Pinecrest SNF, LLC D/B/A Pinecrest Nursing & Rehabilitation Center v. Tasco Bailey, Nathan Bailey, Carlie Bailey, Roy Bailey, Bill Bailey, James Bailey, Earl Bailey, Mary Dunlap and Licille Martin, as Heirs of Archie Bailey ( 2016 )


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  •                                                     NO.
    NO. 12-14-00357-CV
    IN THE COURT OF APPEALS
    TWELFTH COURT OF APPEALS DISTRICT
    TYLER, TEXAS
    PINECREST SNF, LLC D/B/A                              §       APPEAL FROM THE 114TH
    PINECREST NURSING &
    REHABILITATION CENTER,
    APPELLANTS
    V.
    §   JUDICIAL DISTRICT COURT
    TASCO BAILEY, NATHAN BAILEY,
    CARLIE BAILEY, ROY BAILEY, BILL
    BAILEY, JAMES BAILEY, EARL
    BAILEY, MARY DUNLAP AND
    LICILLE MARTIN, AS HEIRS OF
    ARCHIE BAILEY,                   §   SMITH COUNTY, TEXAS
    APPELLEES
    MEMORANDUM OPINION
    Pinecrest SNF, LLC d/b/a Pinecrest Nursing & Rehabilitation Center appeals the trial
    court’s order denying its motion to dismiss the claims against it in a suit filed by Tasco Bailey,
    Nathan Bailey, Carlie Bailey, Roy Bailey, Bill Bailey, James Bailey, Earl Bailey, Mary Dunlap
    and Licille Martin, as heirs of Archie Bailey (the Baileys). In its sole issue, Pinecrest argues that
    the trial court abused its discretion when it overruled Pinecrest’s objections to the Baileys’ suit
    for failure to comply with the expert report requirements under Chapter 74 of the Texas Civil
    Practice and Remedies Code.1 We affirm.
    BACKGROUND
    On June 12, 2010, Archie Bailey was admitted to Pinecrest for long-term care related to
    her Alzheimer’s disease. She was eighty-eight years old and had a history of hypertension,
    1
    See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351 (West Supp. 2015).
    congestive heart failure, diabetes mellitus, and asthma. Bailey required total assistance with all
    activities of daily living.
    In August 2013, Bailey developed a pressure ulcer on her sacrum.2 The ulcer continued
    to worsen, and on September 19, 2013, Bailey was discharged from Pinecrest and transferred to
    Trinity Mother Frances Hospital (TMF). Upon admission, Bailey was diagnosed with a Stage IV
    decubitus ulcer on her sacrum, a Stage II pressure ulcer on her left buttock, leukocytosis, and a
    urinary tract infection. Bailey’s nutritional status was described as “severely compromised,”
    resulting in malnourishment. TMF transferred Bailey to Tyler ContinueCARE Hospital for
    further treatment and management of her wounds, where she developed another Stage II pressure
    ulcer on her right buttock. Bailey had several surgical debridements, and other treatments such
    as placement of a “wound VAC” and aggressive antibiotic therapy, from late September until her
    discharge on October 22, 2013, to Colonial Tyler Care Center. There, Bailey continued to
    receive negative pressure therapy and a therapeutic diet to promote wound healing.                          Her
    condition did not improve, and she was placed on hospice care. Bailey died on December 4,
    2013. Her death certificate indicates that she died from cardiopulmonary arrest.
    The Baileys filed suit against Pinecrest, alleging that it was negligent in allowing the
    development and progression of Bailey’s pressure ulcers. The Baileys attempted to comply with
    the statutory expert report requirements under Chapter 74 of the Texas Civil Practice and
    Remedies Code by filing the report of their expert, Christopher M. Davey, M.D. Pinecrest filed
    written objections to the report. The trial court ruled that Dr. Davey’s report was insufficient,
    but allowed the Baileys time to amend the report and cure its deficiencies. Dr. Davey amended
    his report, and Pinecrest again filed written objections to Dr. Davey’s report on the grounds that
    his opinions regarding causation were conclusory.                  The trial court overruled Pinecrest’s
    objections, and this interlocutory appeal followed.3
    EXPERT REPORT
    In its sole issue, Pinecrest argues that Dr. Davey’s report on causation is conclusory.
