                                 IN THE
                         TENTH COURT OF APPEALS

                               No. 10-15-00440-CV

TEXAS HOME HEALTH SKILLED SERVICES, L.P.

                                                          Appellant
v.

JUDY ANDERSON, INDIVIDUALLY AND
AS REPRESENTATIVE OF THE ESTATE
OF ELIZABETH TIMMONS, DECEASED,

                                                          Appellees




                          From the 278th District Court
                             Walker County, Texas
                             Trial Court No. 1527363


                          MEMORANDUM OPINION


      In one issue, appellant, Texas Home Health Skilled Services, L.P., argues that the

trial court erred in refusing to dismiss a wrongful-death and survival lawsuit filed by

appellee, Judy Anderson, individually and as representative of the estate of Elizabeth
Timmons, deceased, because Anderson failed to serve compliant expert reports.

Specifically, appellant complains that Anderson’s expert reports failed to establish the

qualifications of the doctor writing one of the expert reports and insufficiently addressed

the breach and causation elements. Because we conclude that Anderson’s expert reports

are insufficient as to causation, we reverse and remand.

                                         I.         BACKGROUND

       On April 2, 2015, Anderson filed a wrongful-death and survival suit against

numerous parties, including appellant. In her first amended petition filed on June 9, 2015,

Anderson asserted negligence, vicarious-liability, and gross-negligence claims against

appellant pertaining to the death of Elizabeth Timmons. In her live pleading, Anderson

alleged the following facts:

       Before April 25, 2014, Elizabeth Timmons was under the care of Dr.
       Rosenquist, who monitored Ms. Timmons’ INR (a measure of blood
       coagulation) levels. The normal range for INR is 2-3, with higher levels
       indicating an increased risk of stroke. Ms. Timmons was also under the
       care of Texas Home Health . . . prior to April 25, 2014, who, along with Dr.
       Rosenquist was also responsible for monitoring and testing Ms. Timmons’
       INR levels in addition to her general care. However, prior to April 25, 2014,
       Ms. Timmons’ INR levels were not tested and/or monitored since at least
       February 26, 2014.

              On April 25, 2014, while at a family member’s home. Elizabeth
       Timmons suddenly became unresponsive. Her daughter, Judy Anderson,
       immediately admitted Ms. Timmons to Huntsville Memorial Hospital. A
       physician at Huntsville Memorial Hospital diagnosed Ms. Timmons with a
       stroke and recommended Ms. Anderson seek care for Ms. Timmons from a
       neurologist. At Ms. Timmons’ admission to Huntsville Memorial Hospital,
       her INR level was at 15. Later that day, Ms. Timmons was admitted to West
       Houston Medical Center to receive treatment. While Ms. Timmons was at
Tex. Home Health Skilled Servs., L.P. v. Anderson                                      Page 2
       West Houston Medical Center, she developed skin breakdown to her legs,
       sacrum, and back from the inattentiveness of the nursing staff to properly
       turn Ms. Timmons and/or adequately care for her. The skin breakdown
       developed into bedsores so severe that Ms. Anderson noticed a pungent
       odor and the skin breakdown spread over Ms. Timmons’ legs, buttocks, and
       back.

              Due to the inattentive and inadequate care Ms. Timmons was
       receiving at West Houston Medical Center, her daughter had Ms. Timmons
       transferred to the Huntsville Healthcare Center on May 9, 2014. During Ms.
       Timmons[‘] stay at West Houston Medical Center, her condition[]
       worsened due to the nursing staff’s substandard care. Ms. Timmons
       became dehydrated to such a degree that she developed acute renal failure.
       Ms. Anderson repeatedly informed the staff of Ms. Timmons’ lack of
       drinking and eating[,] but no interventions were made by the staff to
       adequately treat and care for Ms. Timmons. In fact, the nursing staff at
       Huntsville Healthcare Center was providing meat-based meals to Ms.
       Timmons despite Ms. Timmons being a vegetarian.

              Due to Ms. Timmons’ worsening condition, she was transferred by
       EMS to Huntsville Memorial Hospital on May 28, 2014. West Houston
       Medical Center failed to properly communicate Ms. Timmons’ symptoms
       to Huntsville Memorial Hospital, including, but not limited to Ms.
       Timmons’ lack of eating, and drinking, and her skin breakdown. While at
       Huntsville Memorial Hospital, Ms. Timmons continued to receive
       inadequate care for her skin breakdown and nutritional status and needs,
       including the severe dehydration. As a result, Ms. Timmons suffered
       kidney failure, was unable to swallow or talk, and her tongue turned black
       with sores. The combination of a dehydration and prolonged lack of eating
       caused kidney failure and a progressive decline in Ms. Timmons’ condition
       from which Ms. Timmons was unable to recover, resulting in her death June
       7, 2014.

       On May 13, 2015, Anderson served the initial expert report and curriculum vitae

of Paul O. Warshawsky, M.D. Appellant objected to Dr. Warshawsky’s initial expert

report, contending that he was not qualified to testify regarding the standard of care



Tex. Home Health Skilled Servs., L.P. v. Anderson                                   Page 3
applicable to a home-health nurse and that his report was not a “fair summary” of the

applicable standard of care, the alleged breach, and causation.

