                                  IN THE
                          TENTH COURT OF APPEALS

                                 No. 10-11-00191-CV

HILLCREST BAPTIST MEDICAL CENTER
AND HILLCREST HEALTH SYSTEM, INC.,
                                                            Appellant
v.

LILLIE PAYNE,
                                                            Appellee



                           From the 414th District Court
                             McLennan County, Texas
                            Trial Court No. 2010-15045


                          MEMORANDUM OPINION


      In this appeal, appellants, Hillcrest Baptist Medical Center (“HBMC”) and

Hillcrest Health System, Inc. (“HHSI”), complain about the trial court’s denial of their

joint motion to dismiss a health-care-liability claim brought by appellee, Lillie Payne, on

the basis that Payne allegedly failed to timely provide an adequate expert report in

compliance with section 74.351 of the civil practice and remedies code. See TEX. CIV.

PRAC. & REM. CODE ANN. § 74.351 (West 2011). By three issues, appellants assert: (1)

Payne’s expert was not qualified to opine on causation; (2) Payne’s expert reports did
not establish the requisite causal connections between appellants’ alleged negligent

actions and the injuries sustained; and (3) Payne’s expert reports do not adequately

address liability as to HHSI. We affirm, in part, and reverse and remand, in part.

                                            I.   BACKGROUND

        This dispute pertains to treatment Payne, then a sixty-year-old woman, received

while in HBMC’s care. According to Payne, on March 7, 2008, she was admitted to

HBMC with a diagnosis of a fever. However, it was later determined that she had

sepsis from an infected dialysis shunt.          The bacterium that caused the sepsis was

discovered to be Methicillin-resistant staphylococcus auerus (“MRSA”).           Upon this

discovery, Payne was admitted to HBMC’s intensive-care unit, and she was placed on a

ventilator due to the development of septic shock and respiratory failure. In addition,

Payne was “placed on bilateral upper extremity restraints.”            Payne alleged that

“[o]rders for pressure ulcer precautions were instituted on admission” and noted that

she has diabetes, hypertension, and end-stage renal failure that required frequent

dialysis.

        Payne received treatment for the sepsis that she contracted, and she was

subsequently discharged from the hospital on April 9, 2008. However, while in the care

of HBMC, Payne developed “multiple pressure ulcers” that required “long[-]term,

aggressive care[,] and treatment.”

        Thereafter, Payne filed her original petition, asserting health-care liability claims

against HBMC; HHSI; Scott and White Memorial Hospital; and the Scott, Sherwood,




Hillcrest Baptist Medical Center v. Payne                                              Page 2
and Brindley Foundation.1             Specifically, Payne contended that appellants were

negligent in carrying out their medical responsibilities and that their negligence caused

her pressure ulcers. In addition to her original petition, Payne filed an expert report

authored by Joe D. Haines Jr., M.D., M.P.H, which asserted, among other things, that

the staff at HBMC deviated from the applicable standard of care, did not exercise

reasonable care in treating Payne, and ultimately caused her pressure ulcers.

            Appellants responded by filing an original answer denying each of the

allegations contained in Payne’s original petition and asserting numerous affirmative

defenses. Appellants also objected to Dr. Haines’s initial expert report, arguing that he

failed to adequately explain his qualifications to opine “on the standard of care or

breach applicable to nurses or a hospital caring for a hospitalized patient in the ICU or

on the floor who develops pressure ulcers” and that his statements regarding causation

were “speculative and conclusory and fail to establish a link between Defendant’s

alleged breach and Plaintiff’s alleged injury.”

        Payne responded to appellants’ objections by filing two supplemental expert

reports also authored by Dr. Haines, wherein he expounded on his qualifications and

causation. Appellants objected to Dr. Haines’s supplemental expert reports on the same

grounds as previously raised.2




         1 In her first amended petition, Payne dropped her claims against Scott and White Memorial

Hospital and the Scott, Sherwood, and Brindley Foundation. Therefore, only HBMC and HHSI remain as
parties to this appeal.

        2 The record does not contain a written order indicating that the trial court ruled on appellants’
objections.

Hillcrest Baptist Medical Center v. Payne                                                          Page 3
        Subsequently, on November 19, 2010, appellants filed a joint motion to dismiss

Payne’s health-care-liability claims, asserting that Payne had not timely filed a sufficient

expert report in compliance with section 74.351 of the civil practice and remedies code.

See id. § 74.351(a)-(b). The trial court conducted a hearing on appellants’ joint motion to

dismiss, and, on December 20, 2010, entered an order stating that Dr. Haines’s expert

reports were insufficient. However, the trial court granted Payne a thirty-day extension

to cure the deficiencies in the reports. See id. § 74.351(c).

