Fall into a hole in the ground, and it's a med-mal case, or it could be ... Crawl out, go to court, and get buried once more: Comment on Nicole Little v Riverside General Hospital Inc. (Tex.App. - Houston Jan 14, 2016)

News of the weird: You have to be a lawyer to make sense of this, and preferably a regular consumer of Texas Supreme Court juris(mal)prudence to truly appreciate the nuances.  

What is a health-care liability claim? -- Slippery slope is back in operation with grease pit variation on the perennial theme.  

Houston Court of Appeals Justice Marc W. Brown, writing for panel of three, blesses dismissal of premises liability lawsuit by a plaintiff who fell into a grease pit on hospital grounds because she did not file an expert report to explain how her precipitous descent into the netherworld was medical malpractice. 

The problem - you see - is that this personal injury plaintiff was a patient. And patients are held to a higher standard when it comes to proving a negligence claim. Falling into a pit that wasn't properly covered is not enough. Patients also have to jump through some hoops. Like filing expert reports. It's all for their own good, of course. The care providers owe it to them. 

The bitter end: Case dismissed. Defendants get attorney's fees, for good measure; -- to hold them harmless for the trouble of getting the complaint by the uppity injured patient quashed. How dare she sue a hospital!   
  

Nicole Little appeals from the trial court’s dismissal of her suit against
Riverside General Hospital for injuries sustained from a fall on hospital grounds.

The trial court dismissed the suit under section 74.351(b) of the Texas Civil
Practice and Remedies Code, finding that Little failed to provide the hospital with
an expert report as required. In one issue, Little contends that the trial court erred
in dismissing her claim because it is not a “health care liability claim” as defined
by the Civil Practice and Remedies Code.

We hold that Little’s claim is substantively related to the hospital’s provision of
health care and, therefore, is a health care liability claim. We affirm.

Factual and Procedural Background

Appellant Nicole Little filed suit against appellee Riverside General Hospital
for injuries resulting from a fall into a grease pit on hospital grounds. The facts
surrounding the fall are undisputed. Little was an inpatient resident receiving
treatment for substance abuse at Riverside’s Houston Recovery Campus. At the
time of the incident, Little was participating in an informal cookout held outside on
the grounds of the hospital. Little noticed a child standing on a wooden pallet
covering a grease pit. Little approached the child to remove him from the pallet.
Before she could remove him, the child jumped off of the pallet, causing the pallet
to flip upwards and causing Little to fall into the pit. Because of the depth of the
pit, Little was unable to exit the pit by herself. The fire department responded to
the incident and lowered a ladder into the pit to help Little climb out to safety.
Little alleges that she suffered an injury to her ankle as well as severe mental
anguish.
Little filed suit under a premises liability theory, claiming that Riverside
owed a duty of care requiring it to inspect hospital grounds for any latent defects
and to make them safe or to give residents an adequate warning of the dangers
posed by these defects. In its answer, Riverside characterized Little’s claim as a
health care liability claim governed by the Texas Medical Liability Act (TMLA).
Riverside later filed a motion to dismiss under section 74.351(b) of the TMLA,
claiming that Little had failed to present Riverside with the expert report required
by that section of the Act.1
 After a hearing, the trial court granted Riverside’s
motion to dismiss. Little now appeals the dismissal of her case, arguing that
section 74.351 does not apply to this lawsuit because her claim is not a health care
liability claim.

Analysis

Little argues that her claim is not a health care liability claim within the
meaning of the TMLA because it alleges a breach of duty unrelated to Riverside’s
provision of health care. Ordinarily, we review a trial court’s order granting or
denying a section 74.351(b) motion to dismiss for abuse of discretion. Memorial
Hermann Hosp. Sys. v. Galvan, 434 S.W.3d 176, 179 (Tex. App.—Houston [14th
Dist.] 2014, pet. granted), rev’d on other grounds, No. 14-0410, 2015 WL
7791565, —S.W.3d— (Tex. 2015) (per curiam). However, because the issue in
this case requires us to interpret the statute to determine whether it extends to
Little’s claim, we review the trial court’s judgment de novo. Id.
The TMLA defines a “health care liability claim” as:
a cause of action against a health care provider or physician for
treatment, lack of treatment, or other claimed departure from accepted
standards of medical care, or health care, or safety or professional or
administrative services directly related to health care, which
proximately results in injury to or death of a claimant, whether the
claimant’s claim or cause of action sounds in tort or contract.
Tex. Civ. Prac. & Rem. Code Ann. § 74.001(a)(13) (West 2015). According to
this definition, “there are three basic elements of a health care liability claim: (1) a