       Thereafter, Anderson served the expert report and curriculum vitae of Lori Rozas,

R.N. Anderson explained that this report was provided to address appellant’s objections

to the qualifications of Dr. Warshawsky to opine on the standard of care for a home-

health nurse. In any event, appellant filed objections to Nurse Rozas’s expert report, as

well as supplemental objections to Dr. Warshawsky’s initial expert report.

       In response to appellant’s objections, Anderson served supplemental reports from

both Dr. Warshawsky and Nurse Rozas. However, these supplemental reports were met

with additional objections from appellant.

       On September 28, 2015, appellant filed a motion to dismiss Anderson’s claims

against appellant for failure to serve an adequate expert report. On the same day,

Anderson filed a motion to determine the sufficiency of her expert reports. Shortly

thereafter, Anderson filed a response to appellant’s motion to dismiss, arguing that her

expert reports were sufficient and requesting, in the alternative, an opportunity to cure

any potential deficiencies.

       On November 23, 2015, the trial court heard both appellant’s motion to dismiss

and Anderson’s motion to determine the sufficiency of her expert reports. A few days

after the hearing, the trial court signed an order denying appellant’s motion to dismiss,

granting Anderson’s motion, and determining that her expert reports were sufficient.


Tex. Home Health Skilled Servs., L.P. v. Anderson                                  Page 4
This accelerated, interlocutory appeal followed. See TEX. CIV. PRAC. & REM. CODE ANN. §

51.014(a)(9) (West Supp. 2016) (authorizing an interlocutory appeal from the denial of

“all or part of the relief sought by a motion under Section 74.351(b), except that an appeal

may not be taken from an order granting an extension under Section 74.351 . . . .”).

                                    II.     STANDARD OF REVIEW

       We review all rulings related to Section 74.351 of the Texas Civil Practice and

Remedies Code under an abuse-of-discretion standard. Jelinek v. Casas, 328 S.W.3d 526,

538-39 (Tex. 2010); Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 877

(Tex. 2001). Although we defer to the trial court’s factual determination, we review

questions of law de novo. See Haskell v. Seven Acres Jewish Senior Care Servs., Inc., 363

S.W.3d 754, 757 (Tex. App.—Houston [1st Dist.] 2012, no pet.); see also Hillcrest Baptist

Med. Ctr. v. Dixon, No. 10-12-00396-CV, 2013 Tex. App. LEXIS 8565, at **4-5 (Tex. App.—

Waco July 11, 2013, no pet.) (mem. op.). A trial court has no discretion in determining

what the law is, which law governs, or how to apply the law. See Poland v. Orr, 278 S.W.3d

39, 45 (Tex. App.—Houston [1st Dist.] 2008, pet. denied); see also Dixon, 2013 Tex. App.

LEXIS 8565, at *5. An abuse of discretion occurs if the trial court fails to correctly apply

the law to the facts or if it acts in an arbitrary or unreasonable manner without reference

to guiding rules or principles. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002);

see Haskell, 363 S.W.3d at 757 (citing Petty v. Churner, 310 S.W.3d 131, 134 (Tex. App.—

Dallas 2010, no pet.)).


Tex. Home Health Skilled Servs., L.P. v. Anderson                                      Page 5
                                       III.    APPLICABLE LAW

       A plaintiff who asserts a health-care-liability claim, as defined by Chapter 74, must

provide each defendant physician or health-care provider with an expert report which

provides “a fair summary of the expert’s opinions” as of the date of the report regarding

the applicable standards of care, the manner in which the care rendered failed to meet

the applicable standards, and the causal relationship between that failure and the claimed

injury. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a), (r)(6) (West Supp. 2016); see also

Dixon, 2013 Tex. App. LEXIS 8565, at **5-6. “The purpose of the expert report requirement

is to deter frivolous claims, not to dispose of the claims regardless of their merits.”

Scoresby v. Santillan, 346 S.W.3d 546, 554 (Tex. 2011).

       When a plaintiff timely files an expert report and a defendant moves to dismiss on

the basis that the report is insufficient, the trial court must grant the motion only if the

report does not represent a good-faith effort to meet the statutory requirements. See TEX.

CIV. PRAC. & REM. CODE ANN. § 74.351(l); see also Dixon, 2013 Tex. App. LEXIS 8565, at *6.

To constitute a good-faith effort, a report “must discuss the standard of care, breach, and

causation with sufficient specificity to inform the defendant of the conduct the plaintiff

has called into question and to provide a basis for the trial court to conclude that the

claims have merit.” Palacios, 46 S.W.3d at 875; see Wright, 79 S.W.3d at 52.

       A report cannot merely state the expert’s conclusions about these elements;

instead, the report must explain the basis of the statements and link the conclusions to


Tex. Home Health Skilled Servs., L.P. v. Anderson                                     Page 6
the facts. Wright, 79 S.W.3d at 52; see Jelinek, 328 S.W.3d at 539-40. A report that merely

states the expert’s conclusions about the standard of care, breach, and causation is

deficient. Palacios, 46 S.W.3d at 879. Further, a report that omits any of the statutory

elements is likewise deficient. Id. In determining whether the trial court’s ruling on a

motion to dismiss was correct, we review the information contained within the four

corners of the report. Wright, 79 S.W.3d at 53. “The report can be informal in that the

information in the report does not have to meet the same requirements as evidence

offered in a summary-judgment proceeding or at trial.” Palacios, 46 S.W.3d at 879.