    2
    Bailey had previously developed a pressure ulcer in March 2013, but the ulcer resolved by early April
    2013.
    3
    See TEX. CIV. PRAC. & REM. CODE ANN. § 51.014(a)(9) (West Supp. 2015).
    2
    Standard of Review
    A trial court’s ruling on the sufficiency of an expert’s report is reviewed for an abuse of
    discretion. Van Ness v. ETMC First Physicians, 
    461 S.W.3d 140
    , 142 (Tex. 2015). A trial
    court abuses its discretion if it acts without reference to guiding rules or principles.           
    Id. However, in
    exercising its discretion, it is incumbent upon the trial court to review the report,
    sort out its content, resolve any inconsistencies, and decide whether the report demonstrated a
    good faith effort to show that the plaintiff’s claims have merit. See 
    id. at 144.
    When reviewing
    factual matters committed to the trial court’s discretion, an appellate court may not substitute its
    judgment for that of the trial court. 
    Id. Applicable Law
           Chapter 74 of the civil practice and remedies code governs health care liability claims.
    Brewster v. Columbia Med. Ctr. of McKinney Subsidiary, L.P., 
    269 S.W.3d 314
    , 316 n.3 (Tex.
    App.–Dallas 2008, no pet.). Any person who brings suit asserting a health care liability claim
    must provide an expert report for each physician or health care provider against whom a health
    care liability claim is asserted. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a) (West Supp.
    2015). An “expert report” is defined as a written report that provides a fair summary of the
    expert’s opinions as of the date of the report regarding applicable standards of care, the manner
    in which the care rendered by the physician or health care provider failed to meet the standards
    of care, and the causal relationship between that failure and the injury, harm, or damages
    claimed. 
    Id. § 74.351(r)(6);
    Bowie Mem’l Hosp. v. Wright, 
    79 S.W.3d 48
    , 51 (Tex. 2002) (per
    curiam). Although a claimant must timely file an adequate expert report as to each defendant in
    a health care liability suit, Chapter 74 does not require an expert report as to each liability theory
    alleged against that defendant. TTHR Ltd. P’ship v. Moreno, 
    401 S.W.3d 41
    , 45 (Tex. 2013);
    Certified EMS, Inc. v. Potts, 
    392 S.W.3d 625
    , 632 (Tex. 2013). Rather, a single liability theory
    meeting the statutory requirements is sufficient to defeat a motion challenging the adequacy of
    an expert report. Certified 
    EMS, 392 S.W.3d at 632
    .
    A trial court shall grant such a motion only if it appears to the court, after hearing, that
    the report does not represent an objective good faith effort to comply with the definition of
    “expert report” in section 74.351(r)(6). TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(l); see
    also Loaisiga v. Cerda, 
    379 S.W.3d 248
    , 260 (Tex. 2012). To represent an objective good faith
    effort to comply with statutory requirements, the expert report must (1) inform the defendant of
    3
    the specific conduct the plaintiff has called into question, and (2) provide a basis for the trial
    court to conclude that the claims have merit. 
    Loaisiga, 379 S.W.3d at 260
    ; Am. Transitional
    Care Ctrs. of Tex., Inc. v. Palacios, 
    46 S.W.3d 873
    , 879 (Tex. 2001).
    A causal relationship is established by proof that the negligent act or omission was a
    substantial factor in bringing about the harm, and that, absent this act or omission, the harm
    would not have occurred. Costello v. Christus Santa Rosa Health Care Corp., 
    141 S.W.3d 245
    ,
    249 (Tex. App.–San Antonio 2004, no pet.).           Causation is often established in medical
    malpractice cases through evidence of a “reasonable medical probability” or “reasonable
    probability” that the alleged injuries were caused by the negligence of one or more defendants.
    Jelinek v. Casas, 
    328 S.W.3d 526
    , 532–33 (Tex. 2010). In other words, the plaintiff must
    present evidence “that it is ‘more likely than not’ that the ultimate harm or condition resulted
    from such negligence.” 