1 “In a health care liability claim, a claimant shall, not later than the 120th day after the
date each defendant’s original answer is filed, serve on that party or the party’s attorney one or
more expert reports, with a curriculum vitae of each expert listed in the report for each physician
or health care provider against whom a liability claim is asserted.” Tex. Civ. Prac. & Rem. Code
Ann. § 74.351(a) (West 2015). 

physician or health care provider must be a defendant; (2) the claim or claims at
issue must concern treatment, lack of treatment, or a departure from the accepted
standards of medical care, or health care, or safety or professional or administrative
services directly related to health care; and (3) the defendant’s act or omission of
which the claimant complains allegedly must have been the proximate cause of
injury to the claimant.” Galvan, 434 S.W.3d at 179. The parties do not dispute
that Riverside is a health care provider under the statute. The only issue before us
is whether Riverside’s alleged breach of duty is a departure from safety standards
related to health care.

In its recent decision in Ross, the Texas Supreme Court held that, in a safety
standards-based claim against a health care provider, the standards allegedly
breached by the provider need not be “directly related to health care,” but they
must have a “substantive relationship” to the provision of health or medical care.2

Ross v. St. Luke’s Episcopal Hosp., 462 S.W.3d 496, 504 (Tex. 2015). Here, Little
insists that her claim is strictly one of premises liability, alleging a breach of duty
unrelated to the provision of health care. But even though Little has pleaded her
claim as one of premises liability, we must “consider the underlying nature of the
claim” when determining whether it is directly or substantively related to health
care. Omaha Healthcare Ctr., LLC v. Johnson, 344 S.W.3d 392, 394 (Tex. 2011).
Little’s premises liability claim assumes that the duty to inspect, make safe,
or warn arises only from Riverside’s status as the operator of the property and her

2 In Tex. West Oaks Hospital, LP v. Williams, the Texas Supreme Court held that, in the
definition of “health care liability claim” provided in section 74.001(a)(13), the phrase “directly
related to health care” modifies only the terms immediately before it—“professional or
administrative services”—but does not modify “safety.” 371 S.W.3d 171, 185–86 (Tex. 2012).
In Ross, the Court clarified its holding and ruled that, while “directly related to health care” did
not modify “safety,” there nonetheless must be some substantive relationship between the safety
standards that are alleged to have been breached and the provision of health care. 462 S.W.3d at
502–04. 

own status as an invitee on that property. We note that Riverside’s status as
Little’s health care provider also imposes on it a duty to maintain her safety, the
breach of which can be the crux of a health care liability claim under the TMLA.
See Ross, 462 S.W.3d at 505; Diversicare Gen. Partner, Inc. v. Rubio, 185 S.W.3d
842, 850–51 (Tex. 2005) (healthcare facilities have a different obligation to their
residents than non-treating premises owners do). “The pivotal issue in a safety
standards-based claim is whether the standards on which the claim is based
implicate the defendant’s duties as a health-care provider, including its duties to
provide for patient safety.” Ross, 462 S.W.3d at 505.
Relying on the Supreme Court’s decision in Loaisiga v. Cerda, Little argues
that the maintenance of the grease pit on hospital grounds is “wholly and
conclusively inconsistent with, and thus separable from” the rendition of health
care. 379 S.W.3d 248, 257 (Tex. 2012). However, Loaisiga is distinguishable
from the case at hand. Loaisiga involved actions by a health care provider that
were outside the scope of and not incident to the care that the provider’s patients
were seeking.3
 Id. Here, the residential care that Little sought necessarily required
that the hospital take action to ensure her safety at all times in which she was a

