                    IN THE COURT OF APPEALS OF IOWA

                                   No. 20-0553
                               Filed June 3, 2020


IN THE INTEREST OF C.C.,
Minor Child,

J.T., Mother,
       Appellant.
________________________________________________________________


      Appeal from the Iowa District Court for Tama County, Casey D. Jones,

District Associate Judge.



      A mother appeals the termination of her parental rights to her daughter.

AFFIRMED.



      Geneva L. Williams, Cedar Rapids, for appellant mother.

      Thomas J. Miller, Attorney General, and Mary A. Triick, Assistant Attorney

General, for appellee State.

      Deborah M. Skelton, Walford, attorney and guardian ad litem for minor child.



      Considered by Bower, C.J., May, J., and Vogel, S.J.*

      *Senior judge assigned by order pursuant to Iowa Code section 602.9206

(2020).
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VOGEL, Senior Judge.

       A mother appeals the termination of her parental rights to her daughter,

C.C., born in September 2015. Because of the child’s physical and cognitive

disabilities and the mother’s inability to provide the diligent care this child needs,

we affirm the juvenile court’s order of termination.

       C.C. came to the attention of the Iowa Department of Human Services

(DHS) shortly after her birth because of her medically fragile condition and the

mother’s inability to meet the child’s critical needs.1 C.C. was hospitalized for the

first fifteen months of her life with cognitive, digestive, and cardiac issues. She

was eventually moved to her mother’s care; however, concerns began to arise

when the mother failed to take C.C. to scheduled medical appointments, follow

medical advice, and tend to C.C.’s critical needs.          As a result, C.C. was

hospitalized multiple times. In October 2018, at age three, she was removed from

the mother’s care, hospitalized for one month, and then placed in foster care. Upon

the stipulation of all parties, C.C. was adjudicated a child in need of assistance

(CINA) on December 19, 2018. At the April 17, 2019 dispositional hearing, the

court adopted the recommendations of the DHS, which included having the mother

complete a psychological evaluation with a cognitive component and any

recommendations stemming from the evaluation. She was also to attend C.C.’s

medical appointments, cooperate with C.C.’s medical team, and carry out the

team’s regime of C.C.’s required care. A range of services were outlined and

provided for the mother to achieve reunification.


1At the time of the termination hearing, her ongoing medical needs included a
special diet delivered through a G-tube.
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         After more than sixteen months of services offered, but with little progress

being made, the State moved to terminate the mother’s parental rights. A hearing

was held on February 24 and March 2, 2020, after which the juvenile court found

clear and convincing evidence to grant the State’s petition. The mother appeals.2

         We review termination proceedings de novo, giving weight to but not being

bound by the juvenile court’s findings. In re C.B., 611 N.W.2d 489, 492 (Iowa

2000). Our primary concern is the best interest of the child. In re J.E., 723 N.W.2d

793, 798 (Iowa 2006).

         The mother asserts the State failed to prove the last element of Iowa Code

section 232.116(1)(f) (2019),3 namely that C.C. could not be returned to her at the

present time. The thrust of her argument is that she was not given the opportunity

to demonstrate her ability to adequately provide for C.C.’s medical needs. She

notes the inadequacy of the three formal training sessions provided to her: a

University of Iowa Hospitals and Clinics apartment experience from November 6

to 8, 2018; a Gastrostomy Cares Teaching on March 28, 2019; and a Central Line

Cares review on July 18, 2019. Although at first blush this may seem inadequate,


2   The father’s parental rights were also terminated. He does not appeal.
3   Iowa Code section 232.116(1)(f) states:
                (1) The child is four years of age or older.
                (2) The child has been adjudicated a child in need of
         assistance pursuant to section 232.96.
                (3) The child has been removed from the physical custody of
         the child’s parents for at least twelve of the last eighteen months, or
         for the last twelve consecutive months and any trial period at home
         has been less than thirty days.
                (4) There is clear and convincing evidence that at the present
         time the child cannot be returned to the custody of the child’s parents
         as provided in section 232.102.
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the detail notes describing these training sessions all comment on the inability of

the mother to process and retain the procedures necessary to be able to carry

them out unsupervised.      Initially, a manual was provided to the mother that

included printed instructions and diagrams depicting the use of various equipment

and supplies. Later, a hands-on apartment experience was set up to teach the

mother how to properly care for C.C’s constant medical needs. The apartment

experience is normally only a one-day event, but because the mother was not

learning as anticipated, it was extended to two days, which included overnight

care. Several nurses who supervised the experience wrote summaries of their

interaction with the mother and noted that the mother was often asleep or busy

when C.C. required care, resistant to following instructions, impatient with C.C.’s

