Opinion issued July 25, 2013




                                     In The

                               Court of Appeals
                                    For The

                        First District of Texas
                         ————————————
                               NO. 01-12-00658-CV
                            ———————————
SELECT SPECIALTY HOSPITAL-HOUSTON LIMITED PARTNERSHIP
 D/B/A SELECT SPECIALTY HOSPITAL HOUSTON WEST, Appellant
                                       V.
           KEITH SIMMONS AND KIRK SIMMONS, Appellees



                  On Appeal from the 125th District Court
                           Harris County, Texas
                     Trial Court Case No. 2012-02433



                       MEMORANDUM OPINION

     This is an interlocutory appeal from the denial of appellant’s motion to

dismiss appellees’ claims under Chapter 74 of the Texas Civil Practice and

Remedies Code. We affirm.
                                   BACKGROUND

       Plaintiffs/appellees Keith Simmons and Kirk Simmons (Plaintiffs) are the

children of Willie Lee Simmons (Simmons), who is now deceased. Plaintiffs sued

defendant/appellant Select Specialty Hospital-Houston Limited Partnership d/b/a

Select Specialty Hospital Houston West (Select Specialty) complaining of its

nurses’ medical care of Simmons before his death. Plaintiffs served two medical

expert reports, one by Cheryall Sparks, RN and one by Sheila Chachere, MD.

Select Specialty filed objections to the reports and a motion to dismiss. The trial

court denied the motion, and Select Specialty filed this interlocutory appeal.

    A. Plaintiffs’ Allegations

       The following facts are taken from Sparks’s and Chachere’s expert reports.1

Simmons, a 69-year-old man, was transferred from Memorial Hermann City

Medical Center to Select Specialty on July 15, 2011. Select Specialty’s admission

database reflected a diagnosis of “Respiratory Failure, Deconditioning, Pulmonary

Fibrosis, SOB, ARDS, and Malnutrition.” According to the Nurse Progress Notes,

Simmons “arrived alert, on a ventilator, and with a trachcostomy, IV, foley, and

feeding tube.”


1
       Throughout its brief, Select Specialty challenges the accuracy of the statements in
       Sparks’s and Chachere’s reports. For purposes of our review of the adequacy of a
       medical expert report under Chapter 74, however, we take the allegations in the
       report as true. Marino v. Wilkins, 393 S.W.3d 318, 320 n.1 (Tex. App.—Houston
       [1st Dist.] 2012, pet. denied).
                                            2
      Sparks’s report states that, when Simmons arrived at Select Specialty, there

was “no documentation of any skin breakdowns, wounds, redness, or discoloration

anywhere on his body.” Select Hospital’s records reflect that Simmons was rated

as a high risk for bedsores. On August 12, 2011, he was found unresponsive by a

nurse. On September 15, 2011, and again on September 19, 2011, he experienced

a low heart rate and blood pressure. He died later on September 19, 2011.

      Sparks’s report contains the following synopsis of the nurses’ documentation

of treatment of Simmons’s bed sores:

      On July 16, 2011, one day after Mr. Simmons’ admission to Select
      Specialty, the nurses first documented that Mr. Simmons had a Stage
      II wound on his sacrum. A Stage II wound is a wound that shows
      openings in the skin. Stage II wounds are characterized by the partial
      loss of the 1st and 2nd layers of skin. Stage II wounds are shallow
      with a red or pink ulcer bed. On July 17, 2011, the nurses also
      reported that Mr. Simmons had left and right buttock skin wounds
      with light drainage and no odor. As a result, the nurses reported that
      Mr. Simmons’ dressing was to be changed daily per orders. On July
      17, 2011 the nurses applied a santyl dressing to Mr. Simmons’ left and
      right buttock skin wounds. A santyl dressing is a collagenase enzyme
      used to help heal burns and skin ulcers, which are skin wounds. In
      normal practice, santyl is applied daily.

      On July 23 and 24, 2011, Mr. Simmons was not repositioned every 2
      hours. In addition, the nurses did not document dressing changes for
      July 24, 2011. On August 1, 2011, the nurses documented that Mr.
      Simmons developed an inner gluteal fold skin wound. On August 2,
      2011, the nurses applied a hydrocolloid dressing to Mr. Simmons’
      inner gluteal fold skin wound. A hydrocolloid dressing is an adhesive
      wafer applied to skin ulcers, which can be changed every 3-5 days.