        Thereafter, Payne filed an additional expert report from Dr. Haines dated

January 15, 2011, and an expert report from Dora M. Carcoba, a registered nurse who

opined on the standard of care and breach, as it related to nurses. Appellants once

again objected to Dr. Haines’s expert report as not sufficiently demonstrating his

qualifications and asserting causation in a conclusory manner. Appellants also objected

to Carcoba’s qualifications to render an opinion in this matter because she is a nurse,

not a physician. Furthermore, appellants reasserted their joint motion to dismiss. See

id. § 74.351(a)-(b).

        Finally, on April 19, 2011, the trial court, after a hearing, denied appellants’ joint

motion to dismiss and objections.           This interlocutory appeal followed.     See id. §

51.014(a)(9) (West 2008) (permitting the appeal of an interlocutory order from a district

court that “denies all or part of the relief sought by a motion under Section 74.351(b)”).

                                     II.    STANDARD OF REVIEW

        We review a trial court’s denial of a motion to dismiss under section 74.351 for an

abuse of discretion. Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002); Am.

Hillcrest Baptist Medical Center v. Payne                                               Page 4
Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001). A trial court

abuses its discretion if it acts in an arbitrary or unreasonable manner or without

reference to any guiding rules or principles. Walker v. Gutierrez, 111 S.W.3d 56, 62 (Tex.

2003); Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238, 241-42 (Tex. 1985).

                                        III.   APPLICABLE LAW

        Section 74.351 of the civil practices and remedies code provides that within 120

days of filing a health-care-liability claim, a claimant must serve a curriculum vita and

one or more expert reports regarding every defendant against whom a health-care claim

is asserted. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a); see also College Station

Med. Ctr., LLC v. Todd, No. 10-09-00398-CV, 2010 Tex. App. LEXIS 7290, at *3 (Tex.

App.—Waco Sept. 1, 2010, pet. denied) (mem. op.). The expert report must contain

        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 by the physician or health care provider failed to meet the
        standards, and the causal relationship between that failure and the injury,
        harm, or damages claimed.

TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6); see Palacios, 46 S.W.3d at 877. If a

plaintiff timely files an expert report and the defendant moves to dismiss because of the

report’s inadequacy, the trial court must grant the motion “only if it appears to the

court, after hearing, that the report does not represent a good faith effort to comply with

the definition of an expert report in [section 74.351(r)(6)].” Bowie Mem’l Hosp. v. Wright,

79 S.W.3d 48, 51-52 (Tex. 2002); see Palacios, 46 S.W.3d at 878.

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

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

Hillcrest Baptist Medical Center v. Payne                                                 Page 5
plaintiff has called into question; and (2) it must provide a basis for the trial court to

conclude that the claims have merit. Bowie Mem’l Hosp., 79 S.W.3d at 52-53 (noting that

“magical words” are not necessary to provide a fair summary of the standard of care,

breach of that standard, and causation); see Palacios, 46 S.W.3d at 879 (“A report that

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

does not fulfill these two purposes. Nor can a report meet these purposes and thus

constitute a good-faith effort if it omits any of the statutory requirements.”). The trial

court should look no further than the report itself, because all the information relevant

to the inquiry should be contained within the document’s four corners. Bowie Mem’l

Hosp., 79 S.W.3d at 52 (citing Palacios, 46 S.W.3d at 878). An expert report, however,

does not need to marshal all of the plaintiff’s proof; it may be informal and the

information presented need not meet the same requirements as evidence offered in

summary judgment proceedings or in trial. See Spitzer v. Berry, 247 S.W.3d 747, 750

(Tex. App.—Tyler 2008, pet. denied); see also Bakhtari v. Estate of Dumas, 317 S.W.3d 486,

496 (Tex. App.—Dallas 2010, no pet.).

                               IV.     QUALIFICATIONS OF DR. HAINES

        In their first issue, appellants contend that Payne’s expert reports do not

demonstrate that Dr. Haines “is qualified to address the existence of a causal connection

between Appellee’s development of a pressure ulcer and HBMC’s alleged breach of the

applicable standard of care.” Specifically, appellants argue that Dr. Haines’s statements

about his experience treating pressure ulcers are conclusory and fail to show that “he is




Hillcrest Baptist Medical Center v. Payne                                           Page 6
qualified to determine the specific causes of a patient’s pressure ulcer when faced with

at least thirteen possible causes of that ulcer.”

A. Applicable Law

        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 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.