       Furthermore, reports may be considered together in determining whether a

health-care-liability claimant provided a report meeting the statutory requirements. See

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i); see also Salais v. Tex. Dep’t of Aging &

Disability Servs., 323 S.W.3d 527, 534 (Tex. App.—Waco 2010, pet. denied). A single report

need not “address all liability and causation issues with respect to all physicians or health

care providers or with respect to both liability and causation issues for a physician or

health care provider.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(i); see, e.g., Dixon, 2013

Tex. App. LEXIS 8565, at *11 n.2. But read together, the reports must provide a “fair

summary” of the experts’ opinions. TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6); see

Barber v. Mercer, 303 S.W.3d 786, 791 (Tex. App.—Fort Worth 2009, no pet.); Walgreen Co.

v. Hieger, 243 S.W.3d 183, 187 n.2 (Tex. App.—Houston [1st Dist.] 2007, pet. denied).




Tex. Home Health Skilled Servs., L.P. v. Anderson                                      Page 7
                                IV.     ANDERSON’S EXPERT REPORTS

       In its sole issue on appeal, appellant contends that the trial court erred in refusing

to dismiss this action for failure to serve a compliant expert report. Among the reasons

listed by appellant is that the expert reports are conclusory as to the applicable standard

of care and breach; that the reports failed to provide specific information as to how

appellant’s alleged breach of the applicable standards of care was a substantial factor in

Timmons’ death; and that Dr. Warshawsky is not qualified to opine on the standard of

care for home-health-care providers.

A.     Appellant’s expert reports establish Dr. Warshawsky’s qualifications

       At the outset, we address appellant’s complaints about Dr. Warshawsky’s

qualifications. Section 74.351(r)(5)(C) provides that an “expert” in a health-care liability

claim is:

       with respect to a person giving opinion testimony about the causal
       relationship between the injury, harm, or damages claimed and the alleged
       departure from the applicable standard of care in any health care liability
       claim, a physician who is otherwise qualified to render opinions on such
       causal relationship under the Texas Rules of Evidence.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(5)(C); see id. § 74.403(a) (West 2011) (“[A]

person may qualify as an expert witness on the issue of the causal relationship between

the alleged departure from accepted standards of care and the injury, harm, or damages

claimed only if the person is a physician and is otherwise qualified to render opinions on

that causal relationship under the Texas Rules of Evidence.”). However, a professional


Tex. Home Health Skilled Servs., L.P. v. Anderson                                      Page 8
need not be employed in the particular field about which he is testifying so long as he can

demonstrate that he has knowledge, skill, experience, training, or education regarding

the specific issue before the court that would qualify him to give an opinion on that

subject. Broders v. Heise, 924 S.W.2d 148, 153-54 (Tex. 1996); see TEX. CIV. PRAC. & REM.

CODE ANN. § 74.402 (West 2011) (listing the requirements for an expert to be considered

qualified in a suit against a health-care provider); see also TEX. R. EVID. 702 (allowing

experts to testify based on their “knowledge, skill, experience, training, or education”).

“[W]hen a party can show that a subject is substantially developed in more than one field,

testimony can come from a qualified expert in any of those fields.” Broders, 924 S.W.2d

at 154.

          Qualifications of an expert must appear in the expert reports and curriculum vitae

and cannot be inferred. See Salais, 323 S.W.3d at 536; see also Estorque v. Schafer, 302 S.W.3d

19, 26 (Tex. App.—Fort Worth 2009, no pet.) (citing Olveda v. Sepulveda, 141 S.W.3d 679,

683 (Tex. App.—San Antonio 2004, pet. denied)); Baylor College of Med. v. Pokluda, 283

S.W.3d 110, 117 (Tex. App.—Houston [14th Dist.] 2009, no pet.). Analysis of the expert’s

qualifications under section 74.351 is limited to the four corners of the expert reports and

the expert’s curriculum vitae. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a) (requiring

a health-care-liability claimant to file both an expert report and the expert’s curriculum

vitae within 120 days of the filing of the original petition); In re McAllen Med. Ctr., Inc.,

275 S.W.3d 458, 463 (Tex. 2008) (considering an expert’s curriculum vitae and report in


Tex. Home Health Skilled Servs., L.P. v. Anderson                                       Page 9
determining whether the expert was qualified to opine about plaintiff’s negligent

credentialing cause of action); Polone v. Shearer, 287 S.W.3d 229, 238 (Tex. App.—Fort

Worth 2009, no pet.); Pokluda, 283 S.W.3d at 117; Mosely v. Mundine, 249 S.W.3d 775, 779

(Tex. App.—Dallas 2008, no pet.); see also Lewis v. Funderburk, No. 10-05-00197-CV, 2008

Tex. App. LEXIS 9761, at *6 (Tex. App.—Waco Dec. 31, 2008, pet. denied) (mem. op.).

       Merely being a physician is insufficient to qualify as a medical expert. See Broders,

924 S.W.2d at 152; see also Hagedorn v. Tisdale, 73 S.W.3d 341, 350 (Tex. App.—Amarillo

2002, no pet.) (“Every licensed doctor is not automatically qualified to testify as an expert

on every medical question.”). But we defer to the trial court on close calls concerning an

expert’s qualifications. See Larson v. Downing, 197 S.W.3d 303, 304-05 (Tex. 2006); see also

Broders, 924 S.W.2d at 151 (“The qualification of a witness as an expert is within the trial

court’s discretion. We do not disturb the trial court’s discretion absent clear abuse.”).