      On August 3, 7, and 9, 2011, the nurses did not reposition Mr.
      Simmons every 2 hours and documented no dressing changes. On

                                        3
      August 6, 2011, Mr. Simmons developed a Stage II inner thigh skin
      wound. No dressing changes were documented at the report of this
      Stage II wound. On August 10, 2011, the nurses reported that Mr.
      Simmons was incontinent of urine. Incontinent of urine means that
      Mr. Simmons was incapable of controlling his urinary functions. On
      August 20, 2011, the nurses reported that Mr. Simmons was
      incontinent of feces. Incontinent of feces means that Mr. Simmons
      was incapable of controlling his bowel functions. From then, there
      are documentations stating that the nurses dressed Mr. Simmons’ skin
      wounds, including his pressure ulcers, occasionally. As the days
      progressed, Mr. Simmons’ skin wounds, including his pressure ulcers,
      became multiple in numbers.

      Sparks’s report alleges that Select Specialty’s nurses breached the applicable

standard of care in several respects related to the prevention and treatment of

bedsores. Specifically, they (1) failed to treat Mr. Simmons’s skin wounds with

santyl dressing on a daily basis between July 15, 2011 and August 1, 2011 (despite

doctor’s orders to do so and despite daily changing santyl dressings being the

“normal practices”), (2) failed to correctly administer hydrocolloid dressings

between August 1, 2011 and September 19, 2011, and (3) failed to correctly

reposition Mr. Simmons to address his development of bed sores.

      Chachere’s report was based upon a review of Sparks’s report, and opined

that Select Specialty’s breaches of the standard of care caused Simmons’s

bedsores.

      B.    Select Specialty’s Motion to Dismiss

      Select Specialty filed a motion to dismiss, asserting that Sparks and

Chachere were not qualified to render their opinions, and that their reports were

                                         4
otherwise deficient.    The trial court denied Select Specialty’s motion, and it

brought this appeal.

                               ISSUES ON APPEAL

      Select Specialty brings two issues on appeal:

      1.     “[T]he trial court abused its discretion when it overruled
             Appellant’s Objections and denied Appellant’s Motion to
             Dismiss because Cheryall Y. Sparks, R.N. and Sheila L.
             Chachere, M.D. are not qualified to address issues of standard
             of care, breach and causation as to Select Specialty.”
      2.     “[T]he trial court abused its discretion when it overruled
             Appellant’s Objections and denied Appellant’s Motion to
             Dismiss because the expert reports of Cheryall Y. Sparks, R.N.
             and Sheila L. Chachere, M.D. do not adequately address the
             issues of standard of care, breach and causation as to Select
             Specialty Hospital.”

                               APPLICABLE LAW

A.    Standard of Review

      We review a trial court’s ruling on a motion to dismiss for lack of an

adequate medical report for an abuse of discretion.        Larson v. Downing, 197

S.W.3d 303, 304–05 (Tex. 2006) (citing Broders v. Heise, 924 S.W.2d 148, 151

(Tex. 1996)); Strom v. Mem’l Hermann Hosp. Sys., 110 S.W.3d 216, 220 (Tex.

App.—Houston [1st Dist.] 2003, pet. denied). A trial court abuses its discretion if

it acts arbitrarily, unreasonably, or without reference to guiding rules or principles.

See Lookshin v. Feldman, 127 S.W.3d 100, 103 (Tex. App.—Houston [1st Dist.]



                                          5
2003, pet. denied). We do not disturb the trial court’s discretion absent clear

abuse. Larson, 197 S.W.3d at 304 (citing Broders, 924 S.W.2d at 151).

      B.    Chapter 74 Expert Report Requirements

      Section 74.351 serves as a ‘gate-keeper’ through which no medical

negligence causes of action may proceed until the claimant has made a good-faith

effort to demonstrate that at least one expert believes that a breach of the

applicable standard of care caused the claimed injury. See TEX CIV. PRAC. & REM.

CODE ANN. § 74.351 (Vernon 2011); Murphy v. Russell, 167 S.W.3d 835, 838

(Tex. 2005). A report need not marshal all of the plaintiff’s proof, but it must

include the expert’s opinions on the three statutory elements: standard of care,

breach, and causation. See Am. Transitional Care Ctrs. Of Tex. Inc. v. Palacios,

46 S.W.3d 873, 878, 880 (Tex. 2001); Spitzer v. Berry, 247 S.W.3d 747, 750 (Tex.

App.—Tyler 2008, pet. denied) (quoting Palacios, 46 S.W.3d at 880) (stating “fair

summary” is “something less than a full statement” of applicable standard of care,

how it was breached, and how that breach caused injury).

      To constitute a good faith effort, the report must provide enough information

to fulfill two purposes: (1) inform the defendant of the specific conduct that the

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

conclude that the claims have merit. Palacios, 46 S.W.3d at 879. A report that

merely states the expert’s conclusions as to the standard of care, breach, and

                                        6
causation does not fulfill these two purposes. Id. The expert must explain the basis

for his statements and link his conclusions to the facts. Bowie Mem’l Hosp. v.