reactions, and unable to complete the care sessions. She needed to be reminded

time and again as to what was required for safe, hygienic care with little room for

error in treating a child with such complex medical needs. The physicians who

participated in the apartment experience wrote, “[S]ignificant safety concerns

seem to exist regarding [the] mother’s administration of medications, feeds and

handling of her central line during this apartment experience.” The April 17, 2019

dispositional order continued C.C.’s out-of-home placement “because concerns

remain over the mother’s ability to safely take care of the child’s extensive medical

care.” No indications of improvement were noted in the supervised visits that

occurred, and the DHS worker testified the mother was “unsuccessful in—with

demonstrating that she can take care of even her own basic needs, and then on

top of that, to take care of [C.C.]’s basic needs.” The mother admitted during the

termination hearing that C.C.’s physician at the University of Iowa Stead Family
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Children’s Hospital bent over backwards to try to help her with C.C. Nevertheless,

she acknowledged she remained confused as to C.C.’s proper care. We agree

with the juvenile court that throughout these proceedings, the mother “has been

given multiple opportunities to demonstrate that she knows how to perform the

vital, everyday procedures that keep [C.C.] safe and healthy and she has failed in

all of those opportunities.” We find clear and convincing evidence supports the

findings under Iowa Code section 232.116(1)(f) and affirm.

       Next, the mother asserts the juvenile court should have granted her

additional time for reunification. Under Iowa Code section 232.104(2)(b), a court

may authorize a six-month extension of time if it determines “the need for removal

of the child from the child’s home will no longer exist at the end of the additional

six-month period.” When given the opportunity to learn, the mother was often

resistant, stating she would do things her own way if she were able to take C.C.

home. After the mother was granted semi-supervised visits, the visits were quickly

returned to fully supervised after it was determined C.C. ingested ethanol while

being alone in the mother’s care for just forty-five minutes.        C.C. required

hospitalization as a result of that incident. Further, the mother did not complete

DHS’s recommendation, as adopted by the juvenile court, that she undergo a

cognitive evaluation to assess her ability to process, retain, and carry out the

instructions critical to C.C.’s care. The DHS worker testified that additional “time

is irrelevant” because simply providing more time would not make the mother more

capable to do the things that were beyond her capacity to grasp and maintain at a

skill level to keep C.C. safe. The court found the mother showed little improvement

in the areas of feeding and proper cleaning techniques and “there does not appear
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to be any indication that the mother will improve in these areas within an additional

reasonable amount of time.” While “a parent’s intellectual disability ‘alone is not

sufficient grounds for termination,’” such a disability “can be a relevant

consideration when it affects the child’s well-being.” In re A.S., 906 N.W.2d 467,

473 (Iowa 2018) (quoting In re A.M., 843 N.W.2d, 100, 111 (Iowa 2014)). We

agree and affirm the juvenile court’s denial of additional time.

       Lastly the mother asserts termination of her parental rights is not in C.C.’s

best interests. In doing so, the mother conflates Iowa Code section 232.116(2)

and (3).4 Nonetheless, we address her contention that her bond with C.C. is

strong. The State asserts that bond has weakened in part because of several

examples of the mother’s inappropriate statements and behavior in C.C.’s

presence. The record includes some of the mother’s admitted outbursts in front of

C.C. that caused C.C. confusion and trauma, which does not reflect a strong bond.

Moreover, the mother missed more than one-half of the visits she was afforded

with C.C.   In January 2020, just prior to the termination hearing, C.C. was

hospitalized for fourteen days and the mother failed to visit her even one time.

       Although the juvenile court noted the mother’s love for her daughter, the

extent of any bond they may share is “unclear.” Further the court stated it could

not “gamble with [C.C.]’s life that her mother has the ability to properly care for



4 Compare Iowa Code § 232.116(2) (“[T]he court shall give primary consideration
to the child’s safety, to the best placement for furthering the long-term nurturing
and growth of the child, and to the physical, mental, and emotional condition and
needs of the child.”), with id. § 232.116(3)(c) (“The court need not terminate the
relationship between the parent and the child if the court finds . . . that the
termination would be detrimental to the child at the time due to the closeness of
the parent-child relationship.”).
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her,” and it concluded it was in C.C.’s best interests to terminate the mother’s

parental rights. We agree. See In re J.E., 723 N.W.2d 793, 802 (Iowa 2006)

(Cady, J., concurring specially) (stating that a child’s safety and the child’s need

for a permanent home are the “defining elements” in determining a child’s best

interests).

       Agreeing with the juvenile court that the statutory grounds to support

termination were proved by clear and convincing evidence, additional time was not

warranted, it is in the child’s best interests to terminate parental rights, and no

strong parental bond hinders termination, we affirm.

       AFFIRMED.