       Dr. Warshawsky’s curriculum vitae indicates that he is a board-certified physician

who was practicing medicine at the time of the events in question.              Indeed, Dr.

Warshawsky has practiced medicine for approximately thirty years and is board certified

in internal medicine. Furthermore, Dr. Warshawsky has been a medical director of a

medical institution with over 175 doctors and nurses and has been on the teaching faculty

at a medical school. And more specific to this case, Dr. Warshawsky has served as a

hospitalist and physician providing geriatric and nursing-home care at several facilities

in Chicago, Illinois, over the course of many years. Additionally, Dr. Warshawsky noted


Tex. Home Health Skilled Servs., L.P. v. Anderson                                     Page 10
numerous times in his reports that he is familiar with the standard of care applicable to

the health-care providers involved in the claim. See Baylor Med. Ctr. at Waxahachie v.

Wallace, 278 S.W.3d 552, 558 (Tex. App.—Dallas 2009, no pet.).1

        Based on our review of Dr. Warshawsky’s reports and curriculum vitae, we

conclude that he is qualified to opine on the standard-of-care and breach elements of

appellant’s claims. See TEX. CIV. PRAC. & REM. CODE ANN. §§ 74.351(r)(5)(C), 74.403(a); In

re McAllen Med. Ctr., Inc., 275 S.W.3d at 463; Broders, 924 S.W.2d at 153-54; Salais, 323

S.W.3d at 536; Estorque, 302 S.W.3d at 26; Pokluda, 283 S.W.3d at 117; Wallace, 278 S.W.3d

at 558; see also Lewis, 2008 Tex. App. LEXIS 9761, at *6. Thus, we hold that the trial court

did not abuse its discretion in determining that Dr. Warshawsky was qualified to opine



        1   In Wallace, the Dallas Court of Appeals noted the following:

        When a physician fails to state in his expert report or affidavit that he has knowledge of
        the standard of care applicable to the specific types of health care providers involved in
        the claim, or that he has ever worked with or supervised the specific types of health care
        providers involved in the claim, the physician is not qualified on the issue of whether the
        health care provider departed from the accepted standards of care for health care
        providers. . . . However, if the physician states he is familiar with the standard of care for
        both nurses and physicians, and for the prevention and treatment of the illness, injury, or
        condition involved in the claim, the physician is qualified on the issue of whether the
        health care provider departed from the accepted standards of care for health care
        providers. . . . Further, if a physician states he is familiar with the standard of care and
        responsibilities and requirements for physician’s assistants, and he has worked with,
        interacted with, and supervised physician’s assistants, the physician is qualified on the
        issue of whether the health care provider departed from the accepted standards of care for
        health care providers. . . .

Baylor Med. Ctr. at Waxahachie v. Wallace, 278 S.W.3d 552, 558 (Tex. App.—Dallas 2009, no pet.) (citing Cook
v. Spears, 275 S.W.3d 577, 582-84 (Tex. App.—Dallas 2009, no pet.); San Jacinto Methodist Hosp. v. Bennett,
256 S.W.3d 806, 814 (Tex. App.—Houston [14th Dist.] 2008, no pet.); Simonson v. Keppard, 225 S.W.3d 868,
872-74 (Tex. App.—Dallas 2007, no pet.)).


Tex. Home Health Skilled Servs., L.P. v. Anderson                                                        Page 11
on the essential elements in this case. See Wallace, 278 S.W.3d at 558; see also Tenet Hosps,

Ltd. v. De La Rosa, No. 08-13-00290-CV, 2016 Tex. App. LEXIS 6060, at **9-10 (Tex. App.—

El Paso June 8, 2016, no pet.) (mem. op.) (concluding that a doctor can opine about the

standard of care applicable to nurses, especially when the expert reports demonstrate that

the physician “is familiar with the applicable nursing standard of care in a hospital

inpatient setting, he has taught courses to nurses, and he has worked with and interacted

with nurses in the hospital inpatient setting”) (citing Hall v. Huff, 957 S.W.2d 90, 100 (Tex.

App.—Texarkana 1997, pet. denied)).

       And even if we agreed with appellant and found Dr. Warshawsky unqualified to

testify about the standard-of-care and breach elements for home-health-care providers,

we note that Nurse Rozas also submitted an expert report and curriculum vitae

addressing the standard-of-care and breach elements in this case. Moreover, appellant

does not challenge Nurse Rozas’s qualifications on appeal. Therefore, because we have

already concluded that Dr. Warshawsky was qualified to render an expert opinion in this

case, and because we may consider multiple reports in determining whether the health-

care-liability claimant met the statutory requirements, see Salais, 323 S.W.3d at 534, we

conclude that Anderson provided qualified experts to opine on the essential elements of

her claims.