Wright, 79 S.W.3d 48, 52 (Tex. 2002) (citing Earle v. Ratliff, 998 S.W.2d 882, 890

(Tex. 1999)). The trial court may not draw any inferences, but must rely

exclusively on the information contained within the report’s four corners. See

Palacios, 46 S.W.3d at 878.

      In addition to setting forth the requisite criteria, a Chapter 74 report must be

authored by a qualified “expert.” TEX. CIV. PRAC. & REM. CODE ANN. §

74.351(r)(6). The standards governing qualifications of an expert report in support

of a claim against a non-physician defendant are set forth in section 74.402.

      § 74.402. Qualifications of Expert Witness in Suit Against Health
      Care Provider

             (a)   For purposes of this section, “practicing health care” includes:

             (1) training health care providers in the same field as the
             defendant health care provider at an accredited educational
             institution; or

             (2) serving as a consulting health care provider and being
             licensed, certified, or registered in the same field as the
             defendant health care provider.
             (b) In a suit involving a health care liability claim against a health
      care provider, a person may qualify as an expert witness on the issue of
      whether the health care provider departed from accepted standards of care
      only if the person:

             (1) is practicing health care in a field of practice that
             involves the same type of care or treatment as that delivered by
             the defendant health care provider, if the defendant health care
                                          7
             provider is an individual, at the time the testimony is given or
             was practicing that type of health care at the time the claim
             arose;

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

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

             (c) In determining whether a witness is qualified on the basis of
      training or experience, the court shall consider whether, at the time the claim
      arose or at the time the testimony is given, the witness:

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

TEX. CIV. PRAC. & REM. CODE ANN. § 74.402.

                                QUALIFICATIONS

      In its first issue, Select Specialty argues that “neither Nurse Sparks nor Dr.

Chachere are qualified to render opinions against Select Specialty.” According to

Select Specialty, Simmons’s “grave medical conditions” upon his admittance to

Select Specialty, “are significant in determining whether Nurse Sparks, an

obstetrics nurse, and/or Dr. Chachere, a pediatrician, are qualified to offer expert

opinions as to this patient and the care this patient received at Select Specialty.”



                                           8
      As for Nurse Sparks, Select Specialty contends that she is not qualified

because, while she has extensive employment history in the field of obstetrics,

“nothing in her report or her curriculum vitae demonstrate that she has ever worked

at a long-term acute care facility such as Select Specialty or that she has ever cared

for elderly patients suffering from the significant pulmonary and cardiac conditions

Mr. Simmons suffered from at the time he presented to Select Specialty.”

Moreover, “nothing in Nurse Sparks’ report or curriculum vitae evidence any

experience whatsoever in treating patients with a tracheotomy or ventilator

dependence, such as Mr. Simmons, in a long term acute care facility such as Select

Specialty.”

      Similarly, with regard to Dr. Chachere—a board certified pediatrician—

Select Specialty contends that “a review of her expert report and her curriculum

vitae fail to demonstrate her qualifications to offer opinions in this case.” Select

Specialty acknowledges that Chachere has experience treating chronically ill

children, but argues that is not comparable to treatment of a chronically ill elderly

person.

      A.      Plaintiffs’ claims

      Plaintiffs’ petition alleges Select Specialty’s nurses were negligent in the

following specific respects related to the prevention and treatment of bedsores:

             a.     Failing to treat Mr, Simmons’ condition properly;
      specifically: (i) failing to treat Mr. Simmons’ skin wounds, including
                                          9
         his pressure ulcers, with santyl dressing once per day between July 15,
         2011 and August 1, 2011; (ii) failing to treat Mr. Simmons’ skin
         wounds, including his pressure ulcers, with hydrocolloid dressing
         every 3-5 days between August 1, 2011 and September 19, 2011; and
         (iii) failing to reposition Mr. Simmons every two (2) hours to alleviate
         his pressure ulcers.
                b.     Failing to provide the medical and nursing care
         reasonably required for Mr. Simmons’ condition; specifically: (i)
         failing to treat Mr. Simmons’ skin wounds, including his pressure
         ulcers, with santyl dressing once per day between July 15, 2011 and
         August 1, 2011; (ii) failing to treat Mr. Simmons’ skin wounds,
         including his pressure ulcers, with hydrocolloid dressing every 3-5
         days between August 1, 2011 and September 19, 2011; and (iii)
         failing to reposition Mr. Simmons every two (2) hours to alleviate his
         pressure ulcers.
               ....
               f.      Leaving Mr. Simmons unattended for up to ten (10)
         hours at a time; and
                g.    Failing to monitor Mr. Simmons’ pressure ulcers for up
         to ten (10) hours at a time.