Hillcrest Baptist Medical Center v. Payne                                               Page 7
        Qualifications of an expert must appear in the expert reports and curriculum

vitae and cannot be inferred. See Salais v. Tex. Dep’t of Aging & Disability Servs., 323

S.W.3d 527, 536 (Tex. App.—Waco 2010, pet. denied); 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 determining whether the expert was qualified to opine

about plaintiff’s negligent credentialing cause of action); Leonard v. Glenn, 293 S.W.3d

669, 676 (Tex. App.—San Antonio 2009), rev’d on other grounds, 332 S.W.3d 403 (Tex.

2011); 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

Hillcrest Baptist Medical Center v. Payne                                             Page 8
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.”).

B. Discussion

        At the outset of our analysis of this issue, we note that “[e]xpert reports can be

considered together in determining whether the plaintiff in a health care liability action

has provided adequate expert opinion regarding the standard of care, breach, and

causation.” Salais, 323 S.W.3d at 534; see Walgreen Co. v. Hieger, 243 S.W.3d 183, 186 n.2

(Tex. App.—Houston [14th Dist.] 2007, pet. denied); see also TEX. CIV. PRAC. & REM.

CODE ANN. § 74.351(i). Therefore, we consider the language contained within the four

corners of all of the expert reports that Payne proffered.                   In addition, we reject

appellants’ assertion that Dr. Haines cannot qualify as an expert because allegedly he

was unable to rule out thirteen other potential causes for the pressure ulcers. 3 See Baylor

Med. Ctr. at Waxahachie v. Wallace, 278 S.W.3d 552, 562 (Tex. App.—Dallas 2009, no pet.)

(“Nothing in section 74.351 suggests the preliminary report is required to rule out every

possible cause of the injury, harm, or damages claimed, especially given that section

74.351(s) limits discovery before a medical expert’s report is filed.”); see also Whisenant v.

Arnett, 339 S.W.3d 920, 926 (Tex. App.—Dallas 2011, no pet.).

        3 To some extent, this argument is misleading given that Dr. Haines mentioned in his initial

expert report that: “Even though Ms. Payne suffers from end-stage renal disease, hypertension[,] and
diabetes, she had never had problems with pressure ulcers and entered HBMC without pressure ulcers.”
In a subsequent expert report, Dr. Haines stated that: “Within a reasonable degree of medical probability,
Ms. Payne’s co-morbid conditions of diabetes, hypertension[,] and end-stage renal disease did not cause
the pressure ulcer because those conditions cannot spontaneously cause such a condition.”

Hillcrest Baptist Medical Center v. Payne                                                          Page 9
        Texas courts have stated the following regarding expert qualifications:

        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. . . .
        A physician is not required to state he is familiar with the core standards
        contained in the code, establishing the ‘core standards’ for nurse
        practitioners or physician’s assistants.

Wallace, 278 S.W.3d at 558 (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.)).

        In response to appellants’ first objections to his qualifications, Dr. Haines filed an

amended expert report, wherein he noted:

        Regarding the objection made about my qualifications to render opinion
        about the nursing standard of care in this case: I have experience in caring
        for patients with pressure ulcers. I write nursing orders to the nurses
        caring for patients with pressure ulcers. I, therefore, have experience in
        supervising nurses with regard to the carrying out of my orders. I also
        know when a nurse has not followed my orders. I have cared for
        numerous hospitalized patients who have developed pressure ulcers. I
        have cared for numerous hospitalized patients who were at risk for
        developing pressure ulcers[,] and I have managed a hospitalized patient’s

Hillcrest Baptist Medical Center v. Payne                                               Page 10
        treatment of or the prevention of pressure ulcers. Throughout my entire
        medical career, I have supervised nurses in the care, treatment[,] and
        prevention of hospitalized patients who are at risk for or have pressure
        ulcers. The standard of care is the same for nurses and physicians in
        regard to the care, treatment[,] and/or prevention of pressure ulcers
        regardless of where the patient is, i.e. a hospital or a nursing home. The
        standard of care for the prevention of and treatment of pressure ulcers is
        the same for nurses as it is for physicians: the patient should be turned
        every two hours, the area at risk should be kept clean and dry, and the
        skin should be carefully monitored.

        In his January 15, 2011 report, Dr. Haines stated the following with respect

to additional objections made by appellants:

        I have been the treating physician responsible for the care of patients in
        the ICU exactly like Ms. Lillie Payne who have multi-system organ failure,
        end-stage renal disease, febrile illness, MRSA sepsis, septic shock,
        respiratory failure, decreased circulation, diabetes, and hypertension who
        are on a ventilator, pressors, restraints and have restricted nutritional
        intake. The fact that Ms. Payne had multi-system organ failure, end-stage
        renal disease, febrile illness, MRSA sepsis, septic shock, respiratory
        failure, decreased circulation, diabetes, and hypertension and was on a
        ventilator, pressors, restraints[,] and had restricted nutritional intake
        within a reasonable degree of medical probability made her body even
        more at risk for the development of pressure ulcers. I am qualified to give
        opinions about causation in this matter as it relates to the development of
        a pressure ulcer in an ICU patient due to my experience in treating these
        patients, ordering nurses in the care and treatment of these patients to
        prevent pressure ulcers, and through my education in medical school,
        residency[,] and when I obtained my Masters Degree in Public Health.