B.     Appellant’s expert reports are adequate as to the standard of care and breach
       elements

       Section 74.351(r)(6) provides that an expert report is:
Tex. Home Health Skilled Servs., L.P. v. Anderson                                      Page 12
       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 standard, and the causal relationship between
       that failure and the injury, harm, or damages claimed.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6). Chapter 74 further provides:

       Notwithstanding any other provision of this section, a claimant may satisfy
       the requirement of this section for serving an expert report by serving
       reports of separate experts regarding different physicians or health care
       providers or regarding different issues arising from the conduct of a
       physician or health care providers, such as issues of liability and causation.
       Nothing in this section shall be construed to mean that a single expert must
       address all liability and causation issues with respect to all physicians or
       health care providers or with respect to both liability and causation issues
       for a physician or health care provider.

Id. § 74.351(i).

       In this case, Anderson provided numerous expert reports from Dr. Warshawsky

and Nurse Rozas that addressed the standard-of-care and breach elements. Specifically,

among the copious information contained in his reports, Dr. Warshawsky outlined the

following with respect to the standard-of-care and breach elements for appellant:

       Texas Home Health (AccentCare)

       The standard of care requires that the home health nurses institute
       appropriate nursing interventions that might be required to stabilize a
       patient’s condition and/or prevent complications. The home health records
       contained documentation that Ms. Timmons was taking an anticoagulant.
       The appropriate intervention in this case, would be to ensure that the
       proper lab work was ordered and obtained in order to prevent
       complications from the Coumadin. The last documented INR was 4.6 on
       2/19/14. The doctor was notified and requested that the family be called
       regarding changes in Coumadin dosage. Yet, there was no follow up to
Tex. Home Health Skilled Servs., L.P. v. Anderson                                       Page 13
       determine whether this call had occurred and whether there were new
       recommendations for Coumadin dosage and PT/INR checks. This is below
       the standard of care. Ms. Timmons was seen the following day by home
       health but no labs were drawn to recheck the INR. This is below the
       standard of care. Home health visited Ms. Timmons 8 additional times with
       no INR check. This is below the standard of care. The last visit took place
       on 4/21/14. She was hospitalized on 4/25/14 with a severe subdural
       hematoma. The home health nurses knew that Ms. Timmons was taking
       Coumadin between 2/19/14 and 4/21/14—and they certainly know that
       Coumadin is an anticoagulant that can cause uncontrolled bleeding if the
       PT/INR’s are not monitored. This knowledge should have prompted them
       to communicate with Dr. Rosenquist and to request orders for PT/INR’s
       every time they came out to visit and saw that there had been non recent
       PT/INR’s drawn. Had they done this, it would have quickly been
       determined that Ms. Timmons’s PT/INR levels were higher than the
       therapeutic range and adjustments would have been made to her
       Coumadin dosage. This would have prevented the severe bleed that she
       suffered and her death would have been prevented. Unfortunately, the
       home health nursing staff did nothing and Ms. Timmons continued to take
       the Coumadin she had been prescribed. Coumadin prevents the body’s
       clotting mechanisms from working. Its dosage must be tailored to the
       PT/INR levels—which are a reflection of how impaired the body’s clotting
       mechanisms are. Ms. Timmons was receiving Coumadin for atrial
       fibrillation. The goal INR for atrial fibrillation is 2.0-3.0. The standard of
       care required the home health nurses to know this and to call Dr.
       Rosenquist when they saw that no recent PT/INR levels had been ordered
       and so that they could be drawn. Failure to do this was below the standard
       of care. Providing home health nursing care to a patient whom you know
       is taking Coumadin and for whom you know a PT/INR level has not been
       drawn once or twice per week without bringing this to the attention of the
       managing physician is below the standard of care. In this case, continuing
       to take Coumadin caused Ms. Timmons’ clotting mechanisms to become so
       impaired that she began bleeding uncontrollably which manifested in the
       very low hemoglobin level and on the CT that showed bleeding in her brain.

       Nurse Rozas also provided ample information in her expert report regarding the

standard-of-care and breach elements. Citing the Texas Administrative Code, the CMS

Conditions of Participation, and case-specific facts from Timmons’s medical files, Nurse
Tex. Home Health Skilled Servs., L.P. v. Anderson                                       Page 14
Rozas included numerous pages of information pertinent to the applicable elements. A

brief summary culled from Nurse Rozas’s report regarding the pertinent elements is as

follows:

      [Appellant] failed to comply with the CoP Standard of care for initiation of
       home health services, and completion of the comprehensive assessment for
       the start of care, which placed the patient at unnecessary risk, and was
       below the minimum standard of care required.

      [Appellant] failed to meet the standard for drug regimen review and
       reconciliation at multiple points along the care continuum, placing
       Elizabeth Timmons at an even greater risk for drug errors, inaccurate
       medication administration, and serious consequences. This is below the
       minimal standards of care required.

      [Appellant] placed Ms. Timmons at heightened risk by not demonstrating
       an accountable process for notifying MD of critical changes in patient
       status, lack of policy for following receipt, implementation, and
       communication flow for MD orders, care coordination and communication
       to staff, MD and patient/CG. The nursing notes for the agency utilize
       template style information with checklist item choices which do not reflect
       individualized care or content needed to safely communicate anticoagulant
       therapy status and monitoring. There is a lack of consistency among
       clinicians regarding how assessment questions are answered, which may
       indicate a lack of training, questionable competency, and poor
       continuity/consistency of care, all of which are significant factors in
       managing high risk individuals. There are clinician notes showing that
       patient has Class 1 heart disease, others showing no cardiac issues when
       she had multiple cardio diagnosis, including HTN, artificial valve and
       pacemaker. There are notes documenting pt. had wt. loss of 4 lbs, notes
       showing breathlessness, poor skin turgor, poor appetite, and a myriad of
       other pertinent reportable signs/symptoms, without evidence that this was
       communicated to the physician or other staff.