         B.    Nurse Sparks’s Qualifications

         Sparks’s curriculum vitae reflects that she is a nurse who currently practices

and teaches in the field of obstetrics, and that she currently works as a nurse

consultant. She has also worked as nurse manager in the field of oncology, as well

as held positions as a labor-and-delivery nurse, recovery-room nurse, clinical

nurse, cardio-vascular intermediate-care nurse, urology nurse, and medical-surgery

nurse.




                                           10
      Her report states that she “is currently a registered nurse in the State of

Texas with over 30 years of experience,” and describes her qualifications as

follows:

      My nursing experience includes caring for cardiovascular, internal
      medicine, surgical, urology, obstetrical, oncology and radiology
      patients. During my nursing practice, I cared for many elderly
      patients and prevented, dressed, and treated skin wounds including
      pressure ulcers. . . .
      I also managed a nursing staff at Jefferson Davis Hospital and at M.D.
      Anderson Hospital. In that capacity, I was involved in writing patient
      policies and procedures for nurses. I also served on the Peer Review
      Committee at Kelsey Seybold Clinic for two years. While serving on
      the committee, I determined whether nurses fell below the standard of
      care for nurses.
      I currently consult practicing registered nurses on many subjects,
      including how to prevent, treat, and dress patient skin wounds,
      including pressure ulcers, which are the same skin wounds
      complained of by Mr. Willie Lee Simmons. Based upon my
      knowledge, skill, experience, training, and education, I am familiar
      with the applicable standard of care required for nurses to prevent,
      treat, and dress skin wounds, including pressure ulcers.
      Finally, her report states that it is applicable to actions “taken or not taken by

Select Specialty, by and through its registered nurses . . . . during Mr. Simmons’

stay at the hospital.”

      The trial court did not abuse its discretion in concluding that Sparks was

qualified to opine as to whether the Select Specialty’s nurses departed from the

accepted standards of care in preventing and treating pressure ulcers. Sparks’s

curriculum vitae and report reflect that she is currently practicing as a registered


                                          11
nurse, and currently consults with practicing nurses on the prevention and

treatment of pressure ulcers like those suffered by Simmons. TEX. CIV. PRAC. &

REM. CODE Ann. § 74.402(b)(1), (a)(2).2 Her report details her knowledge of the

accepted standards of care and experience in treating both the complained of

condition—i.e., pressure ulcers—and specifically treating them in elderly patients.

      While Select Specialty correctly points out that Sparks does not profess to

have experience caring for “ventilator dependent patients with co-morbidities of

respiratory failure, deconditioning, pulmonary fibrosis, shortness of breath, acute

respiratory distress syndrome and malnutrition at a long term acute care facility,”

section 74.402 of the Texas Civil Practice and Remedies Code does not require

such specific experience to qualify Sparks as an expert in the prevention and

treatment of pressure ulcers—the subject of Plaintiffs’ claims. See, e.g., Mem’l

Hermann Healthcare Sys. v. Burrell, 230 S.W.3d 755, 759 (Tex. App.—Houston

[14th Dist.] 2007, no pet.) (holding physician qualified to opine about standard of

care for preventing bedsores based on report stating, “I am familiar with the
2
      Select Specialty contends that Sparks is not “practicing health care in a field of
      practice that involves the same type of care or treatment as that delivered by the
      defendant health care provider,” as required by section 74.702(b). That argument,
      however, does not take into account section 74.702(a), which provides “practicing
      health care includes . . . serving as a consulting health care provider and being
      licensed, certified, or registered in the same field as the defendant health care
      provider.” Nurse Sparks’ curriculum vitae reflects that she is a licensed, registered
      nurse, and that she currently works as a nurse consultant. Her report states that
      she currently “consult[s] practicing registered nurses on many subjects, including
      how to prevent, treat, and dress patient skin wounds, including pressure ulcers,
      which are the same skin wounds complained of by Mr. Willie Lee Simmons.”
                                           12
standard of care as it pertains to prevention and treatment of decubitus ulcers. I

have experience in instructing nurses and other personnel in the proper techniques

to prevent decubitus ulcers and I have treated patients with decubitus ulcers over

the course of my practice as an infectious disease internist and occupational

doctor.”); Esquivel v. El Paso Healthcare Sys. Ltd, 225 S.W.3d 83, 89–90 (Tex.

App.—El Paso 2005, no pet.) (holding that professor of nursing, who also “served

in various capacities at a 450-bed hospital, including assistant administrator for

nursing services, acting director, director of nursing services, director of staff

education, and nursing supervisor,” whose report states that she was “familiar with

the standard of care for skin care and prevention of decubitus ulcers as well as

documentation, observation, assessment ,and intervention required,” was qualified

as expert as to the standard of care and breach, but not causation).