    Id. (quoting Kramer
    v. Lewisville Mem’l Hosp., 
    858 S.W.2d 397
    , 399–
    400 (Tex. 1993)). An expert may show causation by explaining a chain of events that begins
    with a defendant doctor’s negligence and ends in injury to the plaintiff. See McKellar v.
    Cervantes, 
    367 S.W.3d 478
    , 485 (Tex. App.–Texarkana 2012, no pet.).
    A report is deficient if it states only the expert’s conclusions about the standard of care,
    breach of the standard of care, or causation. See Ortiz v. Patterson, 
    378 S.W.3d 667
    , 671 (Tex.
    App.–Dallas 2012, no pet.). An expert cannot simply opine that the breach caused the injury.
    Van 
    Ness, 461 S.W.3d at 142
    ; 
    Jelinek, 328 S.W.3d at 539
    . Rather, the report must explain, to a
    reasonable degree, how and why the breach of the standard of care caused the injury based on the
    facts presented. Van 
    Ness, 461 S.W.3d at 142
    ; 
    Jelinek, 328 S.W.3d at 539
    –40. The report must
    explain the basis of the expert’s statements to link his conclusions to the facts. Bowie Mem’l
    
    Hosp., 79 S.W.3d at 52
    ; see also Taylor v. Fossett, 
    320 S.W.3d 570
    , 575 (Tex. App.–Dallas
    2010, no pet.) (expert report must contain sufficiently specific information to demonstrate
    causation beyond conjecture).
    In determining whether the expert report represents a good faith effort to comply with the
    statutory requirements, the court’s inquiry is limited to the four corners of the report. Christian
    Care Ctrs., Inc. v. Golenko, 
    328 S.W.3d 637
    , 641 (Tex. App.–Dallas 2010, pet. denied) (citing
    
    Palacios, 46 S.W.3d at 878
    ). “We may not ‘fill gaps’ in an expert report by drawing inferences
    or guessing what the expert likely meant or intended.” Hollingsworth v. Springs, 
    353 S.W.3d 4
    506, 513 (Tex. App.–Dallas 2011, no pet.). “We determine whether a causation opinion is
    sufficient by considering it in the context of the entire report.” 
    Ortiz, 378 S.W.3d at 671
    .
    Discussion
    Dr. Davey opined that Pinecrest failed to prevent Bailey’s pressure ulcer, treat it once it
    developed, maintain sufficient staffing levels, and implement policies to prevent Bailey’s
    injuries. With regard to his theory that Pinecrest failed to prevent Bailey’s pressure ulcer, Dr.
    Davey explained in his report that Bailey suffered from several preexisting conditions such as
    hypertension, congestive heart failure, diabetes mellitus, and asthma. Dr. Davey also stated in
    his report as follows:
    [A] facility and its nurses [should] ensure that a resident who is admitted without pressure sores
    does not develop pressure sores unless the individual’s clinical condition demonstrates that the
    sores were unavoidable and that a resident who develops pressure sores receives necessary
    treatment and services to promote healing, prevent infection, and prevent new sores from
    developing.
    Pinecrest correctly argues that Dr. Davey did not discuss whether Bailey’s preexisting
    conditions made her development of a pressure ulcer unavoidable.                      Therefore, he has not
    adequately demonstrated causation on this theory. See, e.g., Christus Spohn Health Sys. Corp.
    v. Castro, No. 13-13-00302-CV, 
    2013 WL 6576041
    , at *6 (Tex. App.—Corpus Christi Dec. 12,
    2013, no pet.) (mem. op.) (holding that although allegation that nurse’s failure to assess skin was
    sufficient in report, expert failed to explain role of patient’s other complex medical conditions in
    developing pressure ulcer); Nexion Health at Southwood, Inc. v. Judalet, No. 12-08-00464-CV,
    
    2009 WL 3019717
    , at *4 (Tex. App.—Tyler Sept. 23, 2009, no pet.) (mem. op.) (holding expert
    report was insufficient on causation because expert failed to link conclusion that patient’s earlier
    fall resulting in broken leg contributed to congestive heart failure and death and did not discuss
    role of other conditions in death). However, as we have noted, an expert report need only allege
    one viable theory to be sufficient under Chapter 74. See Certified 
    EMS, 392 S.W.3d at 632
    .