      [Appellant] did not provide any written proof of signed MD orders or
       process for order workflow for the agency. The patient flowsheet and
       nurses notes have orders written within, with no formal orders present in
       the chart. This demonstrates a disorganized process which would
Tex. Home Health Skilled Servs., L.P. v. Anderson                                     Page 15
       predictably potentiate a negative outcome. This was below the minimal
       standards of care and a direct violation of state regulation for the practice
       of home health.

      [Appellant] failed to demonstrate standard principles of practice regarding
       the establishment of an adequate record of patient care, and as a result, was
       not able to provide complete and accurate information related to the care of
       this patient. There are missing lab results, lack of assessment and notes to
       document care received, and poor facilitation and compilation for the
       retrieval of information. In the inadequate record received for review, the
       agency demonstrates application of record keeping that is below minimal
       standards.

      It is my opinion that during Elizabeth Timmons[‘] time on service with
       [appellant], the agency provided care that was below the minimal
       standards required by state and federal guidelines for the delivery of home
       health as outlined above. With Ms. Timmons already having a heightened
       risk and potential for critical events, the dereliction of home health
       oversight for her case could easily be viewed as predictive indicators for a
       negative outcome. The patient was a high risk from the initial point of
       contact, and the failure of the original admitting PT to identify this and
       coordinate care accordingly, the failure of the agency supervisor to do the
       same, and the demonstration of continuation of negligible case
       management and supervisory oversight, are all factors that could have
       potentially prevented this predictable outcome. There are well established
       standards of care for both home health provision and specifically for
       anticoagulant therapy management, for which this agency did not
       demonstrate compliance. Having stated this, I have outlined the evidence
       of deficient care that could have lead [sic] to the predictable outcome of
       Elizabeth Timmons’ hospitalization and death. All of my opinions are
       based upon reasonable nursing probability.

       After reviewing the four corners of Anderson’s proffered expert reports, we

conclude that the reports inform appellant of the specific conduct called into question—

appellant’s (1) failure to monitor Timmons’ consumption of Coumadin; (2) continued

dispensation of anticoagulant medication without giving required blood tests to


Tex. Home Health Skilled Servs., L.P. v. Anderson                                      Page 16
determine if the medication level was therapeutic or out of range; and (3) alleged poor

patient management, including documentation and monitoring. Therefore, based on the

foregoing, we further conclude that the trial court was justified in concluding that

Anderson’s expert reports discuss the standard-of-care and breach elements with

sufficient specificity to fulfill the two required purposes: (1) to inform appellant of the

specific conduct the plaintiff has called into question; and (2) to provide a basis for the

trial court to conclude that the claims have merit. See TEX. CIV. PRAC. & REM. CODE ANN.

§ 74.351(i), (r)(6); see also Wright, 79 S.W.3d at 52; Palacios, 46 S.W.3d at 879.

C.     Appellant’s expert reports are inadequate with respect to the causation element

       In her brief, Anderson contends that:

       The cause of action against the Defendant is that the negligence ascribed to
       the Defendant in Plaintiff’s Original Petition was a proximate cause of the
       demise of Ms. Timmons. This negligence is simply that this Defendant
       continued to give Ms. Timmons Coumadin without taking any steps to
       determine if she had received the required blood testes [sic] (PT/INR) to
       determine if the Coumadin level was therapeutic or out of range. As a
       result, she became Coumadin toxic and developed substantial bleeding in
       her brain which required hospitalization.           During this required
       hospitalization, she developed other complications such as pressure ulcers
       and dehydration which resulted in her death.

And as noted above, in her live pleading, Anderson stated:

       While at Huntsville Memorial Hospital, Ms. Timmons continued to receive
       inadequate care for her skin breakdown and nutritional status and needs,
       including the severe dehydration. As a result, Ms. Timmons suffered
       kidney failure, was unable to swallow or talk, and her tongue turned black
       with sores. The combination of a dehydration and prolonged lack of eating
       caused kidney failure and a progressive decline in Ms. Timmons’ condition


Tex. Home Health Skilled Servs., L.P. v. Anderson                                     Page 17
       from which Ms. Timmons was unable to recover, resulting in her death June
       7, 2014.

       However, in his initial expert report, Dr. Warshawsky noted the following:

       Ms. Timmons was taking Coumadin, a prescribed medication used as an
       anticoagulant. This drug requires consistent monitoring due to the narrow
       target range required to prevent complications. If appropriate assessment,
       prevention and interventions had taken place by Dr. Rosenquist and the
       home health nurses, it is my opinion that Ms. Timmons would not have
       suffered massive bleeding in the form of a subdural hematoma which
       required hospitalizations and ultimately led to her death.

               ....

       In this case, the pressure ulcers that were permitted to form on Ms.
       Timmons was a proximate cause of her declining physical condition and
       which made her unable to take in adequate fluid and food to sustain life as
       well as increasing her susceptibility to the effects of dehydration which led
       to her death.

               ....

       Had appropriate assessment, reporting, and treatment been undertaken to
       address the potential for dehydration, it is my opinion that Ms. Timmons
       would not have become dehydrated to the point that she suffered from the
       above mentioned critical conditions, and required transfer to the hospital
       for critical care. Dehydration was the immediate cause of her death.