      C. Dr. Chachere’s Qualifications

      Chachere’s curriculum vitae reflects that she currently works in the field of

pediatrics, caring for “well and chronically ill children and adolescents.” She has

practiced and taught in the field of pediatrics in several capacities for different

employers. Her report elaborates about how her current practice and experience

relates to Select Specialty’s treatment of Simmons:

      My medical knowledge, skill, experience, training, and education
      includes, but is not limited to, caring for and teaching medical
      students how to care for hundreds of children with chronic healthcare
      needs. For example, many of my chronically ill patients included
                                          13
      children with spina bifida, which means that the patient’s spine failed
      to form correctly. Due to spina bifida, the children were highly
      immobile and incontinent of feces and urine. Incontinence of feces
      means that the children were incapable of controlling their bowel
      functions similar to Mr. Willie Lee Simmons’ condition during his
      treatment by [Select Specialty] nurses. Many of my hospice patients
      exhibited identical conditions.
      Due to my patients’ medical conditions, I have to prevent, treat, and
      dress their skin wounds, including pressure ulcers. I also had to teach
      my students how to perform the same acts. Pressure ulcers, also
      known as decubitus ulcers, are open wounds that form whenever
      prolonged pressure is applied to skin covering bony outcrops of the
      body. Patients who are bedridden like many of my patients and Mr.
      Simmons are at high risk of developing pressure ulcers . . . .
      Even though Mr. Simmons was a 69 year old elderly man, his injuries,
      namely skin wounds, including pressure ulcers, are common to and
      equally developed in the field of pediatrics. I also have practical
      knowledge of what is usually and customarily done by nurses
      confronted with a patient suffering from skin wounds, including
      pressure ulcers. As a professor at Baylor College of Medicine, I had
      to train nurses on how to prevent, treat, and dress patient skin wounds,
      including pressure ulcers, during nursing in-service.
      Patients exhibiting a high risk to pressure ulcers include those who are
      obese, elderly; or suffering from chronic diseases, infections, injuries;
      or in a poor nutritional state. Many of my pediatric patients were
      chronically ill, which put them at a high risk for pressure ulcers
      similar to how Mr. Simmons was at a high risk for pressure ulcers
      because he was an elderly, chronically ill man. In addition, I have
      read medical literature, and reviewed case studies on what causes skin
      wounds, including skin ulcers, in both young and elderly patients.
      I currently monitor and prevent skin wounds, including pressure
      ulcers, from developing on my patients with spina bifida and other
      chronic illnesses as a private practitioner at Porter Pediatrics and did
      so during the time that Select Specialty’s nurses treated Mr. Simmons.

      The trial court did not abuse its discretion in concluding that Chachere is

qualified to render an opinion as to causation. Select Specialty argues that she

                                         14
Chachere is not qualified because “[n]either her expert report nor her curriculum

vitae demonstrate any experience or training whatsoever in the field of geriatrics or

in caring for chronically ill elderly patients who are ventilator dependent with the

same multiple co-morbidities Mr. Simmons had at the time he was a patient at

Select Specialty.” But her report explains that the causes and treatment of pressure

ulcers in an elderly patient like Simmons are similar to the causes and treatment of

chronically ill pediatric patients that she currently treats.3 Thus, she “is practicing

health care in a field of practice that involves the same type of care or treatment”

as Select Specialty’s nurses. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.402

(b)(1). Her report demonstrates that she has knowledge of the acceptable standards

of care for the diagnosis, care, and treatment of pressure ulcers, and that she is

qualified on through experience to offer an expert opinion. TEX. CIV. PRAC. &

REM. CODE ANN. § 74.402(b)(2)–(3).

      Moreover physicians with qualifications similar to Chachere’s have

consistently been held qualified as experts to opine on the standard of care, breach,

and causation related to the prevention and treatment of pressure ulcers. For


3
      Her report specifically states that Simmons’s injuries, namely “skin wounds,
      including pressure ulcers, are common to and equally developed in the field of
      pediatrics.” See Newman v. Graham, 316 S.W.3d 197, 200–201 (Tex. App.—
      Dallas 2010, no pet.) (“A medical expert with a different specialty than the
      defendant physician may testify ‘so long as the subject of the inquiry is common
      to and equally recognized and developed in both fields” (quoting Broders, 924
      S.W.2d at 152)).
                                          15
example, in San Jacinto Methodist Hosp. v. Bennett, the Fourteenth Court of

Appeals summarized the expert physician’s qualifications as follows, and affirmed

the trial court’s determination that the expert was qualified:

      In his report, Dr. Hammond stated he was practicing medicine at all
      times relevant to the claims made in the case and was actively
      practicing at the time of his opinion. He is board certified in internal
      medicine and had been board certified in nephrology from 1996 to
      2006, i.e., a period overlapping the time Taylor’s injury allegedly
      occurred. Dr. Hammond stated that the two certifications “directly
      address the subject matter of this claim, as the claim relates to
      management of decubitus ulcers.” Dr. Hammond indicated, because
      he had either trained, served as a consultant to, or observed health care
      providers in the same fields as the defendants, he has knowledge of
      the accepted standards of medical care for the diagnosis, care, and
      treatment related to the prevention and management of decubitus
      ulcers. He further stated he is “familiar with the standard of care for
      both nurses and physicians for the prevention and treatment of
      decubitus ulcers.” Finally, Dr. Hammond explained, “I give direct
      care to patients with decubitus ulcers and was doing so at all times
      relevant to this case. As such, I am also familiar with the
      consequences of improper management of decubitus ulcers that is not
      within the standard of care.”

