. §74.001(a)(24).

                                                        10
determining whether the gravamen of the plaintiff’s claim is a safety claim. Further, the plain

text of the statute does not make reference to hospital licensing regulations as a component of

safety claims. Cf. TEX.CIV.PRAC.&REM.CODE ANN. § 74.001(a)(24)(defining “professional or

administrative services” HCLCs as requiring resort to those duties or services required “as a

condition of maintaining the physician’s or health care provider’s license, accreditation status, or

certification . . . .”). As such, Twilley’s ultimate holding is instructive and properly frames the

inquiry. The question here is not whether the licensing board or some other governmental body

has regulated that particular aspect of a hospital’s construction or operation. The question is

whether the plaintiff alleged that the health care provider defendant breached safety standards

indirectly related to health care.

        Case law from our sister courts makes clear that slip-and-fall claims such as this one are

not even indirectly related to health care. See, e.g., Dewey, 423 S.W.3d at 519 (hospital visitor

on crutches who was injured when automatic door closed did not present HCLC). From a

procedural perspective, “there should be [no] difference between a safety claim occurring in the

lobby of a department store, bakery, or lawyer’s office and a safety claim occurring in the lobby

of a health care provider when health care services are not involved.” Smart, 423 S.W.3d at 467.

Because Vargas’ personal injury claims arose in a context completely divorced from the

rendition of health care, the TMLA did not apply to those claims. The trial court properly denied

Appellant’s motion to dismiss.4

        Issue One is overruled. The judgment of the trial court is affirmed.


November 7, 2014
                                                     YVONNE T. RODRIGUEZ, Justice


4
  Because we hold that denial of dismissal was not error, we decline to reach the constitutional arguments Vargas
raised as unnecessary to the resolution of this appeal. TEX.R.APP.P. 47.1.

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Before McClure, C.J., Rodriguez, J., and Larsen, J. (Senior Judge)
Larsen, J. (Senior Judge, sitting by assignment)




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