Moreover, Dr. Haines’s initial expert report and curriculum vitae demonstrate that he

has been practicing medicine since 1981. Dr. Haines, an active duty naval physician,

has numerous certifications, including board certification in family practice, and




Hillcrest Baptist Medical Center v. Payne                                              Page 11
extensive experience practicing medicine in urgent care, combat zones, and in hospital

settings.4

        Appellants assert that Dr. Haines was required to “show he has expertise on the

‘very matter’ or ‘specific issue’ before the court” and that qualifications “cannot be

established through conclusory statements lacking sufficient facts and explanation.” In

particular, appellants contend that Dr. Haines, in his expert reports, should have

indicated: (1) the number of patients he has treated with symptoms similar to Payne;

(2) when he treated such patients; (3) whether he was able to prevent the development

of pressure ulcers in these patients; and (4) how and why this experience qualifies him

to determine the cause of Payne’s pressure ulcers. Though appellants cite two cases

that allegedly support their contention that Dr. Haines’s expert reports were conclusory

as to his qualifications, we do not find these cases to be on point. See Leland v. Brandal,

217 S.W.3d 60, 63 (Tex. App.—San Antonio 2006) (holding that an anesthesiologist, who

cared for patients that were at risk for strokes and who were taking Plavix and aspirin,

was not qualified “to state the effect of the cessation of Plavix and aspirin during the

time period in question proximately caused Brandal’s stroke”), aff’d, 257 S.W.3d 204

(Tex. 2008); see also Bowie Mem’l Hosp., 79 S.W.3d at 52 (addressing an expert’s

statements regarding causation and stating that “[a] conclusory report does not meet

the Act’s requirements, because it does not satisfy the Palacios test”). Furthermore,



        4 In fact, in his initial expert report, Dr. Haines reduced his curriculum vitae to paragraph form
under the heading “I. Qualification.” Therefore, both this Court and the trial court could determine Dr.
Haines’s qualifications by solely looking at the four corners of his expert reports, though consideration of
his curriculum vitae was not prohibited.

Hillcrest Baptist Medical Center v. Payne                                                           Page 12
appellants do not cite to any authority to support their argument that Dr. Haines’s

expert reports were required to be as precise as appellants desire.

        Here, Dr. Haines specifically mentioned that he has experience treating patients

like Payne who have been hospitalized and developed pressure ulcers. He also has

experience directing nurses in the treatment of pressure ulcers and treating patients

with some of the pre-existing medical conditions that Payne has. Based on the language

contained in Dr. Haines’s expert reports and curriculum vitae, we cannot say that the

trial court clearly abused its discretion in concluding that Dr. Haines has the

“knowledge, skill, experience, training, or education” regarding the standard of care for

the treatment and/or prevention of pressure ulcers or, in other words, that he is

qualified to give an opinion on the particular subject. See Broders, 924 S.W.2d at 153.

Moreover, when a trial court concludes for purposes of chapter 74 that an physician is

qualified to opine about the standard of care for a certain operation or procedure, it is

also reasonable for the trial court to conclude that the physician is qualified to opine on

the causal relationship between that operation or procedure and the complications that

can arise from it. See Whisenant, 339 S.W.3d at 927 (citing Livingston v. Montgomery, 279

S.W.3d 868, 873 (Tex. App.—Dallas 2009, no pet.)). We therefore hold that the trial

court did not clearly abuse its discretion in determining that Dr. Haines is qualified to

opine as to the causation element.          See id.; see also Livingston, 279 S.W.3d at 873.

Accordingly, we overrule appellants’ first issue.




Hillcrest Baptist Medical Center v. Payne                                            Page 13
                         V.      PAYNE’S EXPERT REPORTS AND CAUSATION

        In their second issue, appellants assert that Payne’s expert reports are insufficient

with respect to causation because the statements contained therein are conclusory. In

particular, appellants allege that Dr. Haines was required to: (1) rule out the other

thirteen possible causes for the development of the pressure ulcers; and (2) sufficiently

explain how the pressure ulcers would not have occurred but for HBMC’s actions.