    Dr. Davey separately opined that Pinecrest breached the standard of care by not only
    allowing the ulcer to develop, but also in “allowing the pressure ulcer to progress to a Stage IV,”
    which caused Bailey’s “soft tissues to become distorted and die.” Dr. Davey stated that Bailey
    suffered injuries as a result. In other words, even if the pressure ulcer was unavoidable, Dr.
    Davey directly concluded that it was treatable once it appeared. He specifically tracked the
    5
    development of Bailey’s ulcer while she was in Pinecrest’s care, stating in relevant part as
    follows:
    On 8-12-13, the nursing staff at Pinecrest Nursing noted a 0.3 x 0.2 cm macerated area on Ms,
    Bailey's gluteal fold. The area of skin breakdown on Ms. Bailey’s sacral area had developed a
    scant amount of serous exudate by 8-19-13, and nurses noted the area had “deteriorated.”
    Several days later, on 8-22-13, a Stage II pressure ulcer was discovered on Ms. Bailey’s sacral
    area that measured 1.0 x 0.3 cm and had a small amount of serous exudate present. Ms. Bailey
    began to experience a “continuous” and “aching” pain from her sacral ulcer on 9-3-13, and at this
    time, her Stage II pressure ulcer had increased in size to 0.8 x 1.0 x 0.2 cm. On 9-12-13, the
    nursing staff failed to stage the wound, but they noted measurements of 2.0 x 2.0 x 2.0 cm and the
    presence of serosanguineous drainage. By 9-17-13, Ms. Bailey had an unstageable pressure ulcer
    on her sacrum that measured 8.0 x 15.0 x >2.0 cm. According to the documentation in the weekly
    pressure ulcer record, the wound had a moderate amount of serosanguineous exudate and was
    causing Ms. Bailey a significant amount of pain.
    On September 19, 2013, Bailey was transferred to TMF, and later to other care providers, in
    order to treat her pressure ulcers. Upon admission at TMF, she was diagnosed with a Stage IV
    sacral pressure ulcer. Hospital staff also determined that Bailey was malnourished.
    In the standard of care section of Dr. Davey’s report related to Pinecrest’s failure to
    properly treat Bailey’s pressure ulcer, he stated that Pinecrest should position the patient so that
    pressure on the ulcer is relieved, provide pressure relieving devices, keep the patient clean and
    dry, and properly nourish the patient through a diet that will encourage healing. Dr. Davey also
    stated that the pressure ulcer and surrounding skin should be cleansed at the time of each
    dressing change, or it is unlikely to heal.             Finally, he stated that regular and complete
    assessments must be performed and documented so that the necessary interventions can be
    implemented.
    In the breach section, Dr. Davey opined that Pinecrest failed to comply with these
    standards. He stated that once the skin breakdown was discovered on Bailey’s sacrum, the
    nursing staff at Pinecrest should have been frequently monitoring the area, documenting any
    changes, and describing the progression of the wound. Instead, he continued, the nurses waited a
    week to reassess the area of skin breakdown, and by that time, it had deteriorated into a Stage II
    pressure ulcer. On September 12, 2013, the nurses assessed the ulcer as measuring 2.0 x 2.0 x
    2.0 cm, but failed to stage it. Five days later, Bailey’s ulcer had increased in size from 8.0 x 15.0
    x >2.0 cm, and became unstageable. Dr. Davey explained that once an ulcer is unstageable, it
    means that the ulcer is at least Stage III or Stage IV. But since the ulcer is heavily covered in
    6
    necrotic tissue at that point, the healthcare providers cannot determine how deep the injury
    extends under the skin. Later that same day, according to Dr. Davey, the wound was assessed
    for the first time in the nursing notes, and the entry described the wound as “deteriorated,” 100
    percent necrotic, with measurements of 18.0 x 10.0 cm. According to the entry, the wound’s
    depth could not be measured.