256 S.W.3d 806, 813 (Tex. App.—Houston [14th Dist.] 2008, no pet.). In holding

the physician’s report sufficiently established his qualifications, the Bennett court

noted that his statement “compares favorably to that held sufficient in Burrell”:

      I completed a fellowship in infectious disease and have practiced for
      over 25 years in infectious disease. I am a frequent speaker at various
      regional and national medical conferences and have been a consultant
      for the Massachusetts Department of Health. I have reviewed various
      medical records concerning Katie Whitfield and I am familiar with the
      standard of care as it pertains to prevention and treatment of decubitus
      ulcers. I have experience in instructing nurses and other personnel in
      the proper techniques to prevent decubitus ulcers and I have treated

                                          16
         patients with decubitus ulcers over the course of my practice as an
         infectious disease, internist and occupational doctor.

Id. (quoting Burrell, 230 S.W.3d at 759).

         Similar to the experts in Bennett and Burrell, Chachere states that she has

treated patients with pressure ulcers, and instructed students how to prevent, treat,

and dress pressure ulcers. She has read medical literature, and reviewed case

studies on what causes skin wounds, including skin ulcers, in both young and

elderly patients. At the time of Simmons’s care, part of Chachere’s practice was to

monitor and prevent pressure ulcers from developing on patients suffering from

chronic illnesses. Finally, she explains how her knowledge and experience related

to pressure ulcers are applicable to patients like Mr. Simmons.

         Because we conclude that the trial court did not abuse its discretion in

concluding that Sparks and Chachere were qualified, we overrule appellants’ first

issue.

                                     REPORTS

          In its second issue, Select Specialty contends that the “expert reports of

Nurse Sparks and Dr. Chachere are insufficient on the elements of standard of care,

breach and causation as to Select Specialty.” Specifically, it argues that “neither

Nurse Sparks nor Dr. Chachere are qualified by education, training or experience

to offer opinions on the standard of care, breach or causation as to Select

Specialty.”

                                          17
      With regard to Sparks’s report, Select Specialty relies primarily on American

Transitional Care Centers of Texas v. Palacios, 46 S.W.3d 873, 880 (Tex. 2001) to

argue that her articulation of the standard of care and breach is insufficient. In

Palacios, the supreme court held that a single statement in an expert report “that

precautions to prevent [plaintiff’s] fall were not properly utilized” was not a

sufficient statement of the standard of care applicable to the defendant hospital. Id.

at 879–80. The court explained that “the standard of care for a hospital is what an

ordinary prudent hospital would do under the same or similar circumstances,” and

that “[w]hether a defendant breached his or her duty to a patient cannot be

determined absent specific information about what the defendant should have done

differently.” Id. at 880. According to Select Specialty, Nurse Sparks’ report “fares

no better” because it contains only “generalized statements regarding standard of

care . . . and breach.”

      With regard to Dr. Chachere’s report, Select Specialty argues that it does not

describe, with sufficient specificity, “how the alleged breach of the standard of

care caused the complained of results.”          Rather, Select Specialty argues,

Chachere’s report is impermissibly conclusory.

      A.     Nurse Sparks’s Report

      With regard to bedsores, Sparks’s report states that she is “familiar with the

applicable standard of care required for nurses to prevent, treat, and dress skin

                                         18
wounds, including pressure ulcers.” The report further states that the applicable

standard of care in found in the Texas Standards of Nursing Practice, and provides

in part that: (1) “A nurse shall know the rationale for and the effects of medications

and treatments and shall correctly administer the same,” and (2) “A nurse shall

implement measures to promote a safe environment for clients and others.”