        We recognize that a nurse cannot, as a matter of law, establish the causation

prong required by section 74.351(r)(6).      See TEX. CIV. PRAC. & REM. CODE ANN. §§

74.351(r)(5)(c), 74.403(a); Benish v. Grottie, 281 S.W.3d 184, 205 (Tex. App.—Fort Worth

2009, pet. denied). A nurse may, however, give an opinion on the standard of care for

nurses and a breach of that standard. See Christus Spohn Health Sys. Corp. v. Sanchez, 299

S.W.3d 868, 877-78 (Tex. App.—Corpus Christi 2009, pet. denied); Benish, 281 S.W.3d at

205-06. In addition, the trial court was authorized to consider Nurse Carcoba’s report

on standard of care and breach and Dr. Haines’s report on causation. See TEX. CIV.

PRAC. & REM. CODE ANN. § 74.351(i); Sanchez, 299 S.W.3d at 877-78 (considering together

a nurse’s report on the standard of care for nurses and a physician’s report on

causation).

        In her report, Nurse Carcoba stated the following with regard to the applicable

standard of care:

        The Standard of Care for Hillcrest Baptist Medical Center by and through
        the nurses named above was to:

                1. Perform ongoing nursing assessments of the patient to identify
                   actual and potential problem areas[;]

Hillcrest Baptist Medical Center v. Payne                                             Page 14
                2. Make appropriate nursing diagnoses, i.e. [a]lteration in comfort,
                   alteration in hydration, alteration in skin integrity, alteration in
                   elimination pattern, potential for Urinary tract infection, etc.
                   based on ongoing assessments[;]
                3. Develop a comprehensive plan of care which sets forth
                   identified (actual or potential) problem interventions designed
                   to prevent adverse outcomes from known problem areas[;]
                4. Implement Plan of Care[;]
                5. Evaluate patient’s response to implemented [P]lan of [C]are[;
                   and]
                6. Update Plan of [C]are consistent with the patient[’]s response[.]

        The Standard of Care for Prevention of Pressure Ulcers for Hillcrest
        Baptist Medical Center by and through the nurses named above was to:

                1. Conduct a pressure ulcer admission assessment for all
                   patients[,] including Ms. Payne (Braden Score Scale or Norton
                   Score Scale)[;]
                2. Reassess risk for all patients daily (Braden Score Scale or Norton
                   Score Scale)[,] including Ms. Payne[;]
                3. Inspect skin of at-risk patients daily[,] including Ms. Payne[;]
                4. Manage moisture[;]
                5. Optimize nutrition/hydration[;]
                6. Every 2 to 4 hour 30 degree/lateral tilt[;]
                7. Minimize pressure[; and]
                8. Once a pressure ulcer develops, the wound should be properly
                   documented and photographed in the medical record. Color,
                   size, depth, drainage, odor[,] and progression and notify
                   physician[.]

        The Standard of Care for Hillcrest Baptist Medical Center by and through
        the nurses named above, with regards to Ms. Lillie Payne required that:

                1. The patient be turned every 2 hours to prevent pressure damage
                   to the skin[;]
                2. That proper bedding (air mattress) be provided to prevent
                   pressure ulcers[;]
                3. Once a pressure ulcer develops, the wound should be properly
                   documented and photographed in the medical record. Color,
                   size, depth, drainage, odor[,] and progression and notify
                   physician[;]
                4. Upon discharge, wound care instructions should be provided to
                   family and home healthcare nursing staff[; and]

Hillcrest Baptist Medical Center v. Payne                                                 Page 15
                5. Provision of a therapeutic mattress[.]

        Nurse Carcoba then opined that HBMC, by and through their nurses, deviated

from the standard of care by failing to: (1) “[p]erform ongoing nursing assessments of

the patient to identify actual and potential problem areas”; (2) “[m]ake appropriate

nursing diagnoses, i.e. [a]lteration in comfort, alteration in hydration, alteration in skin

integrity, alteration in elimination pattern, potential for Urinary tract infection, etc.

based on ongoing assessments”; (3) “[d]evelop a comprehensive plan of care which sets

forth identified (actual or potential) problem interventions designed to prevent adverse

outcomes from known problem areas”; (4) “[i]mplement Plan of Care”; (5) “[e]valuate

patient’s response to implemented [P]lan of [C]are”; (6) “[u]pdate Plan of [C]are

consistent with patient[’]s response; (7) “[c]onduct a pressure ulcer admission

assessment for Ms. Payne (Braden Score Scale or Norton Score Scale)”; (8) “[r]eassess

risk for Ms. Payne daily (Braden Score Scale or Norton Score Scale)”; (9) “[i]nspect skin

or at-risk patients daily[,] which includes Ms. Payne”; (10) “[m]anage moisture”; (11)