    Dr. Davey explained further that proper assessment is necessary to treat the ulcer, and
    that measurement and accurate description of wounds is crucial to track a wound’s progress and
    response to treatment. Proper assessment and prompt, accurate documentation and reporting
    inform the treating physicians and dieticians of the condition so that they can timely order and
    implement the proper interventions to treat the ulcer. According to Dr. Davey, based on his
    review of Bailey’s medical records, Pinecrest’s staff failed to regularly assess and accurately and
    consistently document the status and progression of the wound. Consequently, the attending
    physician was not timely notified of Bailey’s worsening condition. Dr. Davey stated that a
    wound care consultation and treatments were not ordered until after Bailey’s ulcer had developed
    a depth of 0.2 cm, which was indicative of a Stage III pressure ulcer. Aside from these orders,
    Dr. Davey explained, Bailey’s pressure ulcer was never mentioned in any of the physician’s
    progress notes or consultations. Dr. Davey opined that the nurses should have brought the
    wound and the fact that it was becoming necrotic to her physician’s attention. The failure to do
    so, he stated, prevented the physician from determining the necessity of interventions such as a
    low air mattress or a wound consult.
    Finally, in relation to Pinecrest’s alleged failure to properly treat the ulcer, Dr. Davey
    opined that Pinecrest failed to adequately monitor Bailey’s nutritional status and monitor her
    laboratory tests. Dr. Davey stated that there is an increased metabolic demand in healing a
    pressure ulcer, and that without monitoring her lab values, nursing staff were unaware of
    worsening albumin and pre-albumin levels. Dr. Davey stated that Bailey’s lab values were not
    taken until September 19, 2013, the date of her discharge. Those values indicated that Bailey
    was malnourished. He acknowledged that a multivitamin was administered, but Pinecrest failed
    to provide other interventions such as snacks, fortified meals, or providing more frequent,
    smaller meals to address the increased metabolic demand and promote healing.
    At the end of the breach section, Dr. Davey opined on causation and concluded that had
    Pinecrest’s nurses complied with these standards of care, the proper interventions could have
    7
    been implemented before Bailey’s pressure ulcer became unstageable, and ultimately progressed
    to a Stage IV ulcer when Bailey was discharged from Pinecrest and admitted at TMF. In the
    causation section of his report, Dr. Davey explained the nature of pressure ulcers and how they
    develop in the clinical setting. He stated that they develop when a patient has sustained pressure,
    often in combination with shear or friction, on soft tissues located over bony prominences. The
    pressure causes distortion in the soft tissues, which will result in a loss of blood flow through the
    vessels. Consequently, without nutrients, the tissue will become ischemic, and if sustained for a
    long enough period of time, necrosis of the tissue occurs.
    Dr. Davey stated that the standards of care related to treatment are intended to prevent
    ulcers from progressing from a Stage I or Stage II wound to a Stage III or Stage IV wound.
    When allowed to progress to those stages, he continued, the patient will suffer a number of
    complications directly caused by the failure to assess and treat the ulcer. Specifically, he noted
    that the ulcer at those stages will cause skin loss with extensive destruction, necrosis, and
    damage to muscle, bone, tendons, and other supporting structures. He noted that such severe
    ulcers will make the patient become more susceptible to infection and other complications
    related to the wound and its treatment, including increased morbidity and a higher mortality rate.
    Finally, he stated that the patient will have problems with pain and loss of dignity associated
    with the wound and its treatment, particularly due to fluid leakage, smell, discomfort, difficulties
    with mobility, and a decrease in appetite. Based on the medical records, Dr. Davey opined that
    Bailey suffered all of these complications. He also stated that she was required to endure
    multiple surgical debridements, placement of a “wound VAC,” and aggressive IV antibiotic
    therapy due to osteomyelitis and an infection with Proteus mirabillis.
    Dr. Davey concluded that “to a reasonable degree of medical probability, the breaches of
    the standard of care identified above proximately caused Ms. Bailey’s injuries, including the
    development of a Stage IV pressure ulcer.” He separately stated as follows:
    In my opinion, to a reasonable degree of medical probability, the breaches of the standard of care
    discussed above related to the assessment, prevention, and treatment of severe pressure ulcers
    were the proximate cause of Ms. Bailey’s severe pressure ulcer. As stated above, Pinecrest
    Nursing and its nursing staff failed to reposition Ms. Bailey every two hours, keep her skin clean
    and dry, and implement other appropriate interventions to relieve pressure and promote skin
    integrity. Pinecrest Nursing and its nursing staff also failed to properly treat the pressure ulcer and
    encourage its healing once it developed. Because Pinecrest Nursing failed to reposition her every
    two hours and failed to implement effective interventions, Ms. Bailey had sustained pressure on
    her sacral area, which caused the blood to stop flowing to that part of the body and the skin to
    8
    distort. Because of the lack of blood flow, the tissue died, causing Ms. Bailey to develop an
    infected Stage IV pressure ulcer.