      Under the heading of “Breach of Standard of Care,” Sparks’s report

discusses the standards of care for the prevention and treatment of bedsores, and

opines that Select Specialty’s nurses breached those standards:

      The nurses breached the standard of care applicable to nurses by
      failing to correctly administer santyl dressings. More specifically, the
      nurses failed to treat Mr Simmons’ skin wounds, including his
      pressure ulcers, with santyle dressing on a daily basis between July
      15, 2011 and August 1, 2011. In normal practice, santyle dressing is
      applied daily to help heal burns and skin ulcers. Further, the nurses
      received orders to change Mr. Simmons’ santyl dressing daily and
      failed to do so, which a nurse of ordinary prudence would not have
      done under the same or similar circumstances. Since the nurses failed
      to treat Mr. Simmons’ skin wounds, including his pressure ulcers,
      with santyl dressing once per day, they breached the standard of care
      applicable to nurses that states that a nurse shall correctly administer
      treatments and medications.
      In addition, the nurses breached the standard of care applicable to
      nurses by failing to correctly administer hydrolloid dressings. More
      specifically, the nurses failed to treat Mr. Simmons’ skin wounds,
      including his pressure ulcers, with hydrocolloid dressing between
      August 1, 2011 and September 19, 2011. A hydrocolloid dressing an
      adhesive wafer applied to skin ulcers every 3-5 days, The nurses’
      failure to apply hydrocolloid dressing every 3-5 days to Mr.
      Simmons’ skin wounds, including his pressure ulcers, was an act that
      a nurse of ordinary prudence would not have done under the same or
      similar circumstances. Since the nurses failed to treat Mr. Simmons’

                                         19
      skin wounds, including his pressure ulcers, with hydrocolloid dressing
      every 3-5 days, they breached the standard of care applicable to nurses
      that states that a nurse shall correctly administer treatment and
      medications.
      Moreover, the nurses breached the standard of care applicable to
      nurses by failing to correctly reposition Mr. Simmons. More
      specifically, when Mr. Simmons arrived at Select Specialty on July
      15, 2011, his Braden Scale for Predicting Pressure Sore Risk totaled
      10, which placed him at a high risk for skin breakdown. On July 22,
      1011, Mr. Simmons developed gluteal skin wounds. On August 1,
      2011, Mr. Simmons developed an inner gluteal fold skin wound. On
      August 6, 2011, Mr. Simmons developed a Stage II inner thigh skin
      wound. On August 8, 2011, Mr. Simmons developed another gluteal
      fold wound. On August 9, 2011, Mr. Simmons developed a right
      inner thigh wound. On August 3, 7, and 9, 2011 the nurses failed to
      reposition Mr. Simmons every two hours, which is not what a nurse of
      ordinary prudence would have done under the same or similar
      circumstances. In addition, on August 2 and 3, 2011, the nurses
      decided not to reposition Mr. Simmons for up to ten (10) hours at a
      time. Since the nurses failed to reposition Mr. Simmons every two
      hours, the nurses breached the standard of care applicable to nurses to
      correctly administer treatment and medications.

      The trial court did not abuse its discretion in concluding that Sparks’s report

adequately addressed the elements of standard of care and breach against Select

Specialty as it relates to Simmons’s development of bedsores. An expert report

must “provide[] a fair summary of the expert’s opinions as of the date of the report

regarding applicable standards of care, the manner in which the care rendered by

the physician or health care provider failed to meet the standards.” TEX. CIV.

PRAC. & REM. CODE ANN. § 74.351(r)(6). “[A] fair summary must set out what

care was expected, but not given, and how that caused the injury.” Spitzer v.

Berry, 247 S.W.3d at 750 (quoting Palacios, 46 S.W.3d at 880).
                                         20
      Unlike the one-sentence standard-of-care statement in Palacios “that

precautions to prevent [plaintiff’s] fall were not properly utilized,” which the

supreme court found insufficient, 46 S.W.3d at 880, Sparks’s report provides a fair

summary of what the Select Specialty’s nurses should have done, and how they

failed to meet the applicable standard. Specifically, Sparks’s report specifically

identifies what should have been done and what was not done in relation to (1)

correctly and timely administering santyl dressing, (2) correctly and timely

administering hydrocolloid dressing, and (3) timely and correctly repositioning

Simmons. E.g., Columbia N. Hills Hosp. Subsidiary, L.P. v. Alvarez, 382 S.W.3d

619, 629 (Tex. App.—Fort Worth 2012, no pet.) (expert reports sufficient because

they “put the hospital on notice of what care [experts] opined was required but not

given”);   Carrillo v. Palacios, No. 13-08-00418-CV, 2008 WL 4981558, at *7

(Tex. App.—Corpus Christi Nov. 25, 2008, no pet.) (holding report was specific

enough to put defendant on notice of what care nurses should have provided, how

nurses breached standard of care, and how that breach caused decubitus ulcers, and

provided the trial court with a basis to determine if claims had merit).

