Select Specialty Hospital-Houston Limited Partnership D/B/A Select Specialty Houston - Houston West v. Keith Simmons and Kirk Simmons ( 2013 )


Menu:
  • 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).
    24