“[o]ptimize nutrition/hydration”; (12) “[e]very 2 to 4 hour 30 degree/lateral tilt; (13)

“[m]inimize pressure”; and (14) “[o]nce a pressure ulcer develops, the wound should be

properly documented and photographed in the medical record. Color, size, depth,

drainage, odor[,] and progression and notify physician.” In particular, Nurse Carcoba

stated that HBMC breached the standard of care applicable to Payne by failing to: (1)

turn her every two hours to prevent pressure damage to the skin; (2) provide proper

bedding (i.e., an air mattress) to prevent the formation of pressure ulcers; (3) properly

document and photograph the pressure ulcers in the medical record; (4) notify a

Hillcrest Baptist Medical Center v. Payne                                            Page 16
physician immediately when the pressure ulcers developed; (5) provide wound care

instructions to family and home healthcare nursing staff; and (6) provide a therapeutic

mattress.5

        In his report, Dr. Haines, relying on Nurse Carcoba’s statements, provided the

following with respect to causation:

               It is my opinion, that the deviations from the standard of care
        stated by Nurse Carcoba in her report, within a reasonable degree of
        medical probability, proximately caused the pressure ulcer suffered by
        Ms. Payne. The pathophysiologic reason why Ms. Payne developed this
        pressure ulcer was because when she was allowed by the nursing staff to
        remain in the same position for greater than two hours without being
        turned, was not laterally tilted at 30 degrees every 2 to 4 hours[,] and did
        not have proper bedding and a therapeutic mattress. This proximately
        caused the circulation to be diminished to the area of her sacrum and
        coccyx and put pressure on the sacrococcygeal area. This diminished
        circulation to this area proximately caused the tissue to be damaged due
        to the lack of blood flow to [the] sacrococcygeal area. The lack of blood
        flow to the sacrococcygeal area proximately caused the tissue to die
        causing the pressure ulcer that Ms. Payne had.

                If the nurses had documented and discussed Ms. Payne’s pressure
        ulcer in the chart using the parameters of size, color, depth, drainage,
        odor[,] and progression, the worsening of the ulcer would have been
        tracked in the record and become apparent to the physicians who then
        would have been alerted. The physicians would then have implemented a
        treatment plan, including off loading, wound care[,] and a specialty
        mattress. Within a reasonable degree of medical probability, these
        interventions would have prevented the pressure ulcer from progressing
        to a Stage IV ulcer. Further, when the nurses failed to inform a physician
        immediately of the formation of the pressure ulcer, this proximately
        caused the wound to go unnoticed and untreated. Had the nurses
        informed the physician of the ulcer, the ulcer would not have progressed
        to a Stage IV ulcer . . . . Within a reasonable degree of medical probability,
        these interventions would have prevented the pressure ulcer from
        progressing to a Stage IV ulcer.



        5   Appellants do not make any complaint as to Nurse Carcoba’s report.

Hillcrest Baptist Medical Center v. Payne                                                Page 17
                Within a reasonable degree of medical probability, Ms. Payne’s
        comorbid conditions listed above did not cause the pressure ulcer because
        those conditions cannot spontaneously cause such a condition. Rather,
        these comorbid conditions made it even more incumbent upon the
        nursing staff to diligently turn and tilt Ms. Payne to prevent a pressure
        ulcer from occurring. It is my opinion that within a reasonable degree of
        medical probability, the pressure ulcer Ms. Payne suffered would not
        have occurred but for the deviations from the standard of care listed in
        Nurse Carcoba’s report for the reasons stated above. This pressure ulcer,
        within a reasonable degree of medical probability, was an absolutely
        preventable injury had the nurses listed in Nurse Carcoba’s report
        followed the standard of care as stated in her report and in this report. It
        is also my opinion that had the nurses properly informed the physicians
        of the formation of this pressure ulcer when it was only a Stage I ulcer, it
        would have been properly treated and would not have progressed to a
        Stage IV ulcer.