      B. Dr. Chachere’s Report

      With regard to causation, Chachere’s report provides the following opinion

of how the breaches of the standard of care identified by Sparks’s report

contributed to Simmons’s development of bedsores:

                                          21
Santyl dressing is applied daily to skin wounds to help heal burns and
skin ulcers. So the nurses’ failure to treat Mr. Simmons’ sacrum,
buttocks (gluteal), and though with santyl dressing once per day
between July 15, 2011 and August 1, 2011 even after being ordered to
do so, more likely than not, in reasonable medical probability, directly
caused skin wounds, including pressure ulcers, to develop on Mr.
Simmons’ sacrum, buttocks, and thigh. Santyl dressing is used to
treat skin ulcers, so the nurses’ failure to apply the santyl dressing to
Mr. Simmons skin wounds once per day could only result in Mr.
Simmons developing skin ulcers on his sacrum, buttocks, and thigh.
Hydrocolloid dressing is applied every 3-5 days to skin wounds to
help heal burns and skin ulcers. As a result, the nurses’ failure to treat
Mr. Simmons’ sacrum, buttocks, and thigh with hydrocolloid dressing
every 3-5 days between August 1, 2011 and September 19, 2011 more
likely than not, in reasonable medical probability, directly caused skin
wounds, including ulcers, to develop on Mr. Simmons’ sacrum,
buttocks, and thigh. Hydrocolloid dressing is used to treat skin ulcers
so the nurses’ failure to apply the hydrocolloid dressing every 3-5
days to Mr. Simmons could only result in Mr. Simmons developing
skin ulcers on his sacrum, buttocks, and thigh. When Mr. Simmons
arrived at Select Specialty on July 15, 2011, he had no skin
breakdowns, wounds, redness, or discoloration anywhere on his body.
Mr. Simmons, however, being a 69 year old elderly and chronically ill
patient was at a high risk for developing pressure ulcers because he
laid immobile in this bed during his treatment at Select Specialty.
One of the major factors in the development of pressure ulcers is a
prolonged pressure on a part due to the weight of the body or a limb.
So the nurses’ failure to reposition Mr. Simmons every two hours
caused prolonged pressure on Mr. Simmons’ sacrum, buttocks, and
thigh, which more likely than not, in reasonable medical probability,
caused skin wounds, including pressure ulcers, to develop on Mr.
Simmons’ sacrum, buttocks, and thigh. The nurses’ failure to
reposition Mr. Simmons every two hours, and in some cases
reposition him only every ten hours, combined with the accumulation
of urine and feces, which causes skin breakdown, more likely than
not, in reasonable medical probability, directly caused skin wounds,
including ulcers, to develop on Mr. Simmons’ sacrum, buttocks, and
thigh.


                                   22
      The trial court did not abuse its discretion in determining that Chachere’s

report adequately addressed the element of causation as it relates to bedsores. An

expert is required to link his or her conclusions to the facts, but no “magical

words” are required. Bowie Mem’l Hosp., 79 S.W.3d at 53.                While Select

Specialty argues that Chachere’s causation opinions are impermissibly conclusory,

we conclude that her opinions are as, or more, specific than causation statements

found to be adequate in other cases. Her report specifically identifies and links

each alleged breach of the standard of care related to failure to treat Simmons with

santyl dressings, failure to treat Simons with hydrocolloid dressing, and failure to

reposition Simmons to his development of bedsores. E.g., Bennett, 256 S.W.3d at

817 (expert report was not impermissibly conclusory with regard to causation

because it set “forth the mechanism of [patient’s] injury, specifically (1) failure to

provide adequate initial skin assessment, hydration, and nutrition led to the

formation of ulcers, and (2) failure to provide skin care nursing and protocol

interventions when decubitus ulcers were detected, as well as failing to optimize

[patient’s] nutrition and hydration led to formation of new ulcers and prevented

healing of existing ulcers”); Gallardo v. Ugarte, 145 S.W.3d 272, 280 (Tex.

App.—El Paso 2004, pet. denied) (report’s giving examples of things that should

have been done to prevent and treat decubitus ulcers—including more frequent

repositioning—adequately addressed causation “by indicating that if the proper

                                         23
steps had been taken the decubitus ulcers could have been prevented or at least

prevented from progressing to stage IV”).

      Because we conclude that the trial court did not abuse its discretion in

concluding that Sparks’s and Chachere’s adequately addressed standard of care,

breach, and causation as to plaintiffs’ claims related to bedsores, we overrule

Select Specialty’s second issue.4

                                    CONCLUSION

          We affirm the trial court’s judgment.




                                                Sherry Radack
                                                Chief Justice

Panel consists of Chief Justice Radack and Justices Sharp and Massengale.

4
      Select Specialty also challenges the sufficiency of the expert reports as they relate
      to claims that Simmons was left unattended in unsanitary conditions such that ants
      and gnats accumulated in his trachea tube. Because we have concluded that the
      reports are sufficient as to the claims related to bedsores, we need not reach Select
      Specialty’s arguments about plaintiffs’ other claims. Certified EMS, Inc. v. Potts,
      392 S.W.3d 625, 630 (Tex. 2013) (case should proceed so long as expert reports
      are adequate as to one theory of liability).
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