    Pinecrest argues that Dr. Davey failed to explain that absent Pinecrest’s acts or
    omissions, the harm would not have occurred. It argues that Dr. Davey did not specifically
    identify the “interventions” or demonstrate how the failure to provide them caused harm to
    Bailey. Pinecrest also argues that Dr. Davey’s reasoning is based on speculation or conjecture.
    We disagree.
    We note that we review the entire report to determine the adequacy of the expert’s
    opinion on causation. See 
    Ortiz, 378 S.W.3d at 671
    . In reviewing the entire report, Dr. Davey
    explained the nature of pressure ulcers, that once they develop, the standard of care shifts from
    prevention to treatment, and that Pinecrest’s nurses should timely and accurately assess,
    document, and report the progression of the pressure ulcer. The purpose of this standard of care
    is to notify the patient’s care team so that the proper interventions can be timely provided to
    prevent progression to a Stage III or Stage IV pressure ulcer. As we have detailed above, Dr.
    Davey explained how Pinecrest failed in this regard. He also identified the “interventions”
    elsewhere in his report. For example, he stated that Pinecrest’s staff should keep Bailey’s skin
    clean and dry, reposition her every two hours, provide pressure relieving devices such as a low
    air mattress, and provide an appropriate diet.          Dr. Davey concluded that these failures, in
    reasonable medical probability, caused Bailey’s pressure ulcer to progress to a Stage IV wound.
    Dr. Davey adequately linked the facts alleged in his report to his conclusions.
    Pinecrest claims that Bailey’s medical records reflect no entries that she had been
    repositioned in her three years as a resident prior to the incident, yet Bailey did not develop a
    pressure ulcer until 2013. It contends that had she not been repositioned during that time period,
    she would have developed pressure ulcers much sooner. Thus, its argument continues, Dr.
    Davey speculated when he opined that the lack of entries related to repositioning meant she was
    not in fact repositioned. Pinecrest relies on authority stating that a medical expert’s opinion
    cannot be based on speculation or conjecture, and must show more than the conduct possibly
    caused the harm. See, e.g., Hutchinson v. Montemayor, 
    144 S.W.3d 614
    , 618 (Tex. App.—San
    Antonio 2004, no pet.). While we agree with that statement of the law, the court in Hutchinson
    held that the expert’s opinion that “[i]f an arteriogram had been done, there would have been a
    possibility that [the patient] may have had bypassable lesions and that the amputation may have
    9
    been avoided[,]” was insufficient. See 
    id. at 617
    (emphasis added). The court further held that
    his conclusion that there was a possibility of a better outcome was speculative. See 
    id. Here, Dr.
    Davey opined that Pinecrest’s nursing staff’s failure to assess, document, and report the
    progression of the pressure ulcer directly caused her harm, because the interventions were not
    timely provided. Moreover, we are confined to the four corners of the report, and defer to the
    trial court’s determination of the facts alleged in the report. See Van 
    Ness, 461 S.W.3d at 144
    ;
    
    Palacios, 46 S.W.3d at 878
    .
    Dr. Davey explained that the basis for his opinion as to preventing the ulcer’s
    advancement is the lack of entries in Bailey’s records, because this prevented her treating
    physician and nutritionist from timely providing interventions. He explained that the standard of
    care requires that Pinecrest’s staff track its progression and document it in the patient’s records.
    Those entries were plainly absent according to Dr. Davey.             To corroborate the lack of
    communication to the physician, Dr. Davey also explained that Bailey did not receive a wound
    care consultation or treatments until after the ulcer had progressed to Stage III, and that other
    than those orders, Bailey’s ulcer was not mentioned in any of the physician’s progress notes. By
    cross referencing these documents, and relying on his experience in practice treating pressure
    ulcers, he explained that “it is clear that the assessments, treatments, and interventions described
    above were not performed here.” Bailey is not required to marshal all her evidence at this stage
    of the proceeding. See 
    Palacios, 46 S.W.3d at 878
    -79. Pinecrest’s theory that the interventions
    were in fact timely performed is an issue for trial.