        Based on our reading of Payne’s expert reports, we cannot say that the trial court

clearly abused its discretion in concluding that the reports adequately addressed the

requisite elements for Payne’s health-care-liability claims such that they: (1) informed

appellants of the specific conduct called into question; and (2) provided a basis for the

trial court to determine that Payne’s claims have merit. See Bowie Mem’l Hosp., 79

S.W.3d at 52; see also Palacios, 46 S.W.3d at 879.       Moreover, we reject appellants’

assertion that Payne’s expert reports are insufficient and conclusory because the reports

allegedly did not rule out all of the thirteen other reasons for developing a pressure

ulcer. This holding is based on the following: (1) Texas courts have held that an expert

report need not rule out all other potential causes for the injury sustained in a health-

care setting, see Wallace, 278 S.W.3d at 562; Arnett, 339 S.W.3d at 926; (2) an expert report

need not marshal all of the plaintiff’s proof or meet the evidentiary standards applicable

to summary judgment proceedings or trial, see Bakhtari, 317 S.W.3d at 496; Spitzer, 247


Hillcrest Baptist Medical Center v. Payne                                              Page 18
S.W.3d at 750; and (3) Dr. Haines opined that, based on a reasonable degree of medical

probability, the other conditions did not contribute to the development of Payne’s

pressure ulcers. And because we have concluded that the trial court did not abuse its

discretion in concluding that Payne’s expert reports were sufficient, we cannot say that

the trial court abused its discretion in denying appellants’ joint motion to dismiss on

these grounds. See Bowie Mem’l Hosp., 79 S.W.3d at 52; see also Palacios, 46 S.W.3d at 875.

Accordingly, we overrule appellants’ second issue.

         VI.      WHETHER PAYNE’S EXPERT REPORTS ADEQUATELY ADDRESSED HHSI

        In their third issue, appellants argue that Payne failed to timely file an expert

report mentioning HHSI, much less addressing HHSI’s role in this matter. According

to appellants, “Appellee’s failure to provide the trial court with an expert report

regarding her claims against HHSI left the trial court with no discretion other than

dismissal of those claims.” Payne responds that her expert reports implicate HBMC

and HHSI because they expressly list all the names of the nurses involved in her

treatment and those nurses are agents, employees, or representatives of HBMC and/or

HHSI.

        The parties do not dispute that Payne asserted health-care-liability claims against

both HBMC and HHSI. The parties also do not dispute that neither Dr. Haines nor

Nurse Carcoba specifically referenced HHSI in their expert reports. Instead, Nurse

Carcoba listed the actions of several nurses whose alleged treatment, or lack thereof, of

Payne was negligent. The Texas Supreme Court has specifically held that “[w]hen a

party’s alleged health care liability is purely vicarious, a report that adequately

Hillcrest Baptist Medical Center v. Payne                                           Page 19
implicates the actions of that party’s agents or employees is sufficient.” Gardner v. U.S.

Imaging, Inc., 274 S.W.3d 669, 671-72 (Tex. 2008) (citing Univ. of Tex. Med. Branch v.

Railsback, 259 S.W.3d 860, 864 (Tex. App.—Houston [1st Dist.] 2008, no pet.); Univ. of

Tex. Sw. Med. Ctr. v. Dale, 188 S.W.3d 877, 879 (Tex. App.—Dallas 2006, no pet.); Casados

v. Harris Methodist H-E-B, No. 2-05-080-CV, 2006 Tex. App. LEXIS 6357, at **12-13 (Tex.

App.—Fort Worth July 20, 2006, no pet.) (not designated for publication)).

        However, in her report, Nurse Carcoba does not attribute the actions of the

nurses to HHSI or implicate HHSI in any way. Like Dr. Haines, Nurse Carcoba does

mention HBMC in her report; however, we are left to speculate about HHSI’s role in

this matter. See Taylor v. Christus Spohn Health Sys. Corp., 169 S.W.3d 241, 244 (Tex.

App.—Corpus Christi 2004, no pet.) (“An expert report may not assert that multiple

defendants are all negligent for failing to meet the standard of care without providing

an explanation of how each defendant specifically breached the standard and how that

breach caused or contributed to the cause of injury. Collective assertions of negligence

against various defendants are inadequate.”) (citing Eichelberger v. St. Paul Med. Ctr., 99

S.W.3d 636, 638 (Tex. App.—Dallas 2003, pet. denied); Doades v. Syed, 94 S.W.3d 664,

671-72 (Tex. App.—San Antonio 2002, no pet.); Rittmer v. Garza, 65 S.W.3d 718, 722-23

(Tex. App.—Houston [14th Dist.] 2001, no pet.); Whitworth v. Blumenthal, 59 S.W.3d 393,

396 (Tex. App.—Dallas 2001, no pet.) (“[T]he report . . . does not identify any particular

defendant to which it applies and instead generally asserts ‘the health care providers’

failed to meet the standard of medical care.”); Wood v. Tice, 988 S.W.2d 829, 831 (Tex.




Hillcrest Baptist Medical Center v. Payne                                           Page 20
App.—San Antonio 1999, pet. denied) (“The report must specifically refer to the

defendant and discuss how that defendant breached the applicable standard of care.”).