               ....

       With reasonable medical probability, the failure of the nursing staff at
       [appellant] to abide by the accepted standards of care as I have described it
       within this report caused Ms. Timmons to suffer a coagulopathy which
       caused significant anemia and an acute subdural hematoma necessitating a
       prolonged hospitalization during which her physical condition declined
       and she developed multiple pressure ulcers, severe dehydration, and died.
       Thus, the negligence of [appellant] was the proximate cause of significant
       pain and suffering to Ms. Timmons’ [sic] and eventually her death.


Tex. Home Health Skilled Servs., L.P. v. Anderson                                      Page 18
(Emphasis added).

       In his supplemental expert report, Dr. Warshawsky further opined:

       The breaches in the standards of care set out above, in my original report,
       and in Nurse Rozas’ reports are linked to avoidable injuries to Mrs.
       Timmons. Based on reasonable medical probability[,] the failure of
       [appellant] to provide acceptable home health care was a proximate cause
       of injuries and damages to Mrs. Timmons. Had appropriate documentation
       been kept, and follow up and coordination of care been performed[,] Mrs.
       Timmons would have most probably received appropriate anticoagulant
       therapy. Lapses in recordation of INR I.E., between 2/19/14 and 4/27/19 [sic]
       caused no action to be taken to assess and control INR readings.
       Anticoagulants such as that Mrs. Timmons was taking are high-risk drugs
       that require regular and constant monitoring. Higher than normal ratios
       are well understood to cause or contribute to uncontrolled bleed while
       lower than acceptable rations [sic] are understood to allow clotting and
       development of emboli. Either of these situations is dangerous and
       potentially fatal. In reasonable medical probability[,] the breaches listed
       contributed to the development of the large acute right cerebral subdural
       hematoma that ultimately contributed to Mrs. Timmons[‘] death. In this
       case, continuing to be provided powerful anticoagulants without the
       monitoring and communication that [appellant] was charged with
       providing caused Ms. Timmons’ clotting mechanisms to become so
       impaired that she began bleeding uncontrollably. This uncontrolled
       bleeding then manifested in the very low hemoglobin level and on the CT
       that showed bleeding in her brain. For a more in-depth analysis of this
       situation[,] see my original report. In summary, based on reasonable
       medical probability, had [appellant] provided appropriate care
       information, appropriate testing, and monitoring would have been
       performed. If such had been done[,] this information would have been
       passed on to physicians and the physicians would have modified the
       anticoagulant therapy to obtained [sic] therapeutic INR reading. Had these
       events occurred, in reasonable medical probability, the severe brain bleed
       Mrs. Timmons suffered from and that ultimately contributed to her death
       would not have occurred. My review of the medical records confirms that
       there are no other medically reasonable explanations for the unfortunate
       outcome that befell Mrs. Timmons.

       With regard to causation, the Texas Supreme Court has stated:
Tex. Home Health Skilled Servs., L.P. v. Anderson                                      Page 19
       An expert cannot simply opine that the breach caused the injury. Stated so
       briefly, the report fails the second Palacios element—it does not give the trial
       court any reasonable basis for concluding that the lawsuit has merit. . . . An
       expert’s conclusion that “in medical probability” one event caused another
       differs little, without an explanation tying the conclusion to the facts, from
       an ipse dixit, which we have consistently criticized. . . . Instead, the expert
       must go further and explain, to a reasonable degree, how and why the
       breach caused the injury based on the facts presented. While we have said
       that no “magical words” need be used to meet the good-faith requirement,
       mere invocation of the phrase “medical probability” is likewise no
       guarantee that the report will be found adequate.

Jelinek, 328 S.W.3d at 539-40 (internal citations omitted & emphasis in original); see Van

Ness v. ETMC First Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (“An expert must explain,

based on facts set out in the report, how and why the breach caused the injury.” (emphasis

in original)).

       In this case, Anderson alleged that appellant’s nurses failed to monitor Timmons’

consumption of Coumadin and, instead, kept giving her the medication without giving

required blood tests to determine if the medication level was therapeutic or out of range.

See Regent Health Care Ctr. of El Paso, L.P. v. Wallace, 371 S.W.3d 434, 441 (Tex. App.—El

Paso 2008, no pet.) (“Mere reference to general concepts regarding assessment,

monitoring, and interventions are insufficient are a matter of law.” (citing Palacios, 46

S.W.3d at 873)). This alleged negligence led to Timmons sustaining a subdural hematoma

and being hospitalized at different health-care facilities, including Huntsville Memorial

Hospital, West Houston Medical Center, and Huntsville Healthcare Center, where she

purportedly received inadequate treatment that resulted in kidney failure and
Tex. Home Health Skilled Servs., L.P. v. Anderson                                         Page 20
dehydration. See, e.g., Mendez-Martinez v. Carmona, No. 08-15-00265-CV, 2016 Tex. App.