3 In Loaisiga, the patients were seeking treatment for sinus and flu-like symptoms. 379
S.W.3d at 253. During the course of the exams, the doctor groped the patients’ breasts. Id. The
Supreme Court concluded that this touching was inappropriate and not within the scope of the
treatment sought, meaning that the plaintiffs’ claims were not within the scope of the TMLA. Id.
at 257. The Court distinguished Loaisiga from a similar case, Vanderwerff, in which the plaintiff
filed suit after a chiropractic exam in which she alleged that the chiropractor inappropriately
touched her genitals. Id. at 256–57; Vanderwerff v. Beathard, 239 S.W.3d 406, 409 (Tex.
App.—Dallas 2007, no pet.). The Vanderwerff court held that the touching of the plaintiff’s
genitals could have been within the scope of the exam because the plaintiff was seeking care for
pain running from her knee to her upper thigh. 239 S.W.3d at 409. Because the touching
ostensibly could have been within the scope of the care requested, the court of appeals held that
the plaintiff’s claim was a health care liability claim. We conclude that Little’s case is more like
Vanderwerff than Loaisiga because the maintenance of safety on hospital grounds is certainly
within the scope of Little’s residential treatment program and thus is not separable from the
provision of her health care. 

patient at the facility. Protection of patient safety—including maintenance of
hospital grounds to prevent injury—is part and parcel of the provision of health
care, especially in the context of residential treatment. We find case law regarding
a health care liability claim in the residential nursing home context to be
illustrative. Little’s case is similar to Johnson, where the claim involved a resident
of a nursing home who was fatally injured when she was bitten by a brown recluse
spider. 344 S.W.3d at 393. Like Little, the deceased’s representative pleaded the
claim under a premises liability theory, alleging that the nursing home failed to
inspect the premises for pests. Id. at 393. The Texas Supreme Court held in
Johnson—and reiterated in Ross—that the claim was ultimately a health care
liability claim because it alleged a departure from the “fundamental patient care
required of a nursing home . . . to protect the health and safety of its residents.” Id.
at 394 (citing 40 Tex. Admin. Code §§ 19.1701, 19.401(b) (2015)); Ross, 462
S.W.3d at 502 (discussing Johnson as a case in which the patient’s negligence
claim was directly related to the provision of health care). 4

Substance abuse treatment centers like Riverside are required to adhere to
the same standard of care for their patients—a standard that includes the
maintenance of a safe environment. 25 Tex. Admin. Code § 448.211 (2015)
(Department of State Health Servs. Substance Abuse Treatment Standard of Care)
(requiring substance abuse treatment centers to provide an “appropriate, safe,
clean, and well-maintained environment”). Little’s allegation that Riverside failed
to make its grounds safe for its residents is an allegation that it did not comport

4 The Texas Administrative Code provides that a nursing home must provide “a safe,
functional, sanitary, and comfortable environment” for residents. 40 Tex. Admin. Code
§ 19.1701 (2015) (Tex. Dep’t of Aging and Disability Servs. Nursing Facility Quality of Life
Requirements). The Code also contains a “Statement of Resident Rights” that provides a right to
“safe, decent, and clean conditions” for nursing home residents. Id. § 19.401(b) (2015) (Tex.
Dep’t of Aging and Disability Servs. Nursing Facility Statement of Resident Rights). 

with the required standard of patient care. We conclude that the Little’s claim,
despite being pleaded in the language of premises liability, alleges a “violation[] of
safety standards directly related to the provision of health care,” which includes
protecting patients from injury on hospital premises. Ross, 462 S.W.3d at 502
(citing Johnson, 344 S.W.3d at 394–95).

Conclusion

Under Ross, Little’s claim is a health care liability claim and, as such, is
subject to the requirements set forth in section 74.351. We affirm the judgment of
the trial court dismissing Little’s claim for noncompliance with the TMLA.

/s/ Marc W. Brown

Justice

Panel consists of Justices Boyce, Busby, and Brown.