        Nonetheless, Payne cites to this Court’s decision in Hillcrest Baptist Medical Center

v. Wade to support her contention that “[e]ven if this Court believes the relationship of

Appellants is not entirely clear from the record, this Court has assumed in medical

malpractice cases that vicarious liability claims are being asserted when nurses’ actions

are being criticized.” See 172 S.W.3d 55, 57 (Tex. App.—Waco 2005, pet. granted, appeal

dism’d). Based on our reading, we do not find the Wade case to be persuasive in this

matter.

        The facts stated in the Wade majority opinion do not appear to correspond with

those involved here—a plaintiff suing what appears to be two separate health-care

facilities and/or entities. Id. at 56. The Wade majority opinion merely stated that “Wade

sued Hillcrest Baptist Medical Center, two emergency room doctors, and their

employers . . . .“ Id. However, the majority opinion does not clarify who were the

employers of the emergency room doctors and the relationship the emergency room

doctors had with Hillcrest. Rather, the majority opinion states that “[t]he relationship

of the defendants in the underlying medical malpractice case is not entirely clear from

the record.” Id. at 57. Nevertheless, the majority in Wade presumed that Hillcrest’s

liability “would be based on, at a minimum, any negligence by its nursing staff, which

will be the subject of our inquiry.” Id.

        To the extent that the Wade court looked outside the four corners of the expert

report or presumed facts in the determination of whether the report properly

Hillcrest Baptist Medical Center v. Payne                                             Page 21
implicated Hillcrest, we disapprove of that practice. See id. at 61 (Gray, C.J., dissenting)

(“Though addressing the alleged breaches by Hillcrest’s codefendant’s, the two reports

by physicians do not address Hillcrest’s conduct, and in particular any causal

relationship between Hillcrest’s conduct and the injury to Wade. . . . The trial court

abused its discretion in overruling Hillcrest’s motion.”); see also Bowie Mem’l Hosp., 79

S.W.3d at 52 (noting that the trial court should look no further than the report itself,

because all the information relevant to the inquiry should be contained within the

document’s four corners); Palacios, 46 S.W.3d at 878 (same). Texas case law clearly

states that the expert reports tendered by a health-care-liability claimant must clearly

explain and address the elements as to each named defendant in a health-care-liability

action. See Taylor, 169 S.W.3d at 244; Eichelberger, 99 S.W.3d at 638; Doades, 94 S.W.3d at

671-72; Rittmer, 65 S.W.3d at 722-23; Whitworth, 59 S.W.3d at 396; Wood, 988 S.W.2d at

831. Therefore, because the Wade majority opinion is not clear about the relationship

between Hillcrest, the emergency room doctors, and their purported employers, and

because the majority appeared to go outside of the expert report to implicate Hillcrest, a

practice that is not supported by case law, we do not find the Wade case to be persuasive

in this matter.

        Looking no further than the four corners of the expert reports tendered, we

cannot say that the expert reports of Dr. Haines and Nurse Carcoba informed HHSI of

the specific conduct Payne called into question and provided a basis for the trial court

to conclude that Payne’s claims against HHSI have merit. See Bowie Mem’l Hosp., 79

S.W.3d at 52; see also Palacios, 46 S.W.3d at 879. To date, we are not clear as to why

Hillcrest Baptist Medical Center v. Payne                                            Page 22
HHSI is involved in this case. As such, we conclude that the expert reports tendered by

Payne do not constitute a good-faith effort with regard to HHSI. See Bowie Mem’l Hosp.,

79 S.W.3d at 52; see also Palacios, 46 S.W.3d at 879. Accordingly, we hold that the trial

court abused its discretion in denying the motion to dismiss as to HHSI. See Bowie

Mem’l Hosp., 79 S.W.3d at 52; see also Palacios, 46 S.W.3d at 879. Appellants’ third issue

is sustained.

                                            VII.   CONCLUSION

        Based on the foregoing, we affirm the trial court’s judgment as it pertains to

HBMC. However, we reverse the trial court’s denial of appellants’ motion to dismiss as

it pertains to HHSI. As such, we render judgment dismissing Payne’s claims against

HHSI with prejudice and remand for the determination of reasonable attorney’s fees

and costs owed to HHSI. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(b).




                                                      AL SCOGGINS
                                                      Justice


Before Chief Justice Gray,
       Justice Davis, and
       Justice Scoggins
       (Justice Davis concurring with a note)*
Affirmed, in part, and reversed and remanded, in part
Opinion delivered and filed November 16, 2011
[CV06]

*(Justice Davis concurs in the Court’s judgment only. A separate opinion will not
issue.)




Hillcrest Baptist Medical Center v. Payne                                           Page 23