LEXIS 4243, at *21 (Tex. App.—El Paso Apr. 22, 2016, no pet.) (“A break in the logical

chain between the negligent act and the injury renders the causation conclusions in a

report insufficient.” (citing Wallace, 271 S.W.3d at 441; Clark v. HCA, Inc., 210 S.W.3d 1, 11

(Tex. App.—El Paso 2005, no pet.))). Anderson seems to suggest that appellant’s actions

launched a series of events that eventually contributed to Timmons’ death. See, e.g.,

Granbury Hosp. Corp. v. Hosack, No. 10-09-00297-CV, 2010 Tex. App. LEXIS 3132, at **5-7

(Tex. App.—Waco Apr. 28, 2010, no pet.) (mem. op.) (concluding that an expert report

was insufficient as to causation when the health-care provider’s actions “launch[ed] a

series of events that eventually contributed to her death.”).2

       A review of Dr. Warshawsky’s expert reports reveals that dehydration was the

cause of Timmons’ death; however, he failed to explain how Timmons’ subdural

hematoma was a substantial factor in her death from dehydration. Because Anderson’s

expert reports fail to connect the occurrence of the subdural hematoma to Timmons’




       2   Specifically, in Granbury Hospital Corporation v. Hosack, we determined the following:

       In his report, Rushing concludes that LGMC’s conduct violated the standard of care by
       allowing Hall to remain on the bedpan for too long, resulting in the development of
       pressure ulcers, which released infection and toxins into Hall’s system, and launching a
       series of events that eventually contributed to her death. However, his report indicates
       that Hall died of cardiorespiratory arrest. Rushing does not explain how Hall’s
       development of pressure ulcers resulted in her cardiorespiratory arrest. Because Rushing’s
       report fails to connect the occurrence of pressure ulcers to Hall’s death, his report is
       insufficient on the element of causation. . . .

No. 10-09-00297-CV, 2010 Tex. App. LEXIS 3132, at *6 (Tex. App.—Waco Apr. 28, 2010, no pet.) (mem. op.).

Tex. Home Health Skilled Servs., L.P. v. Anderson                                                   Page 21
death, we conclude that Anderson’s expert reports are insufficient on the element of

causation. See id.; Wallace, 371 S.W.3d at 441 (“[W]hile the report indicates that the breach

of the standard of care resulted in worsening of the described skin conditions, there is no

linkage to the cause of death, aside from the assertion of a close temporal proximity

between the conditions and the premature death.”); see also Nexion Health at Southwood,

Inc. v. Judalet, No. 12-08-00464-CV, 2009 Tex. App. LEXIS 7404, at *11 (Tex. App.—Tyler

Sept. 23, 2009, no pet.) (mem. op.) (concluding that an expert report was deficient on

causation because the expert “failed to explain the causal relationship between the

decedent’s leg fracture and her death;” i.e., “how a fractured leg caused her to experience

congestive heart failure”). Accordingly, we sustain appellant’s sole issue. See Tenet

Hosps., Ltd. v. Barnes, 329 S.W.3d 537, 543 (Tex. App.—El Paso 2010, no pet.) (“There can

be no analytical gap between a breach of the standard of care and the ultimate harm.”

(citing Clark, 210 S.W.3d at 11)); Austin Heart, P.A. v. Webb, 228 S.W.3d 276, 279 (Tex.

App.—Austin 2007, no pet.) (noting that courts are precluded “from filling gaps in a

report by drawing inferences”).

       However, if an adequate expert report has not been served within the period

specified by statute because elements of the report are found deficient, the court may

grant one thirty-day extension to the claimant to cure the deficiency. See TEX. CIV. PRAC.

& REM. CODE ANN. § 74.351(c). Where a report is not “so deficient as to constitute no

report at all,” a plaintiff is entitled to remand of the case to the trial court to consider


Tex. Home Health Skilled Servs., L.P. v. Anderson                                     Page 22
granting an extension to cure. See Gardner v. U.S. Imaging, Inc., 274 S.W.3d 669, 670-71

(Tex. 2008) (citing Ogletree v. Matthews, 262 S.W.3d 316, 323 (Tex. 2007) (Willett, J.,

concurring); Lewis v. Funderburk, 253 S.W.3d 204, 211 (Tex. 2008) (Willett, J., concurring)).

       In the instant case, we cannot say that Anderson’s expert reports are “so deficient

as to constitute no report at all.” See Gardner, 274 S.W.3d at 670; see also Leland v. Brandal,

257 S.W.3d 204, 207-08 (Tex. 2008). Nevertheless, Anderson’s expert reports are deficient

with respect to the element of causation. And under these circumstances, Anderson is

entitled to remand. See Gardner, 274 S.W.3d at 670; see also Leland, 257 S.W.3d at 207-08;

Wallace, 271 S.W.3d at 441; see also Judalet, 2009 Tex. App. LEXIS 7404, at *14.

                                         V.         CONCLUSION

       In summary, we sustain appellant’s sole issue on appeal, reverse the trial court’s

order denying appellant’s motion to dismiss, and remand this cause for consideration of

whether the deficiency in Anderson’s expert reports can be cured, and thus, whether to

grant an extension of time. See Samlowski v. Wooten, 332 S.W.3d 404, 411-13 (Tex. 2011)

(noting that the trial court is in the best position to decide whether a cure is feasible).




                                                       AL SCOGGINS
                                                       Justice




Tex. Home Health Skilled Servs., L.P. v. Anderson                                       Page 23
Before Chief Justice Gray,
       Justice Davis, and
       Justice Scoggins
Reversed and remanded
Opinion delivered and filed October 19, 2016
[CV06]




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