Robinson v. Canton Harbor Healthcare Ctr., Inc.

314 A.3d 451

261 Md.App. 560

Felicia ROBINSON, et al.

v.CANTON HARBOR HEALTHCARE CENTER, INC.

No. 2169, September Term, 2022

Appellate Court of Maryland.

April 24, 2024

Circuit Court for Baltimore City, Case No.: 24-C-22-001200, Jeffrey M. Geller, Judge

Argued by Mark E. Herman, Baltimore, MD, on brief, for Appellant.

Argued by Dylan K. Bernstein (D. Elizabeth Walker, Rockville, MD), on brief, for Appellee.

Argued before: Arthur, Beachley, Deborah S. Eyler (Senior Judge, Specially Assigned), JJ.

Beachley, J.

[1] In this appeal from the dismissal of a complaint against a skilled nursing facility under Maryland’s Health Care Malpractice Claims Act (the "HCMCA"), alleging negligent failure to prevent and treat decubitus ulcers, we resolve a question of first impression by holding that the statutorily required certificate of qualified expert ("CQE") may be predicated on a proximate cause attestation from a registered nurse ("RN"), rather than a physician. See Md. Code (1974, 2020 Repl. Vol.), § 3-2A-04 of the Courts & Judicial Proceedings Article ("CJP").

As personal representative of her late husband Everett Robinson’s estate, and in her capacity as his survivor, Felicia Robinson, appellant, sued Canton Harbor Healthcare Center, Inc., appellee ("Canton Harbor"), where Mr. Robinson was an inpatient for approximately five months following his hospitalization for a stroke.¹ Mrs. Robinson alleged that this skilled nursing facility was negligent in its care of her husband, causing him to suffer injuries from decubitus (or pressure) ulcers.

The Circuit Court for Baltimore City dismissed her complaint, ruling that a registered nurse is not qualified to attest to proximate causation for the purpose of satisfying Maryland’s statutory requirement that "[a] person having a claim against a health care provider for damage due to a medical injury" must timely file a CQE "attesting to departure from standards of care, and that the departure from standards of care is the proximate cause of the alleged injury[.]" See CJP § 3-2A-04(a)(1)(i), (b)(1)(i). The court also denied Mrs. Robinson’s request for leave to amend her CQE and complaint, effectively foreclosing any further relief given the expiration of limitations.

Interpreting Maryland’s statutory language in light of its purpose and related regulations, we conclude that in a medical negligence case alleging ulcer injury, a CQE may be predicated on a proximate causation attestation by a registered nurse with sufficient education and experience in skilled nursing standards for preventing and treating pressure ulcers.² Because Mrs. Robinson’s CQE is sufficient based on the certifying registered nurse’s expertise, the Circuit Court for Baltimore City erred in dismissing this action. Consequently, we will vacate the judgment and remand for further proceedings.

BACKGROUND

The Complaint and Certificate of Qualified Expert

On March 7, 2022, Felicia Robinson, as personal representative of the Estate of Everett Robinson and as his surviving widow, filed a complaint against Canton Harbor. She alleged that Mr. Robinson was admitted to this long-term care facility "after being transferred from Johns Hopkins Hospital for follow up care due to a stroke." "During his admission, the deceased developed left leg ulcers which were brought to the attention of the facility in which [he] should have been properly treated and care[d] for." Yet "[t]he bedsores were allowed to develop and spread to the buttocks area as well as the inner thigh." "As a direct and proximate result of the Defendant’s neglect," Mrs. Robinson contended, "the areas became infected and deceased was transferred and received further treatment and care for his condition at other facilities[;] however, this condition worsened and he became septic and died." Canton Harbor allegedly "breached the standard of care by failing to proper[ly] turn the deceased, failure to do proper skin checks, failure to respond to complaint[s] about the pressure ulcers and was otherwise negligent."

In Count One, Mrs. Robinson alleged that "[a]s a direct and proximate result, the deceased suffered pain, incurred medical bills and the Estate incurred funeral expenses." In Count Two, she and Mr. Robinson’s three surviving children alleged that "[a]s a result of the negligence" by Canton Harbor, they "suffered and continue to suffer enormous grief, sadness, and emotional pain and suffering as a direct and proximate result of the wrongful death and were otherwise injured and damaged." Mrs. Robinson and her children later abandoned their wrongful death claim.

Canton Harbor was served with the complaint and corresponding documents, including a CQE in which a registered nurse, Anjanette Jones-Singh, attested:

1. I am a registered nurse and am familiar with and knowledgeable of the standards of care applicable to the treatment and care of an individual under the circumstances of the treatment and care as provided to Everette [sic] Robinson in this matter.