    Pinecrest also argues that Dr. Davey failed to discuss the fact that ulcers may develop and
    deteriorate very quickly in patients despite adequate care, and that Bailey continued to develop
    pressure ulcers even after she left Pinecrest. As we have discussed, we examine only the four
    corners of the report, giving deference to the trial court’s resolution of the factual allegations in
    the report. See Van 
    Ness, 461 S.W.3d at 144
    ; 
    Palacios, 46 S.W.3d at 878
    . As we have
    explained, Dr. Davey adequately linked his discussion of the facts in his report to the conclusion
    that Pinecrest’s breach of the standard of care proximately caused Bailey’s harm on at least one
    theory. Furthermore, by the time the other hospitals began treating it, the ulcer had already
    progressed to a Stage IV ulcer with necrosis. He explained that the basis for this theory was that
    Pinecrest failed to prevent it from becoming a Stage III or Stage IV. The other health care
    10
    providers’ treatment of the wound after it had advanced to Stage IV is irrelevant at this stage of
    the proceeding to this particular theory asserted by the Baileys.
    Finally, Pinecrest argues that although Dr. Davey contended that Bailey’s Stage IV
    pressure ulcer contributed to her death, he did not opine, under the correct legal standard, that the
    ulcer was a “substantial factor” in her death. The Baileys sued Pinecrest only in their capacity as
    heirs, not in their individual capacities. Their petition specifically identifies only a survival
    cause of action. However, in the damages section, the Baileys averred that not only did Bailey
    suffer damages, but they did as well. The Baileys concede in their brief that they are seeking
    damages only under a survival cause of action for Bailey’s damages, not their own damages
    under a wrongful death cause of action. In other words, the Baileys make no contention that
    Pinecrest’s actions caused Bailey’s death, even though Dr. Davey attempted to opine on that
    issue.
    We hold that the trial court correctly concluded that Dr. Davey’s report satisfies Chapter
    74’s requirements on at least one theory.4 Consequently, Pinecrest’s sole issue is overruled.
    DISPOSITION
    Having overruled Pinecrest’s sole issue, we affirm the trial court’s order denying its
    motion to dismiss.
    BRIAN HOYLE
    Justice
    Opinion delivered May 27, 2016.
    Panel consisted of Worthen, C.J., Hoyle, J., and Neeley, J.
    (PUBLISH)
    4
    Since we have held that the failure to treat theory was sufficiently alleged, we need not address the
    Baileys’ remaining theories. See Certified 
    EMS, 392 S.W.3d at 632
    .
    11
    COURT OF APPEALS
    TWELFTH COURT OF APPEALS DISTRICT OF TEXAS
    JUDGMENT
    MAY 27, 2016
    NO. 12-14-00357-CV
    PINECREST SNF, LLC D/B/A PINECREST NURSING & REHABILITATION
    CENTER,
    Appellants
    V.
    TASCO BAILEY, NATHAN BAILEY, CARLIE BAILEY, ROY BAILEY, BILL BAILEY,
    JAMES BAILEY, EARL BAILEY, MARY DUNLAP AND LICILLE MARTIN, AS
    HEIRS OF ARCHIE BAILEY,
    Appellees
    Appeal from the 114th District Court
    of Smith County, Texas (Tr.Ct.No. 14-0856-B)
    THIS CAUSE came to be heard on the oral arguments, appellate record
    and briefs filed herein, and the same being considered, it is the opinion of this court that there
    was no error in the trial court’s order.
    It is therefore ORDERED, ADJUDGED and DECREED that the order
    denying Appellants’ motion to dismiss of the court below be in all things affirmed, and that all
    costs of this appeal are hereby adjudged against the Appellants, PINECREST SNF, LLC D/B/A
    PINECREST NURSING & REHABILITATION CENTER, for which execution may issue,
    and that this decision be certified to the court below for observance.
    Brian Hoyle, Justice.
    Panel consisted of Worthen, C.J., Hoyle, J., and Neeley, J.