…

3. I have reviewed the pertinent medical records pertaining to the deceased’s treatment and care.

4. In my opinion to a reasonable degree of medical certainty [Canton Harbor] breached the standard of care and the breach was the proximate cause of Mr. Robinson’s injuries, i[.]e., the development of his pressure ulcers.

5. I hereby incorporate my report herein dated September 7, 2021.

Consequently, we next examine the contents of Jones-Singh’s detailed report.

Jones-Singh’s Affidavit and Report

Jones-Singh prepared a 19-page report and affidavit, reviewing Mr. Robinson’s care at Canton Harbor, where "he was completely dependent for care" and unable to either communicate effectively or move independently. Jones-Singh had been a registered nurse for over sixteen years, during which she had "routinely perform[ed] skin evaluations on [her] patients, identified pressure ulcers, classified the staging³ of each ulcer and proposed a treatment and care plan to heal the ulcer" for more than "500 patients." She had "worked as a wound care nurse … at Arcola Nursing and Rehabilitation Center," from 2006-2008, during which she "routinely diagnosed the cause of pressure ulcers." In her current position as "a longterm care Director of Nursing and Resident Assessment Coordinator[,]" she has "received annual updates in the field of wound care and pressure ulcers." She stated that she is "abundantly qualified by background, education and experience to address the issues as to whether Mr. Robinson’s treatment was within the standard of care and whether the failure to comply with the standard caused him injury, which it did, in the form of a pressure ulcer."

Jones-Singh reviewed Canton Harbor’s records related to Mr, Robinson, which included those relevant to the "development of wounds in this case," i.e., the "[a]dmission assessment" and "[s]ubsequent skin" and "[n]utritional assessments," "[c]are [p]lans" and "progress notes" by physicians and nurse practitioners, "[w]ound [e]valuations," and the "MDS."⁴ In addition, she reviewed Mr. Robinson’s medical history showing his "admitting diagnoses" and medications.

Mr. Robinson was admitted on August 16, 2018, and discharged on January 5, 2019. According to Jones-Singh, given Mr. Robinson’s physical and cognitive limitations throughout his admission, he "was only oriented to himself" and "relied heavi- ly on staff to turn and reposition him, assist him with ADL care,⁵ provide him with nutrition, and anticipate his needs."

At his "initial admission assessment, conducted by Tracey Tralany, RN on August 16, 2018[,] … Mr. Robinson did not have a pressure ulcer on admission." According to Jones-Singh, although he presented "with a surgical incision to the left side of his head[,]" it was "[d]uring his stay at Future Care" that "Mr. Robinson developed pressure ulcers to his right buttock and left buttock, which were then merged into a sacral ulcer."

Jones-Singh recounted Mr. Robinson’s deteriorating skin condition following his admission to Canton Harbor. Given his "initial Braden scale, which is a tool used to determine the risk that a person has to develop pressure ulcer[s]," Mr. Robinson "was at high risk for developing pressure ulcers, with a score of 11." Initial orders called for the facility to implement orders to "Float heels[,]" "Turn and Reposition[,]" and use "Barrier Cream[,]" a "Pressure reducing Mattress[,]" and a "Pressure reducing cushion[.]"

According to facility records, on August 20, just four days after admission, Mr. Robinson had "developed a right buttock ulcer" and "a left buttock ulcer." Moreover, the same day, Mr. Robinson was noted to have "skin impairment to his sacral area." According to Jones-Singh,

[i]nitially, this area was classified as Incontinence Associated Dermatitis (IAD). The standard of practice states that any wound noted on a pressure ulcer site must be classified as such. Therefore, IAD cannot be the etiology of a sacral ulcer. The same sacral ulcer was initially observed as a stage 2 ulcer and had declined to a stage 3 ulcer, where it needed a topical debriding agent in which Santyl was ordered.

Mr. Everett Robinson was noted with a Suspected Deep Tissue Injury surrounding his sacral ulcer in a weekly skin note[ ] dated September 28, 2018. A suspected deep tissue injury is damage[ ] to underlying skin only caused by friction and/or shearing. Therefore, Future Care Canton Harbor directly caused the SDTI to the sacrum noted on Mr. Robinson as there is no other etiology for this type of wound.

Jones-Singh noted that Mr. Robinson "was not started on Eliquis until September 11, 2018," even though such anti-coagulant "intervention … should have [been] put in place" from the outset "to assist with tissue perfusion[,]" given the patient’s high risk of developing pressure ulcers. In turn, "this delay led to a decrease in Mr. Robinson’s tissue perfusion" that contributed to his development of pressure ulcers. By the time he began receiving Eliquis, Mr....